Opinion ID: 783927
Heading Depth: 4
Heading Rank: 1

Heading: Western-Southern

Text: 27 Western-Southern claims that there are two issues which this Court must address in order to resolve this appeal. The first issue is whether Western-Southern substantially complied with ERISA's procedural requirements, and if not, whether the substantive remedy imposed by the district court was proper. Western-Southern argues that the district court's order should be reversed because the district court erroneously concluded that it had failed to comply with ERISA's procedural requirements in terminating McDonald's LTD benefits, and thus, the district court improperly granted a substantive remedy to McDonald as a result of this alleged procedural defect. Specifically, Western-Southern asserts that the district court erred in holding that the telephone call between members of its Appeals Committee and Dr. Clary was improper and constituted a procedural defect because neither McDonald nor his counsel were included in the telephone call. Based upon this finding of an alleged procedural defect, Western-Southern contends that the district court improperly disregarded a highly relevant portion of the administrative record, i.e., Dr. Clary's supplemental report. 28 Western-Southern argues that it provided McDonald with a full and fair review of the record on his administrative appeal and that the procedures which occurred in this case substantially complied with the requirements of 29 U.S.C. § 1133. Western-Southern asserts that, contrary to the district court's characterization, there was nothing improper about its employees contacting Dr. Clary for a clarification of his initial report. Western-Southern contends that ERISA's claims procedures are not adversarial or trial-like as described by the district court; on the contrary, ERISA's claims procedures are designed to be an inexpensive, expeditious, and non-adversarial method of claims settlement. Thus, Western-Southern asserts that the district court erred in failing to fully consider Dr. Clary's supplemental report because this Court has adopted a rule of substantial compliance under § 1133. See Kent v. United of Omaha Life Ins. Co., 96 F.3d 803, 808 (6th Cir.1996)(holding that when claim communications as a whole are sufficient to fulfill the purposes of Section 1133 the claim decision will be upheld even if a particular communication does not meet those requirements.). 29 Furthermore, Western-Southern argues that its ERISA fiduciary obligations and the terms of the plan itself required it to investigate McDonald's claims on appeal. Contrary to the district court's conclusions, Western-Southern contends that Dr. Clary's initial report is not in conflict with his supplemental report. In both reports, Dr. Clary concludes that McDonald is not disabled, as that term is defined by the plan, and his supplemental report merely explains whatever ambiguity exists in his initial report. Thus, Western-Southern claims that the district court had no basis to disregard Dr. Clary's supplemental report. 30 Finally, Western-Southern argues that, even assuming arguendo that a procedural defect exists, the remedy of wholly discounting Dr. Clary's supplemental report is contrary to Sixth Circuit precedent. See Id. at 807 (holding that [g]enerally, the courts have recognized in ERISA cases that procedural violations entail substantive remedies only when some useful purpose would be served.). 31 The second issue that Western-Southern claims must be resolved in this appeal is whether the district court erred in holding that its decision to terminate McDonald's LTD benefits was arbitrary and capricious. Given the plan's definition of long-term disability or long-term disabled as the incapacity to engage in any and every occupation for wages, given Dr. Clary's opinion that McDonald is not suffering from a condition which prevents his return to work, and given Dr. Goodman's medical reports which indicate that McDonald is playing bridge for points, golfing, boating, and going on vacations, Western-Southern contends that it would defy logic to affirm the district court's decision because it is possible to offer a reasoned explanation, based upon the administrative record, for the termination of McDonald's LTD benefits. Accordingly, Western-Southern asks the Court to reverse the district court's order and to remand this case with directions to the district court to enter judgment in its favor.