Opinion ID: 770872
Heading Depth: 2
Heading Rank: 2

Heading: Appellant's Arguments on the Merits

Text: 18 Appellant's arguments on the merits also fail to persuade us that summary judgment was not appropriate. We agree with the lower court that, as a matter of law, the termination of appellant's disability benefits did not violate ERISA. 19
20 Appellant's first argument is that the lower court erred in finding no ERISAviolation because she has been collecting Social Security disability benefits since 1990 based on the same disability for which she received benefits from appellee up until February of 1996. She argues that this demonstrates the unreasonableness of appellee's noneligibility determination. 21 Appellant's argument falls short of the mark, for two principal reasons. First, we have before suggested and today hold that benefits eligibility determinations by the Social Security Administration are not binding on disability insurers. See Doyle, 144 F.3d at 186 n.4. The criteria for determining eligibility for Social Security disability benefits are substantively different than the criteria established by many insurance plans, including the plan in this case. See generally 42 U.S.C. § 416(i), 423(d). Consequently, although a related Social Security benefits decision might be relevant to an insurer's eligibility determination, it should not be given controlling weight except perhaps in the rare case in which the statutory criteria are identical to the criteria set forth in the insurance plan. 22 Second, and more important in this case, the conclusions reached in appellant's social security litigation date from 1992. Appellee does not contest that appellant was disabled at that time; to the contrary, it concedes such disability. ITT Hartford's reason for terminating appellant's benefits was a lack of evidence that she remained disabled in February of 1996. On that issue, the social security litigation is singularly uninformative, because, although appellant continues to receive social security disability benefits, no review of her eligibility has been undertaken since 1992. 23 The same is true of nearly all of the medical evidence submitted by appellant that tends to support her disability claim. The majority of documents that she submitted to the appellee and to the court date from well before the termination of her benefits in 1996; they range from documentation of the initial determination of her disability in 1990 to comments from physicians prepared as late as 1994. The only favorable evidence arguably within the relevant time period consisted of a statement of disability by her treating physician, Dr. Calvo, in June of 1995, and further comments from the same physician in December of that year. Included in the December comments of Dr. Calvo, however, was his own suggestion that appellant undergo an IME by an orthopedic or rehabilitation specialist chosen by appellee. This would tend to bolster the reasonableness of ITT Hartford in demanding such an examination. In light of the other evidence, Dr. Calvo's mixed comments from June and December of 1995 are simply not enough to create a genuine dispute as to the reasonableness of ITT Hartford's termination decision. 24
25 Appellant's next contention is that the appellee was unreasonable in terminating her benefits without conducting a vocational assessment to determine what specific jobs she was, or could become, qualified to perform. We agree with the district court that such an assessment was not necessary in this case. 26 The only case cited by the appellant to support such a requirement is Quinn v. Blue Cross & Blue Shield, 161 F.3d 472 (7th Cir. 1998). As the magistrate's report and recommendation correctly noted, Quinn involved a termination of benefits in the face of conflicting medical evidence and, importantly, where the plan administrator made no inquiry, nor did any doctor's opinion state whether there were any limitations in [the claimant's] ability to work. Id. at 476. The facts of this case are quite different. First, appellee asserts that the initial termination of benefits was based on the combination of (1) a lack of evidence of appellant's ongoing disability and (2) her refusal or failure to undergo an IME requested by appellee (as it was entitled to request under the plan). This alone would likely justify the termination of benefits, because we decline to read contractual language such as that of this insurance plan to allow a beneficiary to avoid termination of benefits simply by studiously refusing to document her present condition. 2 Second, and even more damaging to appellant's argument, when she eventually did submit herself to IME's, both of the physicians who evaluated her opined explicitly as to the limitations on her ability to work and concluded that a modest weight limit on her lifting and (in the opinion of the orthopedic specialist) the avoidance of repetitive neck movements were the only conditions required to make her fit to perform any number of jobs. 3 Granted, no physician or other person proceeded to speculate or investigate and report on actual particular positions that would be appropriate for appellant to fill, but in light of the medical evidence and the conclusions of the reviewing physicians such a job-specific laundry list hardly seems necessary. Under these circumstances, we are unwilling to require the insurance company to do more than it did in this case -- evaluate the claimant's medical condition and, based on that evaluation, determine if she was able to perform any job comparable in compensation to her previous position. The touchstone of our review, as we have said, is reasonableness, and we find appellee's determination in this case entirely reasonable and well supported by the record.