Opinion ID: 2997339
Heading Depth: 2
Heading Rank: 1

Heading: Provident’s Decision to Terminate Benefits

Text: When a participant of an ERISA employee benefits plan challenges the denial of benefits, we must review that denial “under a de novo standard unless the benefit plan gives the administrator or fiduciary discretionary authority to determine eligibility for benefits or to construe the terms of the plan.” Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989); see Hightshue v. AIG Life Ins. Co., 135 F.3d 1144, 1147 (7th Cir. 1998). When a plan confers such discretion upon the plan administrator or fiduciary, we shall not disturb a decision concerning eligibility for benefits unless it is arbitrary and capricious. See Firestone Tire, 489 U.S. at 114-15. In this case, the policy grants Provident “full, exclusive, and discretionary authority to control, manage, and administer claims.” R.95, Ex.D at 25. Thus, we shall apply the arbitrary and capricious standard and shall not overturn Provident’s decision to terminate Ms. Houston’s long term disability benefits “as long as (1) ‘it is possible to offer a reasoned explanation, based on the evidence, for a particular outcome,’ (2) the decision ‘is based on a reasonable explanation of relevant plan documents,’ or (3) the administrator ‘has based its decision on a consideration of the relevant factors that encompass the important aspects of the problem.’ ” Hess v. Hartford Life & Accident Ins. Co., 274 10 No. 03-2776 F.3d 456, 461 (7th Cir. 2001) (quoting Exbom v. Cent. States, Southeast & Southwest Areas Health & Welfare Fund, 900 F.2d 1138, 1142-43 (7th Cir. 1990)).
As noted earlier, the plain language of the policy provides that a person is “disabled” from her own occupation if she is unable to perform each of the material duties of the occupation that she regularly performed for her employer. R.115 at 227. Notably, Provident informed Ms. Houston that she was ineligible for disability benefits under the policy because “[t]he physical capacity findings indicate you have the ability to perform not only your own occupation as a legal secretary but also many other sedentary jobs.” R.115 at 3 163-64. Provident maintains, and we agree, that its determination had a reasonable basis when Dr. Ryan and Dr. Suk, both orthopedic specialists, had documented that Ms. Houston’s back injury did not functionally limit her ability to perform the material duties of her occupation. Ms. Houston and the district court consider Dr. Ryan’s opinion the least reliable because he did not account for the results of the MRI exam (his evaluation preceded the MRI). However, as Provident submits, the MRI merely aided the diagnosis of a herniated disc, and the record offers insufficient objective documentation that this medical condition rendered Ms. Houston unable to perform sedentary work. Thus, the absence of the MRI is not fatal to Dr. Ryan’s functional capacity test. Sim- 3 Provident’s ERISA appeals committee denied Ms. Houston’s claim as supplemented on the same grounds—neither her vision problem nor depression rendered her unable to perform her own occupation. R.115 at 102-17; 168-69. No. 03-2776 11 ilarly, although Dr. Suk suspected Ms. Houston of having herniated discs and suggested further neurological evaluation, he more importantly found her capable of a wide range of work activity. Dr. Suk’s physical capacities form indicated that, over a full workday, Ms. Houston could stand, walk, sit and drive without restriction; occasionally lift up to ten pounds; use her hands for grasping, fine manipulation and repetitive motion (but not for pushing or pulling); occasionally bend, squat, kneel and balance; and frequently 4 use a foot control. Further, the form cleared her for light duty work pending neurological evaluation. In sum, we believe that the record here leads firmly to the conclusion that Provident reasonably concluded that Ms. Houston was not “disabled” as defined in the policy based upon Dr. Ryan’s and Dr. Suk’s evaluation that she had the functional capacity to perform the material duties of her occupation. See Blickenstaff, 378 F.3d at 678 (holding that plan administrator reasonably terminated benefits based upon functional capacity evaluation); Sisto v. Ameritech 4 Sidley & Austin’s job description for legal secretaries, a part of the administrative record, is worth noting; it lists the “essential duties” as: (1) using word processing; (2) organizing court filings, clerical functions and work flow; (3) inputing attorney daily time; (4) coordinating attorney travel arrangements and maintaining travel expenses; (5) proofreading documents; (6) receiving and transmitting telephone calls, conference calls and messages; (7) processing mail; (8) coordinating meetings and appointments for attorneys and clients; (9) maintaining attorney calendars; (10) coordinating prompt production and delivery of legal work; (11) obtaining cases from the library; (12) maintaining client and other files; (13) performing secretarial functions, such as processing new client/matter reports and expense reports. In addition, the job description states that Sidley & Austin would make “[r]easonable accommodations” to enable employees to perform those essential duties. R.115 at 29. 12 No. 03-2776 Sickness & Accident Disability Benefit Plan, No. 01 C 8262, 2003 WL 22472022, at -7, 9 (N.D. Ill. Oct. 31, 2003) (finding reasonable basis for denial of disability benefits even though MRI found two herniated cervical discs, because medical consultants concluded that the medical records did not establish that claimant was unable to perform any work); Rivera v. Bd. of Trustees, No. 02 Civ. 7844, 2003 WL 21710763, at , 9 (S.D.N.Y. July 23, 2003) (finding that denial of disability benefits was reasonable even though claimant’s physician diagnosed him with a herniated disc and concluded that he was totally disabled, because independent medical examiner concluded that condition was not so severe as to limit all work-related activity), aff’d, 2004 WL 287154, at  (2d Cir. Feb. 12, 2004) (holding that substantial evidence supported the denial of benefits, including examining physician’s conclusion that claimant could return to work).