Court Opinion

ID: 9597020
Source: CourtListenerOpinion
Date Created: 2023-08-22 00:54:59.990889+00
Date Added: 2024-06-11T09:41:28.196707
License: Public Domain

ALICE M. BATCHELDER, Circuit Judge,
dissenting.
I respectfully dissent, because I believe that the district court failed to apply the appropriate standard of review. “Where, as here, an insurance plan administrator is vested with discretion to interpret the plan, we review the denial of benefits under the arbitrary and capricious standard.” Rochow v. Life Ins. Co. of N. Am., 482 F.3d 860, 865 (6th Cir.2007) (citing Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115, 109 S.Ct. 948, 103 L.Ed.2d 80 (1989)). “This standard ‘is the least demanding form of judicial review of administrative action.... When it is possible to offer a reasoned explanation, based on the evidence, for a particular outcome, that outcome is not arbitrary and capricious.’ ” Evans v. UnumProvident Corp., 434 F.3d 866, 876 (6th Cir.2006) (quoting Killian v. Healthsource Provident Adm’rs, Inc., 152 F.3d 514, 520 (6th Cir.1998)). “Consequently, a decision will be upheld ‘if it is the result of a deliberate principled reasoning process, and if it is supported by substantial evidence.’ ” Id.
Although the district court acknowledged that Sun Life had presented a sig*449nificant quantity of medical evidence in support of its finding of no disability, the court discounted the quality of this evidence. Specifically, the court had difficulty with the fact that Sun Life’s reviewing professionals conceded DeLisle’s “veritable cornucopia of afflictions” but nonetheless concluded that she was not disabled. In the court’s opinion, “[t]he most likely explanation” for DeLisle’s termination was that she had become disabled as a result of her deteriorating physical condition. Under the arbitrary-and-capricious standard, however, it is improper for a reviewing court to weigh conflicting evidence or substitute its judgement for that of the plan administrator. Gismondi v. United Technologies Corp., 408 F.3d 295, 298 (6th Cir.2005); Whitaker v. Hartford Life & Accident Ins. Co., 404 F.3d 947, 949-50 (6th Cir.2005).
Substantial evidence in the record supports Sun Life’s findings that DeLisle was terminated from her job at Sidney Kran-dall & Sons for reasons unrelated to her health and that she was not disabled as of April 17, 2002, the date of her termination. The same day Krandall terminated her employment, DeLise told her therapist, Diane Cushing, that she “got fired.” Cush-ing’s session notes recite that the firing was “based on personality issues vs. job performance.” A Krandall representative reported to Sun Life that DeLisle “was terminated because she was not doing her job.” In an application for state unemployment benefits, DeLisle stated that she lost her job at Krandall due to “lack of work.” DeLisle secured other employment but was fired two weeks later over a dispute about her work hours.
As part of its own investigation, Sun Life had three physicians and a rehabilitation consultant review DeLisle’s medical records. Although these professionals agreed with some of the diagnoses of De-Lisle’s conditions, they all concurred that there was insufficient evidence that she was disabled as of April 17, 2002. When DeLisle appealed that determination, Sun Life had three additional physicians review the records. They, too, agreed that DeLi-sle’s information did not support a finding of disability. The district court noted that “[Sun Life’s] medical consultants found bases for many of [DeLisle’s] maladies but, without conducting personal examinations, discounted the effect of these maladies on her ability or inability to work. Had [Sun Life’s] consultants disputed the major diagnoses of [DeLisle’s] physicians, this case might reach a different result.” DeLisle did not file her claim for plan benefits until eight months after the date of her termination. At that point, Sun Life’s reviewing physicians had to rely on available medical records because they could not observe DeLisle’s physical condition as it existed on or about April 17, 2002. There is no reason to conclude that these professionals were less capable of reaching an opinion on DeLisle’s disability based on those records than they were of making independent diagnoses. Whatever weight we may be inclined to give Sun Life’s evidence, it was sufficient to support “a reasoned explanation” for Sun Life’s denial of long-term disability benefits.
The district court also held that Sun Life failed to give due consideration to the Social Security Administration’s disability determination. Although a failure to consider an SSA determination is a factor in reviewing a claim denial, Glenn v. Metropolitan Life Ins. Co., 461 F.3d 660, 666 (6th Cir.2006), aff'd, — U.S. -, 128 S.Ct. 2343, 171 L.Ed.2d 299 (2008), “an ERISA plan administrator is not bound by an SSA disability determination when reviewing a claim for benefits under an ERISA plan,” Whitaker, 404 F.3d at 949. In this case, DeLisle submitted only the SSA’s conclusion that she was disabled *450under its own eligibility criteria; she did not submit an accompanying opinion or anything else indicating the basis of the SSA’s decision. As the majority recognizes, “the plan’s disability criteria may differ from the Social Security Administration’s.” Majority Op. at 6. For example, the SSA’s conclusion could have been influenced by the greater deference to treating physicians that applies in the SSA context but not in ERISA actions. See Black & Decker Disability Plan v. Nord, 538 U.S. 822, 832-33, 123 S.Ct. 1965, 155 L.Ed.2d 1034 (2003) (declining to import a treating physician rule from the Social Security Act to ERISA).
Finally, the district court noted that Sun Life had a conflict of interest in that it was both the plan administrator and insurer and therefore had an incentive to deny DeLisle’s claim, especially given her young age. See Calvert v. Firstar Fin., Inc., 409 F.3d 286, 292 (6th Cir.2005). The Supreme Court has declined to adopt a less-deferential standard of review where a conflict of interest exists: the conflict is “but one factor among many that a reviewing judge must take into account.” Metropolitan Life Ins. Co. v. Glenn, — U.S. -, 128 S.Ct. 2343, 2351, 171 L.Ed.2d 299 (2008); see also Calvert, 409 F.3d at 293 (noting that this Circuit has consistently viewed a conflict of interest as a factor to consider in applying the arbitrary-and-capricious standard). Here, Sun Life retained six, independent medical professionals to review DeLisle’s medical records, and all of them concluded that her evidence did not support a finding of disability. Even if the experts retained by Sun Life might have had an incentive to find no disability, DeLisle’s treating physicians likewise may have been motivated to find a disability. See Black & Decker, 538 U.S. at 832, 123 S.Ct. 1965 (“[I]f a consultant engaged by a plan may have an ‘incentive’ to make a finding of ‘not disabled,’ so a treating physician, in a close case, may favor a finding of ‘disabled.’ ”); see also Eastover Mining Co. v. Williams, 338 F.3d 501, 510 (6th Cir.2003) (“[Tjreating physicians may have strong pro-claimant biases and lack the expertise held by non-treating doctors.”). Sun Life, in its role as administrator, weighed the opinions of the experts and sided with the professionals it had retained. Given the substantial evidence supporting a finding of no disability, DeLisle has failed to show how any conflict of interest caused Sun Life to abandon a reasoned, decision-making process.
Accordingly, I would REVERSE the judgment of the district court.