Opinion ID: 70646
Heading Depth: 4
Heading Rank: 3

Heading: Lack of Physical Examination

Text: McDonald argues that Hartford abused its discretion by failing to order a new physical examination, or Functional Capacity Examination (FCE), as Drs. Hubbell and Steck recommended during the administrative review process. However, the policy places the burden on the claimant to provide proof of loss—at the claimant’s own expense—including “[o]bjective medical findings which support [the] disability. Objective medical findings include but are not limited to tests, procedures, or clinical examinations standardly [sic] accepted in the practice of medicine, for [the] disabling condition(s).” In addition,“the burden is not solely on the administrator to generate evidence relevant to deciding the claim.” Gooden v. Provident Life & Accident Ins. Co., 250 F.3d 329, 335 (5th Cir. 2001) (modification and internal quotation marks omitted); Gothard v. Metro. Life Ins. Co, 491 F.3d 246, 249 & n.7 (5th Cir. 2007) (declining to require a physical examination prior to denial of claim and citing cases in support); cf. Holland, 576 F.3d at 250 (declining to require administrator to consult with vocational expert, and quoting Duhon, 15 F.3d at 1309, for proposition that a “reviewing court [may] decide, on a case-by-case basis, whether under the particular facts the plan administrator abused his discretion 18 Case: 09-30381 Document: 00511007186 Page: 19 Date Filed: 01/19/2010 No. 09-30381 by not obtaining the opinion of a vocational rehabilitation expert”). McDonald fails to show abuse of discretion on this point. 4. Lack of Deference to Treating Physicians’ Opinions McDonald contends that Hartford abused its discretion by improperly discounting the opinions of her treating physicians. However, the Supreme Court has explicitly disapproved of a “treating physician” rule in the ERISA context and held that “plan administrators are not obliged to accord special deference to the opinions of treating physicians.” Black & Decker Disability Plan v. Nord, 538 U.S. 822, 825 (2003). Administrators do not bear “a heightened burden of explanation . . . when they reject a treating physician’s opinion.” Id. at 830. “So long as the [p]lan [a]dministrator’s decision is rationally related to the evidence, we do not require the [p]lan [a]dministrator to credit a particular area of expertise when deciding on an applicant’s prognosis.” Holland, 576 F.3d at 249, 250 (quoting language from Black & Decker, 538 U.S. at 834, that courts may not “impose on plan administrators a discrete burden of explanation when they credit reliable evidence that conflicts with a treating physician’s evaluation”). While the record does contain some evidence indicating that McDonald suffers from some permanent health issues,8 Hartford’s decision to deny benefits also finds support in the record. The fact that Hartford’s support comes from reviewing physicians does not render its decision arbitrary or capricious; even 8 McDonald relies on a letter from Dr. Hubbell contending that it is “very unlikely that [McDonald] will be able to return to work in any type of gainful employment” and concluding that she is “totally and permanently disabled due to her degenerative condition of her cervical and lumbar spine causing her to have persistent pain and muscle spasms.” This letter was written on August 21, 2007, and forwarded to Hartford on September 4, 2007. However, as discussed above, the administrative record closed in June 2006, when McDonald filed suit, and McDonald did not request that the letter be included in the record during the remand. Therefore, this letter from Dr. Hubbell is not part of the administrative record and we cannot consider it when analyzing whether Hartford acted arbitrarily or capriciously. 19 Case: 09-30381 Document: 00511007186 Page: 20 Date Filed: 01/19/2010 No. 09-30381 McDonald’s physicians have not expressed consistent opinions regarding the extent of her disability and her ability to perform sedentary work. For example, during the remand period, when Hartford re-interviewed Dr. Steck—the neurosurgeon who performed McDonald’s surgery—he did not give a clear “yes” or “no” answer when asked about the extent of McDonald’s disability. The interviewer asked: “Is there anything medically really why [McDonald] could not have done [sedentary work] three months post-op?” Dr. Steck replied: We are dealing basically with subjective complaints but they are based on objective data in that she has degenerative disc disease in the lumbar spine[;] she has documented lumbar disc herniation that was bad enough to require a lumbar decompression fusion, and I have dealt with enough of these patients [to know] that there will be a significant subset who will not return to any type of employment due to complaints of pain and there is no way I can prove that she doesn’t have pain, we could always say well I don’t see why she can’t work, most people could but not everybody . . . . The objective data is that, yes, she did have surgery, the subjective component is that although she is neurologically normal and everything looks just fine, although many people in this situation would be able to work although she tells me that she actually is better from the surgery, she had it, but doctor I just hurt too much to work. Based on that I just can’t sign a letter or do a dictation saying that I think she can work. (emphasis added). While Dr. Steck expressed concern for McDonald’s subjective complaints of pain and noted that the subjective complaints were based objectively on her degenerative disc disease, he also made the statement that “she is neurologically normal and everything looks just fine.” When Hartford reached its final decision, it had consistent reports from the three reviewing physicians indicating that McDonald did not meet the definition of “disabled”; it had Dr. Steck’s mixed statement; and it had Dr. Hubbell’s letter dated February 13, 2006, which recommended that McDonald 20 Case: 09-30381 Document: 00511007186 Page: 21 Date Filed: 01/19/2010 No. 09-30381 receive additional pain treatment and indicated: “I know that she can’t perform full-time work at this time, but I believe that if her cervical pain were resolved, she would be able to return to at least twice as much work as she is able to do today if not full-time work.” Hartford’s decision to deny benefits has clear support in the administrative record, and the decision is rationally related to the evidence Hartford had before it at the time of the decision. See Holland, 576 F.3d at 249. “[T]he job of weighing valid, conflicting professional medical opinions is not the job of the courts . . . [but rather the job of] the administrators of ERISA plans,” Corry, 499 F.3d at 401, and therefore McDonald’s argument that Hartford failed to give adequate weight to the opinions of her treating physicians must fail. Hartford did not abuse its discretion in adopting the opinions of the reviewing physicians over the treating physicians. 5. Lack of Consideration of Subjective Complaints of Pain McDonald argues that Hartford abused its discretion by failing to give adequate weight to her consistent complaints of pain. To support her argument, McDonald relies on Audino v. Raytheon Company Short Term Disability Plan, 129 F. App’x 882 (5th Cir. 2005) (per curiam), where we reversed a summary judgment in favor of a plan administrator that had denied benefits to a claimant who complained of pain. In Audino, we found an abuse of discretion because the administrator ignored [the claimant’s] consistent complaints of pain as subjective, either minimized or ignored objective evidence of disability corroborating those complaints, and concluded that the evidence did not show an inability to do her job functions without analyzing the effect that her conditions would have on her ability to perform her specific job requirements. 129 F. App’x at 885. However, in that case the claimant presented specific evidence of misstatements and oversights by the reviewing physicians that the plan administrator relied upon in denying the claim. Id. at 884–85 (noting that 21 Case: 09-30381 Document: 00511007186 Page: 22 Date Filed: 01/19/2010 No. 09-30381 one physician misstated objective test results, while another mentioned exam results in a summary of evidence but failed to discuss those results in analysis of whether claimant was disabled). More applicable than Audino is the case of Corry v. Liberty Life Assurance Co. of Boston, where we addressed in detail whether an administrator’s review adequately considered a claimant’s subjective complaints of pain. 499 F.3d at 399–401. There, the claimant’s experts opined that she was disabled due to fibromyalgia—a diagnosis reached by reliance on the claimant’s subjective reports of pain. Id. at 401. The plan administrator ultimately rejected the claimant’s assertion that she was disabled, relying on the opinions of three outside reviewing physicians. Id. All three reviewing physicians discussed the claimant’s subjective complaints and her previous diagnosis of fibromyalgia in their analyses; yet they each ultimately concluded that no medical evidence existed establishing a disability. Id. In Corry, we concluded that this constituted a “battle of the experts,” where the administrator was “vested with discretion to choose one side over the other”; therefore, we rejected the argument that the administrator “fail[ed] to consider and give proper weight to relevant evidence” of subjective pain. Id. Here, Hartford and its reviewing physicians clearly “considered, evaluated, and addressed” McDonald’s subjective complaints of pain; however, the reviewing physicians still reached the conclusion that McDonald’s administrative record did not contain objective medical evidence of disability. Corry, 499 F.3d at 401. The denial letters indicate that Hartford considered her subjective complaints. In the first denial letter, Hartford acknowledged McDonald’s continuing neck pain and her “difficulties with pain” but concluded that no neurological abnormalities were present and that the evidence did not “support a functional impairment that would preclude [her] from performing the 22 Case: 09-30381 Document: 00511007186 Page: 23 Date Filed: 01/19/2010 No. 09-30381 material and substantial duties of [her] regular occupation on a full-time basis.” When denying her first appeal, Hartford informed McDonald that: we considered your self-reported symptoms and to what extent the findings on physical examination and testing results confirm the symptoms. We also considered the impact the findings would have as far as your ability to funciton on a daily basis and how it would continuously affect your ability to perform your regular occupational work activity on a full-time basis. In its final denial letter, Hartford mentioned that it had considered letters from McDonald herself and from Dr. Hubbell detailing her subjective complaints. In addition, the administrative record contains notes from an interview with McDonald, detailing the impact of her pain on her daily life at work and at home. The reviewing physicians also clearly considered and addressed McDonald’s subjective complaints. Dr. LeForce, the initial reviewing physician, noted “complaints of neck and low back pain,” and “continued neck pain.” On the first administrative appeal, Dr. Turner discussed McDonald’s reports that she suffers radiating low back pain, aggravated by sitting and walking and partially relieved by rest, as well as chronic neck pain. Finally, Dr. Pick considered evidence that McDonald suffered from “chronic pain” and clinical notes from her treating physicians regarding her subjective complaints, including: “a history of an insult with severe low back pain and radiating right pain and recent onset numbness in her upper extremities”; “lumbar pain as well as leg pain”; “[s]he states the pain is getting worse”; “[s]he still has some low back pain, some buttock pain, some chronic neck pain, but all those better than preop.” All three reviewing physicians considered McDonald’s subjective complaints but ultimately concluded that these subjective complaints were insufficient to support a finding of disability. 23 Case: 09-30381 Document: 00511007186 Page: 24 Date Filed: 01/19/2010 No. 09-30381 Unlike in Audino, the reviewing physicians did not ignore McDonald’s complaints but included them in their analyses. McDonald argues that the reviewing physicians “mischaracterized the results of her MRIs,” but even Dr. Steck, her treating physician, stated that McDonald was “neurologically normal.” Any difference of opinion between the reviewing and treating physicians on the interpretation of her MRIs falls into Hartford’s area of discretion; McDonald does not point to any affirmative misstatements of objective test results of the kind presented in Audino. While Hartford’s conclusions conflict with Dr. Hubbell’s evaluation of McDonald’s condition, Dr. Steck’s final interview with Hartford on remand contains language that supports the conclusion that the record did not contain objective medical evidence of disability. Hartford has discretion in this battle of experts, and in the absence of evidence that Hartford failed to consider McDonald’s complaints of pain, Hartford was within its discretion to accept the opinions of its three qualified medical experts. Hartford’s decision was neither arbitrary nor capricious on this point. 6. Insufficient Evidence to Support Denial of Claim Finally, and more generally, McDonald complains that Hartford “cherrypicked” quotes and facts out of the administrative record to support its decision to deny her claim for benefits. However, under Fifth Circuit law, Hartford has discretion under the plan to investigate the claim and draw the conclusions it deems proper. “The law requires only that substantial evidence support a plan fiduciary’s decisions, including those to deny or to terminate benefits, not that substantial evidence (or, for that matter, even a preponderance) exists to support the employee’s claim of disability.” Ellis, 394 F.3d at 273. Here, Hartford solicited the medical opinions of three separate physicians. Drs. Turner and Pick are both board certified orthopedic surgeons, “specialists and qualified experts in [a] field[] specifically related” to McDonald’s symptoms; 24 Case: 09-30381 Document: 00511007186 Page: 25 Date Filed: 01/19/2010 No. 09-30381 at least two of the three physicians reached their conclusions independently.9 Corry, 499 F.3d at 402. In Corry, we found it “indisputable that the medical opinions of [the plan administrator’s] three consulting physicians . . . constitute substantial evidence supporting [the disability decision].” Id. In addition to the opinions of the three reviewing physicians, the administrative record contains other evidence in support of Hartford’s decision: in particular, Dr. Steck’s statement that McDonald was “neurologically normal and everything looks just fine.” Furthermore, McDonald admitted that she gets help to fulfill the duties of her job and that her employer has been cooperative and flexible. Hartford’s decision does not need to be correct; it simply must not be arbitrary. Cf. Gothard, 491 F.3d at 250 (“MetLife’s decision may not be correct, but we cannot say that it was arbitrary.”). On the administrative record, Hartford’s decision to deny her claim was supported by substantial evidence and there was no abuse of discretion.