Opinion ID: 4494568
Heading Depth: 2
Heading Rank: 1

Heading: standard of review

Text: To succeed in his claim for disability benefits under ERISA, Bruton must “prove by a preponderance of the evidence that he was ‘disabled,’ as that term is defined in the Plan.” Javery v. Lucent Techs., Inc. Long Term Disability Plan for Mgmt. or LBA Employees, 741 F.3d 686, 700–01 (6th Cir. 2014) (citing Tracy v. Pharmacia & Upjohn Absence Payment Plan, 195 F. App’x 511, 516 n.4 (6th Cir. 2006); Rose v. Hartford Fin. Servs. Grp., Inc., 268 F. App’x 444, 452 (6th Cir. 2008)). Bruton must therefore establish by a preponderance of the evidence both that he was in “Regular Attendance of a Physician” for his injury and that he “cannot perform the Material and Substantial Duties of his Regular Occupation.” (R. 18 at PageID 81). The parties agree that, because American United delegated its discretionary authority under the Plan to DRMS, our review is de novo. Shelby Cty. Health Care Corp. v. Majestic Star Casino, LLC, 581 F.3d 355, 365 (6th Cir. 2009). Under this standard, “we take a ‘fresh look’ at the administrative record, . . . giving proper weight to each expert’s opinion in accordance with supporting medical tests and underlying objective findings, and ‘accord[ing] no deference or presumption of correctness’ to the decisions of either the district court or plan administrator.” Javery, 741 F.3d at 700 (quoting Wilkins v. Baptist Healthcare Sys., Inc., 150 F.3d 609, 616 (6th Cir. 1998), and Hoover v. Provident Life & Accident Ins., 290 F.3d 801, 809 (6th Cir. 2002)). B. The Preponderance of Evidence Supports the Conclusion that Bruton was in “Regular Attendance” of a Physician. Under the terms of the Plan, to establish “Regular Attendance,” an applicant for benefits must show both that he “personally visit[ed] a Physician as medically required according to - 13 - Case No. 19-3466, Bruton v. Am. United Life Ins. Co. standard medical practice, to effectively manage and treat his Disability”; and that he “is receiving the most appropriate treatment and care that will maximize his medical improvement and aid in his return to work.” (R. 18 at PageID 80). The parties hold radically different views as to what this requirement obligates an applicant to do. In American United’s view, despite the great deal of contact Bruton had with medical professionals, he was not in “Regular Attendance” under the terms of the Plan because he “failed to obtain recommended medical care including a repeat MRI, aqua therapy, and treatment for his chronic pain complaints with pain specialist Dr. Whetstone[.]” (Appellee Br. at p. 27). Bruton argues that he satisfies the requirement because he received medical treatment routinely from competent physicians, and no evidence suggests that those treatments fell below the standard of care. (Appellant Br. at p. 32–33). Many courts have concluded that a benefits plan clause that obligates a claimant to be under the “regular care” or in “regular attendance” of a physician does not empower an administrator to micromanage a claimant’s medical care—instead, it exists merely to prevent malingering and fraud. Eichacker v. Paul Revere Life Ins., 354 F.3d 1142, 1148 (9th Cir. 2004); Heller v. Equitable Life Assurance Soc’y of U.S., 833 F.2d 1253, 1257 (7th Cir. 1987); Russell v. Prudential Ins. Co. of Am., 437 F.2d 602, 607 (5th Cir. 1971); Sullivan v. N. Am. Accident Ins. Co., 150 A.2d 467, 472 (D.C. 1959). But here, unlike in those cases, the provision obligates a claimant to “receiv[e] the most appropriate treatment and care” that is designed to “maximize his medical improvement and aid in his return to work.” (R. 18 at PageID 80). Some courts—including one in this circuit— have concluded that when a “regular attendance” requirement specifies that a claimant must receive treatment “appropriate for the condition causing the disability,” it implies an affirmative duty on the part of the insured to seek and accept care designed to enable the insured to return to his former employment. See, e.g., Reznick v. Provident Life & Accident Ins. Co., 364 F. Supp. 2d - 14 - Case No. 19-3466, Bruton v. Am. United Life Ins. Co. 635, 638 (E.D. Mich. 2005) (“A disability policy that requires an insured claiming benefits to be ‘under the care and attendance’ of a physician cannot reflect an intent of the parties that the insurer will be obligated to pay benefits even if the insured stubbornly refuses the only appropriate ‘care’ recommended.” (citation omitted)); see also Mack v. Unum Life Ins. Co. of Am., 471 F. Supp. 2d 1285, 1290–1291 (S.D. Fla. 2007); Provident Life & Accident Ins. v. Henry, 106 F. Supp. 2d 1002, 1004–1005 (C.D. Cal. 2000); Doe v. Provident Life & Accident Ins., No. Civ. A. 96–3951, 1997 WL 799439 at  (E.D. Pa. Dec. 30, 1997). In Reznick, we affirmed the district court’s decision upholding denial of benefits pursuant to a clause that obligated a patient to receive care “appropriate for the condition causing the disability.” Reznick v. Provident Life & Acc. Ins. Co., 181 F. App’x 531, 534–35 (6th Cir. 2006). We reasoned that the clause required that, “to be eligible for benefits under the policy, one must both be totally disabled and receiving care that is appropriate for a person who is totally disabled.” Id. (emphasis in original). American United argues that Bruton failed to meet the “Regular Attendance” requirement because he “did not obtain a recommended MRI, he did not comply with requests to see pain management specialist Dr. Whetstone, he did not comply with recommendations for aqua therapy, and he was only seeing a counselor and Psychiatrist . . . once per month.” (Appellee Br. at p. 24). It seems that, in American United’s view, the failure to pursue any treatment recommended by any medical professional with any level of confidence that the treatment would lead to medical improvement puts the applicant outside the realm of “total disability”—even in circumstances when a patient declined treatment that is prohibitively expensive, or experimental, or risky, or painful. We do not read the “Regular Attendance” requirement so stringently. Instead, we read it as we did in Reznick: to be in “Regular Attendance” of a physician under the Plan terms, a patient - 15 - Case No. 19-3466, Bruton v. Am. United Life Ins. Co. must pursue all care that is appropriate for a person who is totally disabled. Reznick, 181 F. App’x at 534–35. And the preponderance of evidence suggests that Bruton has done so. Our march through the record reveals that he received extensive treatment from medical professionals from May 2014 to February 2016—including over a dozen visits with his primary care provider and multiple visits with specialists ranging from neurosurgeons to neurologists to physical rehabilitation doctors to pain management doctors. As for the treatments that Bruton declined to pursue—a second MRI, aqua therapy, and an appointment with one specific pain management specialist, Dr. Whetstone—the record offers little to no evidence that Bruton would have improved his health outcomes had he pursued them. Bruton had received an MRI five months prior to Dr. Briones’s recommendation and there is no reason to believe that an additional MRI would have meaningfully altered his course of treatment; there is no basis to believe that aquatic therapy would have been more successful than other physical therapy, particularly because his physical therapist recommended it only “to determine effectiveness” (R. 18-1 at PageID 367); and although he failed to see Dr. Whetstone he did see two other pain management specialists. In short, this is not the type of case that concerned the court in Reznick, where the insured “stubbornly refuse[d] the only appropriate ‘care’ recommended.” 364 F. Supp. 2d at 638 (emphasis added). This is instead a case where the insured made reasonable decisions about his own care and pursued a quantum of treatment one would expect of a person who is totally disabled. The preponderance of evidence therefore supports the conclusion Bruton met the “Regular Attendance” requirement.1 1 Because it is not necessary to our holding, we do not address Bruton’s alternate claim that DRMS abandoned its “Regular Attendance” argument. - 16 - Case No. 19-3466, Bruton v. Am. United Life Ins. Co. C. The Preponderance of Evidence Supports the Conclusion that Bruton was Unable to Pursue His “Regular Occupation” Due to Disability. The second basis upon which DRMS denied Bruton’s claim was his alleged failure to prove that he was unable to perform the Material and Substantial Duties of his Regular Occupation. In reaching this conclusion, it reasoned that his occupation of Technology Development Manager was “performed at a sedentary level”—a conclusion Bruton does not dispute—and that the “available data supports that Mr. Bruton is capable of performing full time sedentary physical demand level work” (R. 18-1 at PageID 580)—a conclusion Bruton disputes ardently. In reviewing medical evidence in an ERISA case, courts may not conclude that the opinion of treating physicians is entitled to more weight than that of non-treating physicians. Black & Decker Disability Plan v. Nord, 538 U.S. 822, 830 (2003). But it is also true that “Plan administrators . . . may not arbitrarily refuse to credit a claimant’s reliable evidence, including the opinions of a treating physician.” Id. at 834. Moreover, a claimant’s documented limitations may not simply be dismissed as being “subjective exaggerations,” particularly where—as here—the individuals purporting to make that credibility determination did not meet or examine the claimant. Calvert v. Firstar Fin., Inc., 409 F.3d 286, 296–97 (6th Cir. 2005). On review, the preponderance of the evidence in the administrative record supports the conclusion that Bruton is unable to perform his Regular Occupation due to a combination of debilitating back pain as well as the impairing cognitive effect of medication required to treat that back pain. Bruton’s subjective level of pain is well-documented: he has been consistent in reporting that his pain is debilitating and increasing. More than that, Bruton’s pain is documented objectively. Dr. Briones performed monthly examinations and reviewed MRI results to reach her determination that Bruton was disabled. Dr. Mosley, a specialist in pain medicine, administered a number of tests to detect axial lower back pain, including the Gaenslens test, the Yeomans test, - 17 - Case No. 19-3466, Bruton v. Am. United Life Ins. Co. and the FABER test.2 He also searched for Waddell’s signs—a group of signs designed to detect whether pain is attributable to a physical ailment. He detected none of those signs, suggesting that Bruton was not malingering. It is true that DRMS-affiliated medical professionals reviewed Bruton’s claims file and determined that the evidence contained therein was inconsistent with his reported amount of pain. But there is no basis upon which to elevate the opinions of DRMSaffiliated practitioners who did not observe or physically assess Bruton over those of his treating practitioners. Indeed, as the Seventh Circuit has observed, when a patient undergoes a host of pain-treatment procedures like Bruton did—including epidurals, spinal ablation, transcutaneous electrical nerve stimulation, multiple consultations with specialists, physical therapy, and heavy doses of strong drugs—it is highly improbable that he did so “merely in order to strengthen the credibility of [his] complaints of pain and so increase [his] chances of obtaining disability benefits.” Carradine v. Barnhart, 360 F.3d 751, 755 (7th Cir. 2004). So too is it improbable that Bruton was a “good enough act[or] to fool a host of doctors and emergency-room personnel into thinking []he suffers extreme pain, and the (perhaps lesser) improbability that this host of medical workers would prescribe drugs and other treatment for h[im] if they thought []he were faking [his] symptoms. Such an inference would amount to an accusation that the medical workers who treated [Bruton] were behaving unprofessionally.” Id. Moreover, even if Bruton were not precluded from sedentary work based on his physical health alone, DRMS may not ignore the “intellectual aspects” of Bruton’s job requirements. Javery, 741 F.3d at 702. It is undisputed that Bruton’s position required a high degree of cognitive capability. DRMS’s own Vocational Consultant described his duties as “highly skilled,” 2 All three of these tests are physical maneuvers performed on a patient to evaluate the pathology of the sacroiliac joints. - 18 - Case No. 19-3466, Bruton v. Am. United Life Ins. Co. “requir[ing] frequent talking, hearing and near vision acuity,” and involving “directing controlling[,] or planning the activities of others . . . dealing with people, and making judgments and decisions.” (R. 18-1 at PageID 345). Dr. Briones concluded that the opioid medications Bruton took were both “require[ed] . . . around the clock to stabilize and assist in managing his pain” and also had the unfortunate effect of negatively impacting “his memory and processing, therefore, his ability to be productive at work.” (R. 18-1 at PageID 323). And it was partially on that basis that she concluded that “returning to work even in a sedentary capacity” was not feasible. (Id.). American United urges this court to decline to credit Dr. Briones’s assessment, and instead credit the opinion of Dr. Russell, a physician employed by DRMS who reviewed Bruton’s medical records. Dr. Russell reasoned that the cognitive effect of opiates is “short-lived, generally less than two weeks, as the patient adjusts to them” and that “[t]he only long-term side effect of opiates is constipation . . . [which] would not preclude full-time sedentary work.” (R. 18-1 at PageID 681). But the preponderance of evidence in the record supports the conclusion that Bruton’s longterm use of prescription opioids impacted his ability to perform the cognitive tasks of his job. Just as we did in Wagner v. American United Life Insurance Company, we now observe that Dr. Russell’s credibility determination was “entitled to little weight” because he “did a paper review even though the policy gave American [United] ‘the right to have [the claimant] examined’ by an independent doctor.” 731 F. App’x 495, 497–98 (6th Cir. 2018).