Opinion ID: 164993
Heading Depth: 2
Heading Rank: 3

Heading: Application of Amendment 23

Text: 47 As detailed in the foregoing discussion, we hold that Ms. Welch's benefits were not vested under the LTD plan. Accordingly, we hold that it was not improper for UNUM to retroactively apply Amendment 23 to Ms. Welch's claims, because it did not deprive her of vested benefits. Member Services, 130 F.3d at 954. However, the question remains as to whether UNUM appropriately applied Amendment 23's self-reported symptoms limitation to Ms. Welch's claim for disability benefits based upon a diagnosis of fibromyalgia. 48 Amendment 23's twenty-four-month self-reported symptoms limitation applies to payments on disabilities, due to sickness or injury, which are primarily based on self-reported symptoms. Aplt's App. vol. I, at 143. Self-reported symptoms are defined as 49 the manifestations of your condition which you tell your doctor, that are not verifiable using tests, procedures, or clinical examinations standardly accepted in the practice of medicine. Examples of self-reported symptoms include, but are not limited to headaches, pain, fatigue, stiffness, soreness, ringing in ears, dizziness, numbness and loss of energy. 50 Id. at 144. 51 UNUM contends that Ms. Welch could present no evidence, other than `self-reported symptoms' to justify continuation of her disability benefits for fibromyalgia. Aplt's Br. at 26. Ms. Welch, on the other hand, contends that her condition is confirmed by the results of a variety of objective tests performed over a period of time, showing varying degrees of connective tissue and inflammatory disease. Aple's Br. at 19. Because proving the disease is difficult . . ., fibromyalgia presents a conundrum for insurers and courts evaluating disability claims. Walker v. Am. Home Shield Long Term Disability Plan, 180 F.3d 1065, 1067 (9th Cir.1999). Compare id. (holding that no objective test exists for proving fibromyalgia); Jordan v. Northrop Grumman Corp. Welfare Benefit Plan, 370 F.3d 869, 872 (9th Cir.2004) ([F]ibromyalgia's cause or causes are unknown, there is no cure, and, of greatest importance to disability law, its symptoms are entirely subjective.); Green-Younger v. Barnhart, 335 F.3d 99, 108 (2d Cir.2003) ([A] growing number of courts, including our own, . . . have recognized that fibromyalgia is a disabling impairment and that `there are no objective tests which can conclusively confirm the disease.') (quoting Preston v. Sec. of Health and Human Servs., 854 F.2d 815, 818 (6th Cir.1988)); Hawkins v. First Union Corp. Long-Term Disability Plan, 326 F.3d 914, 919 (7th Cir.2003) (noting that fibromyalgia itself can be diagnosed more or less objectively by the 18-point test . . ., but the amount of pain and fatigue that a particular case of it produces cannot be); and McPhaul v. Bd. of Comm'rs of Madison County, 226 F.3d 558, 562 (7th Cir.2000) (holding that fibromyalgia's cause is unknown, there is no cure, and the symptoms are entirely subjective); with Boardman v. Prudential Ins. Co. of Am., 337 F.3d 9, 16 n. 5 (1st Cir.2003) (While the diagnoses of chronic fatigue syndrome and fibromyalgia may not lend themselves to objective clinical findings, the physical limitations imposed by the symptoms of such illnesses do lend themselves to objective analysis.); Brosnahan v. Barnhart, 336 F.3d 671, 678 (8th Cir.2003) (noting that Social Security claimant's testimony and reports to the Social Security Administration were supported by objective medical evidence of fibromyalgia); and Russell v. UNUM Life Ins. Co. of Am., 40 F.Supp.2d 747, 751 (D.S.C.1999) (considering a nearly identical self-reported symptoms limitation and holding that fibromyalgia is an objectively diagnosable condition). 52 There is no dispute that the Coleman LTD plan gives UNUM discretionary authority to determine eligibility for benefits and to construe the terms of the plan. Aplt's App. vol. I, at 50. However, in making those discretionary determinations, UNUM, as the plan administrator and insurer, operates under a conflict of interest. Pitman v. Blue Cross and Blue Shield of Okla., 217 F.3d 1291, 1296 n. 4 (10th Cir.2000) (holding that when one party serves as both insurer and administrator of the plan, there is an inherent conflict of interest between its discretion in paying claims and its need to stay financially sound). In these circumstances, under our circuit's sliding scale approach, a court reviewing a benefits determination will always apply an arbitrary and capricious standard, but the court must decrease the level of deference given to the conflicted administrator's decision in proportion to the seriousness of the conflict. Chambers v. Family Health Plan Corp., 100 F.3d 818, 825 (10th Cir.1996). 53 In this case, the magistrate judge's finding that Amendment 23 could not be applied to Ms. Welch obviate[d] the need to decide whether fibromyalgia falls within the self-reported symptom limitation of the new plan. Aplt's App. vol. II, at 579. Therefore, the lower court never applied the arbitrary and capricious standard to UNUM's benefits determination for Ms. Welch. 54 As a general rule, we do not consider issues not passed on below, and it is appropriate to remand the case to the district court to address an issue first. N. Tex. Prod. Credit Ass'n v. McCurtain County Nat'l Bank, 222 F.3d 800, 812 (10th Cir. 2000). Accordingly, we remand the case to give the district court the opportunity to consider the evidence and arguments of the parties regarding UNUM's determination that fibromyalgia falls into the self-reported symptoms limitation.