Opinion ID: 183519
Heading Depth: 3
Heading Rank: 1

Heading: Support for the Termination Decision

Text: We determined in Schwing that where there was an abundance of evidence of [the claimant's] misconduct to support the denial of [the] claim, a structural conflict of interest or procedural irregularities would not serve to tip[] the scales in favor of finding that the [administrator] abused its discretion. 562 F.3d at 526. American contends, at the outset, that there was overwhelming evidence of the absence of a disability that plainly supports the termination of Miller's benefits, and that we should not consider whether any procedural irregularities tainted their decision-making. (American Br. at 19, 34.) In this regard, American relies heavily on Dr. Gonzalez's description of Miller as being asymptomatic to argue that there was substantial support for their decision to terminate benefits and that any irregularities should be disregarded. American essentially argues that because Dr. Gonzalez labeled Miller as asymptomatic, he had actually been erroneously awarded benefits in the past and this had gone unnoticed. We disagree. The record demonstrates, contrary to American's assertion that Miller simply slipped through the cracks, that American exercised frequent oversight in Miller's case. In fact, American reviewed and relied on documentation from Dr. Gonzalez stating that Miller was asymptomatic and, on multiple occasions over several years, found that this description supported the payment of benefits. Notably, in 2003, American determined that Miller [m]edically qualifies for [the] disability pension program and reinstated his LTD benefits after receiving records describing him as asymptomatic. (App. at 148.) Yet, after receiving additional reports containing this same description, American terminated Miller's benefits. As such, American interpreted Dr. Gonzalez's characterization of Miller as asymptomatic to mean that he was both eligible for disability benefits and that his benefits should be terminated. American's reliance on the term asymptomatic as the linchpin of Miller's ineligibility for disability benefits is, therefore, misplaced. Further, the record reveals that although Dr. Gonzalez reported that Miller was no longer taking medication, he consistently stated that Miller was still under his care. Indeed, American noted twice after receiving records from Dr. Gonzalez that Miller was unable to return to work as a pilot. ( Id. at 105-06.) In addition, American's internal records repeatedly state that Miller was diagnosed with anxiety and brief reactive psychosis. ( Id. at 104-06.) Notably, only a few days before American terminated Miller's benefits, American's records state that Miller's diagnosis was the same. ( Id. at 107.) Finally, Dr. Gonzalez's letter in support of Miller's appeal to the PBAC notes that his psychiatric conditions are permanent and that continued treatment is necessary to stabilize his health. A review of the administrative record, therefore, demonstrates that although Miller may not have been outwardly manifesting symptoms, his psychiatric diagnoses remained constant and required regular treatment. As such, Dr. Gonzalez's report that Miller suffered from anxiety diagnosis and brief reactive psychosis constituted an illness or injury verified through a qualified medical authority, thus satisfying the definition of disability under the Plan. ( Id. at 717.) Unlike Schwing, the administrative record does not contain an abundance of evidence of ineligibility such that we should ignore any procedural defects in the termination decision. 562 F.3d at 526. Because we disagree with American's assertion that Dr. Gonzalez's description of Miller as being asymptomatic forecloses our inquiry into whether the termination of benefits was arbitrary and capricious, we consider each factor in turn.