Opinion ID: 173185
Heading Depth: 2
Heading Rank: 2

Heading: The Benefits Denial

Text: As Prudential noted in its initial denial letter, the plan covers a “total and permanent loss of sight” that occurred “independently of all other causes” and was not “directly or indirectly” the result of a “[b]odily or mental infirmity, disease of any kind, or medical or surgical treatment for any such infirmity or disease.” Aplt. App., Vol. 1 at A138, A139. Dove argues that Prudential acted unreasonably in denying benefits because it failed to interpret the phrase, “loss of sight,” to mean a loss of “practical vision.” Aplt. Br. at 11, 13, 16, 21-22, 26, 29. 4 Dove argues that Prudential’s conflict of interest necessitates that it bear the burden of proving the reasonableness of its benefits denial. Aplt. Br. at 10. The Supreme Court in Glenn, however, rejected “special burden-of-proof rules, or other special procedural or evidentiary rules, focused narrowly upon the evaluator/payor conflict.” 128 S. Ct. at 2351; see also Hancock, 2009 WL 5103121, at . -7- Dove offers no convincing authority to support this argument, 5 and the argument misapprehends the basis of the benefits denial. Prudential denied benefits on the basis that Dove’s pre-existing eye conditions contributed to his total and permanent loss of sight. 6 But there is no evidence in the record regarding such a contributing effect. In other words, nothing indicates how Dove’s pre-existing eye conditions combined with the accident to produce the result. Nor is there any evidence about whether the accident, by itself, would have been sufficient to destroy Dove’s sight. Instead, Prudential relied on the fact that it found Dove blind before the accident to conclude that the accident did not independently destroy his sight. Nevertheless, Dove does make several cogent observations. First, he notes that “[t]he accident was the direct and independent cause of a diminution in the sight of Mr. Dove’s right eye.” Aplt. Br. at 28. Prudential conceded as much in its first denial of reconsideration, observing that the accident “further damaged 5 For instance, Dove relies on Order of United Commercial Travelers of Am. v. Knorr, 112 F.2d 679 (10th Cir. 1940), to argue that “‘loss of sight’ has been uniformly held to mean a loss of ‘practical vision.’” Aplt. Br. at 11. But Knorr was not an ERISA case, and it merely held that an insurance policy that lacked a definition for “loss of an eye” was not ambiguous because courts had uniformly interpreted it to mean that “the eye is no longer of some practical value or benefit.” Knorr, 112 F.2d at 682. Here, in contrast, the Prudential plan contains a definition for “loss of sight,” and that is “a total and permanent loss of sight.” Aplt. App., Vol. 1 at A138. 6 There appears to be no dispute that, following the accident, Dove’s loss of sight was “total and permanent” under the plan. -8- [Dove’s] eye.” Aplt. App., Vol. 2 at A251. But Prudential made no attempt to determine whether that “further damage[ ]” caused Dove’s total and permanent loss of sight. Instead, Prudential announced in its denial letters that the accident did not create a “new circumstance.” See id. The phrase “new circumstance” is not in the benefit plan. “[W]here the administrator imposes a standard not required by the plan’s provisions, . . . [the administrator’s] actions may well be found to be arbitrary and capricious.” Pepe v. Newspaper & Mail Deliveries’- Publishers’ Pension Fund, 559 F.3d 140, 147 (2d Cir. 2009) (quotation omitted); accord Swaback v. Am. Info. Techs. Corp., 103 F.3d 535, 541-42, & 542 n.14 (7th Cir. 1996); Epright v. Envtl. Res. Mgmt., Inc. Health & Welfare Plan, 81 F.3d 335, 342-43 (3d Cir. 1996); cf. Allison v. Bank One-Denver, 289 F.3d 1223, 1236 (10th Cir. 2002) (“We have repeatedly rejected efforts to stray from the express terms of a plan, regardless of whom those express terms may benefit.”). Second, Dove notes that during the medical review process, Prudential described his pre-accident right eyesight as “legally” blind to infer that the accident was not the independent cause of his sight loss. Aplt. App., Vol. 2 at A231, A233, A235. But the benefit plan does not mention “legal” blindness, and we question its probative value. At least one prominent authority states that “legal blindness is a misnomer because 90% of individuals who have 20/200 or less visual acuity [i.e., legal blindness] are not blind but have significant residual -9- vision that can be enhanced through vision rehabilitation.” American Medical Association, Guides to the Evaluation of Permanent Impairment 286 (6th ed. 2008) (second emphasis added). Indeed, Dr. Lederer stated that Dove had useful residual vision before the accident. Thus, the fact that Dove could be considered “legally” blind before the accident does not necessarily mean that the accident could not have been the independent source of his total sight loss. Finally, Dr. Kowalski appears to have reached his opinion on the causal source of Dove’s sight loss through a misunderstanding of the facts. Dr. Kowalski stated that Dove’s visual acuity scores “on 2/8/05 [prior to the accident are] similar to his visual acuity in the right eye prior to the accident.” Aplt. App., Vol. 2 at A235. While that statement is certainly true (in that it refers to only one visual acuity test), it provides absolutely no support for the process of determining causation by comparing pre-accident and post-accident vision. Given Prudential’s reliance on standards not contained in the benefits plan, and Dr. Kowalski’s confusion regarding Dove’s pre-accident visual acuity test, we conclude that Prudential’s decision was arbitrary and capricious. 7 But “[t]his is not a case where it is so clear-cut that it was unreasonable for [Prudential] to deny [Dove] benefits.” Rekstad v. U.S. Bancorp, 451 F.3d 1114, 1121 (10th Cir. 2006). On the one hand, Dove had significant pre-existing eye problems. On the 7 While we note Prudential’s conflict of interest in this case, nothing indicates that it affected the benefits denial, or that it is otherwise of any consequence on the record before us. -10- other hand, the accident worsened whatever eyesight he had. Specifically, Dr. Lederer noted that before the accident Dove’s right eye could count fingers at three feet and “certainly” would have been useful in “tasks of daily living.” Aplt. App., Vol. 1 at A165. Dr. Lee stated that no pre-existing medical conditions contributed to Dove’s injury, id. at A118, and that Dove’s right eye vision went from 20/400 (distance) and 20/200 (near) to only light perception after the accident. Between these two extremes lies the unresolved issue in this case: whether the accident was the independent cause of Dove’s vision loss, such that it would have brought about the loss without the direct or indirect influence of Dove’s pre-existing conditions. But there is no evidence in this case that untangles the physical effects of the accident from those of the pre-existing medical conditions. Moreover, we are not convinced that Prudential would reach the same conclusion in this case after restricting its medical review to the express terms of the plan and properly comparing Dove’s pre- and post-accident vision. Consequently, reconsideration by Prudential is the most prudent course of action. Cf. Rekstad, 451 F.3d at 1121 (reversing and remanding to the plan administrator where it was unclear whether substantial evidence supported the administrator’s decision and there had been less than full consideration given to all the evidence). -11- C ONCLUSION We REVERSE the judgment of the district court and REMAND this matter to the district court with instructions that it order Prudential to reconsider Dove’s application for benefits consistent with this court’s decision. Entered for the Court Paul J. Kelly, Jr.