Court Opinion

ID: 1006342
Source: CourtListenerOpinion
Date Created: 2013-07-04 19:10:03.352541+00
Date Added: 2024-06-11T15:13:10.028697
License: Public Domain

UNPUBLISHED

UNITED STATES COURT OF APPEALS
                FOR THE FOURTH CIRCUIT

KAY C. TUMBLESTON,                    
               Plaintiff-Appellant,
                 v.                              No. 01-1738
A.O. SMITH CORPORATION,
               Defendant-Appellee.
                                      
           Appeal from the United States District Court
          for the District of South Carolina, at Florence.
                Terry L. Wooten, Magistrate Judge.
                         (CA-99-1297-4-23)

                      Argued: December 5, 2001

                      Decided: January 16, 2002

      Before MICHAEL and TRAXLER, Circuit Judges, and
    Joseph R. GOODWIN, United States District Judge for the
     Southern District of West Virginia, sitting by designation.

Affirmed by unpublished per curiam opinion.

                             COUNSEL

ARGUED: Martin Scott Driggers, Sr., DRIGGERS & MOYD, Harts-
ville, South Carolina, for Appellant. Derwood Lorraine Aydlette, III,
GIGNILLIAT, SAVITZ & BETTIS, L.L.P., Columbia, South Caro-
lina, for Appellee.
2                    TUMBLESTON v. A.O. SMITH CORP.
Unpublished opinions are not binding precedent in this circuit. See
Local Rule 36(c).

                                OPINION

PER CURIAM:

   Plaintiff Kay C. Tumbleston sued her employer A.O. Smith Corpo-
ration, pursuant to the Employee Retirement Income Security Act of
1974 ("ERISA"), see 29 U.S.C.A. § 1001 - 1461 (West 1999 & Supp.
2001), following termination of her long term disability ("LTD") pay-
ments. On cross-motions for summary judgment, the district court
denied Tumbleston’s motion and granted Smith’s motion. We affirm.

                                    I.

   Prior to August 1994, Tumbleston was a customer service supervi-
sor employed by Smith. As a Smith employee, Tumbleston was
enrolled in Smith’s benefits plan, which included provisions for the
payment of LTD benefits under defined circumstances. Smith is the
Plan Administrator for its Long Term Disability Plan (the "Plan"),
and Provident Life and Accident acted as the Claims Administrator
for the Plan.1 The Plan is self-funded for the first five years of a claim,
and thereafter is insured by a private insurer.

  Under Smith’s LTD Plan, an employee is considered totally dis-
abled:

        a. during the first 24 months if the injury or disease pre-
           vents [the employee] from performing any and every
           duty of [her] occupation; and

        b. thereafter only if the injury or disease prevents [the
           employee] from performing any and every duty of
           every occupation for which [she is] qualified.
    1
   Because Provident acted on Smith’s behalf, we refer to the two
together as the "Plan Administrator."
                   TUMBLESTON v. A.O. SMITH CORP.                       3
J.A. 37. However, with one exception not applicable here, benefits
payable for a disability "[c]aused by [n]ervous or [m]ental [d]isease"
are always limited to 24 months. J.A. 34. The parties agree that the
Plan Administrator is given discretionary authority to determine eligi-
bility for benefits and to construe the terms and provisions of the
Plan.

   In early August, 1994, Tumbleston left her employment with Smith
and has never returned. On February 17, 1995, Tumbleston applied
for LTD benefits under the Plan by completing an "Initial Claim for
Group Long Term Disability Benefits." J.A. 49. Tumbleston claimed
that her disability was job-related, with an onset date of August 2,
1994, and listed Dr. James Bell, her family physician, and Dr. Judith
Tolhurst, her psychiatrist, as treating physicians. Her claim was ini-
tially supported by an "Attending Physician’s Statement of Disability"
completed by Dr. Bell. J.A. 51. In the "Diagnosis" section of the
form, Dr. Bell listed Tumbleston’s diagnoses as major depression and
anxiety (created by job stress), panic disorder, and lumbosacral disc
disease with sciatica. With regard to Tumbleston’s disability, Dr. Bell
opined that Tumbleston had been totally disabled since August 4,
1994, due to "interpersonal relationships that have led to confronta-
tion," and stated that Tumbleston would not be able to return to work.
J.A. 51. In addition, Dr. Bell indicated that Tumbleston’s lifting capa-
bility was not applicable to her claim for disability, that her range of
motion was not impaired, and that she had no "[c]ardiac [f]unctional
[c]apacity" limitation. J.A. 51-52. According to Dr. Tolhurst’s
records, obtained by the Plan Administrator to evaluate the claim,
Tumbleston had reported that in August 1994, her "boss jumped on
her in front of [four] people [and] she quit on med[ical] leave per Dr.
Bell." J.A. 61. Because Tumbleston had dropped out of treatment,
however, Dr. Tolhurst offered no opinion as to whether Tumbleston
could work.

   In June 1995, the Plan Administrator asked Tumbleston to submit
to an independent psychological evaluation by Jill Banks, Ph.D. Dr.
Banks confirmed that Tumbleston suffered from "depression, insom-
nia, agitation, lack of self-confidence, indecisiveness, and inability to
interact with others as she once did," apparently related at least in part
to Tumbleston’s prior interactions with her supervisor. J.A. 73. Dr.
Banks opined that Tumbleston was "significantly depressed," that she
4                 TUMBLESTON v. A.O. SMITH CORP.
was "unable to cope with stressful situations," and that her depression
"impair[ed] her ability to carry out work-related functions." J.A. 75.
The Plan Administrator approved Tumbleston’s claim for benefits in
August 1995, but Tumbleston was encouraged at approximately the
same time to consider rehabilitative services because her LTD bene-
fits would terminate after 24 months.

   During the ensuing 24 months, the Plan Administrator requested
several updates from Tumbleston and Dr. Bell concerning Tumbles-
ton’s disability status. In February 1996, the Plan Administrator
requested that a "Proof of Continuance of Disability" form be com-
pleted by Tumbleston and Dr. Bell. J.A. 81. On the form, Tumbleston
indicated that "job stress" was the "injury or sickness causing [her]
disability." J.A. 81. For his part, Dr. Bell again opined that Tumbles-
ton’s condition was due to "job stress creat[ing] major depression
[and] anxiety," but listed no impairments in Tumbleston’s range of
motion or cardiac function. J.A. 82.

   On August 7, 1996, Tumbleston suffered a lumbar compression
fracture and was referred to Dr. Hassler, an orthopaedist, for treat-
ment. Dr. Hassler treated Tumbleston until September 18, 1996, when
she was released to be seen as needed. In October and November
1996, the Plan Administrator again requested "Proof of Continuance
of Disability" from Tumbleston, and Tumbleston again advised that
she was disabled from "job stress associated with [managers]." J.A.
89. Dr. Bell also remained consistent in his opinion that Tumbleston’s
disabling condition was the result of "job stress creat[ing] major
depression [and] anxiety" and that there were no range of motion lim-
itations. J.A. 88.

   On February 2, 1997, Tumbleston’s benefits expired under the 24-
month limitation, prompting the Plan Administrator once again to
request information from Dr. Bell. At this point, however, Dr. Bell
completed a "Physical Capacities" assessment indicating, for the first
time, and in sharp contrast to his earlier reports, that Tumbleston had
significant physical limitations presumably resulting from her com-
pression fracture and her history of lumbosacral disc disease. The
Plan Administrator, in turn, requested information from Dr. Hassler,
the orthopaedist who had treated Tumbleston a few months earlier.
Dr. Hassler advised that, because Tumbleston had not returned to see
                  TUMBLESTON v. A.O. SMITH CORP.                     5
him after September 1996, he assumed that she was doing very well.
In addition, Dr. Hassler completed a "Physical Capacities" assessment
which indicated no physical limitations or restrictions and opined that
Tumbleston had "no permanent partial disability" and "no restrictions
for her work." J.A. 132.

   In May 1997, the Plan Administrator notified Tumbleston that her
LTD benefits would not be continued beyond the 24-month limitation
period based upon a determination that she "would not be considered
totally disabled from a physical standpoint" and that her "men-
tal/nervous limit expired effective February 3, 1997." J.A. 136. In
response, Dr. Bell wrote the Plan Administrator, stating that although
Tumbleston’s mental disorders were her predominant problem when
he responded to the Plan Administrator’s earlier inquiries, Tumbles-
ton also suffered from physical problems that added to her disability.
According to Dr. Bell, "[t]his was an error made by myself because
she had these problems and I should have recorded them. If I had
known she had a two year clause related to mental illness, I would
have added these at that time." J.A. 140. Dr. Bell advised that he felt
Tumbleston was totally and permanently disabled from "the summa-
tion of all [her] medical problems." J.A. 141. The Plan Administrator
treated Dr. Bell’s letter as an appeal and upheld the denial. Tumbles-
ton then initiated this action.

                                  II.

                                  A.

   We review the district court’s grant of summary judgment de novo.
See Ellis v. Metropolitan Life Ins. Co., 126 F.3d 228, 232 (4th Cir.
1997). However, because the Plan gives the Plan Administrator dis-
cretionary authority to construe the terms of the Plan and determine
Tumbleston’s eligibility for benefits, we review the Plan Administra-
tor’s decision to deny continued LTD benefits for an abuse of discre-
tion. See Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115
(1989).

   Under this standard, the Plan Administrator’s decision will not be
disturbed if it is reasonable, even if this court would have come to a
different conclusion independently. See Feder v. Paul Revere Life Ins.
6                  TUMBLESTON v. A.O. SMITH CORP.
Co., 228 F.3d 518, 522 (4th Cir. 2000). "[A] decision is reasonable
if it is the result of a deliberate, principled reasoning process and if
it is supported by substantial evidence." Ellis, 126 F.3d at 232 (inter-
nal quotation marks omitted). Because the Plan gives discretion to an
administrator or fiduciary who is operating under a conflict of inter-
est, however, we must also weigh that conflict "in determining
whether there [has been] an abuse of discretion." Firestone, 489 U.S.
at 115; see Booth v. Wal-Mart Stores, Inc. Assocs. Health & Welfare
Plan, 201 F.3d 335, 342 (4th Cir. 2000). We reduce the amount of
deference given to the fiduciary’s decision and determine, based on
review of the record before the fiduciary at the time of decision-
making, whether the fiduciary’s decision is consistent with a decision
that might have been made by a fiduciary acting free of the interests
that conflict with those of the beneficiaries. See Ellis, 126 F.3d at 233.

  In Booth, we assimilated the criteria for determining the reason-
ableness of a fiduciary’s decision, concluding that the court:

     may consider, but is not limited to, such factors as: (1) the
     language of the plan; (2) the purposes and goals of the plan;
     (3) the adequacy of the materials considered to make the
     decision and the degree to which they support it; (4) whether
     the fiduciary’s interpretation was consistent with other pro-
     visions in the plan and with earlier interpretations of the
     plan; (5) whether the decisionmaking process was reasoned
     and principled; (6) whether the decision was consistent with
     the procedural and substantive requirements of ERISA; (7)
     any external standard relevant to the exercise of discretion;
     and (8) the fiduciary’s motives and any conflict of interest
     it may have.

Booth, 201 F.3d at 342-43. In this case, the district court carefully
applied these criteria and concluded that the Plan Administrator’s
decision to terminate Tumbleston’s LTD benefits was not an abuse of
discretion. Accordingly, the court denied Tumbleston’s motion for
summary judgment and granted Smith’s motion for summary judg-
ment.

  On appeal, Tumbleston raises two primary challenges to the district
court’s ruling. First, Tumbleston asserts that the nervous or mental
                   TUMBLESTON v. A.O. SMITH CORP.                      7
disease limitation in the Plan is ambiguous as applied to her LTD
claim and that the limitation should not be applied to her because her
disability involves a combination of physical and mental conditions.
Second, Tumbleston argues that the Plan Administrator violated its
fiduciary duty to her and abused its discretion by classifying her dis-
ability as one "[c]aused by a nervous or mental disease," J.A. 34, and
limiting her benefits to 24 months without clearly informing her of
this classification.2

   We have considered Tumbleston’s arguments on appeal and find
no error in the district court’s disposition. Accordingly, we affirm the
district court’s order primarily upon its reasoning. See Tumbleston v.
A.O. Smith Corp., No. 4:99-1297-23BF (D.S.C. filed Feb. 23, 2001)
(J.A. 147). We address below only those portions of Tumbleston’s
appellate arguments that require some elaboration.

                                   B.

   We begin with Tumbleston’s contention that the "nervous or men-
tal" limitation of the Plan is ambiguous as applied to her claim. Spe-
cifically, Tumbleston asserts that it is unclear whether the "nervous
or mental" disease limitation applies solely to disabilities caused by
"nervous or mental" diseases, or whether it also applies to disabilities
caused by a combination of physical and mental health conditions.
She seeks a narrow interpretation of the limitation, which would ren-
der it inapplicable to disabilities that have both physical and mental
causes, and contends that she falls outside its parameters.

  Tumbleston’s argument, however, misses the mark. Tumbleston
ceased active employment with Smith following a conflict with her
supervisor. She was awarded LTD benefits based upon reports offered
by herself and her family physician, confirmed in substance by her
  2
   Tumbleston’s complaint does not contain a separate cause of action
for breach of fiduciary duty. Rather, this argument appears to be offered
as purported evidence of the Plan Administrator’s motives and of the
conflict of interest — factors which are to be weighed in determining
whether the Plan Administrator abused its discretion in interpreting and
applying the nervous or mental limitation to Tumbleston’s claim for LTD
benefits.
8                   TUMBLESTON v. A.O. SMITH CORP.
treating psychiatrist and an independent psychologist, that she was
disabled solely as a result of the severe depression and anxiety caused
at least in part by her interpersonal conflicts with others. For nearly
two years, the nature of Tumbleston’s disability was repeatedly con-
firmed by both Dr. Bell and Tumbleston herself to be a result of her
major depression and anxiety. We have no trouble accepting that the
common and ordinary meaning of "nervous or mental disease" would
encompass Tumbleston’s diagnoses of depression and anxiety, see
e.g., Brewer v. Lincoln Nat’l Life Ins. Co., 921 F.2d 150, 154 (8th Cir.
1990); Lynd v. Reliance Standard Life Ins. Co., 94 F.3d 979, 983-84
(5th Cir. 1996), and that it was reasonable to conclude that Tumbles-
ton was permanently disabled solely as result of her nervous or men-
tal diseases. Accordingly, we conclude that the Plan’s "nervous or
mental" limitation is not ambiguous as applied to Tumbleston’s con-
dition and that the Plan Administrator did not abuse its discretion in
concluding that the provision applied to Tumbleston’s claim for bene-
fits.3

   We are likewise unpersuaded by Tumbleston’s argument that the
Plan Administrator breached its fiduciary duty and abused its discre-
tion by not sufficiently informing her that it was classifying her dis-
ability as having been caused by a nervous or mental disease.
Specifically, Tumbleston asserts that the Plan Administrator classified
her disability as being "nervous or mental" in nature in order to thwart
and limit her benefits, that she was never made aware that the Plan
Administrator classified her disability as being caused by a nervous
or mental disease and, indeed, that "to the best of [her] knowledge
[she] was never told and [she] never understood that [she] had a men-
tal disease." J.A. 23.
    3
   Tumbleston relies heavily upon the decision in Cothran v. Reliance
Standard Life Ins. Co., No. 99-1238, 1999 WL 1092644 (4th Cir. Dec.
3, 1999), which Tumbleston argues is "strikingly similar" to her facts.
The district court disagreed, and so do we. In particular, we are satisfied
that the nervous or mental limitation in Smith’s LTD Plan is not ambigu-
ous as applied to Tumbleston’s disabling conditions. In addition, we note
that under our internal rules, unpublished opinions are not precedential.
Indeed, "[i]n the absence of unusual circumstances," we are bound as a
court "not [to] cite an unpublished disposition in any of [our] published
opinions or unpublished dispositions." Local Rule 36(c). No such
unusual circumstances are present here.
                   TUMBLESTON v. A.O. SMITH CORP.                       9
   Having reviewed the administrative record, we are unpersuaded.
Tumbleston’s initial claim for disability, accompanied by medical
support from Dr. Bell, refers only to an alleged disability arising from
her depression and anxiety and, in particular, her inability to success-
fully engage in the interpersonal relationships required in her position.
There is at best a perfunctory reference by Dr. Bell to diagnoses of
physical conditions in the section of the claim form requesting such
information, but there is no reference to a physical disability, existing
either alone or in combination with Tumbleston’s disabling mental
conditions. Based upon the information submitted by Tumbleston, the
Plan Administrator notified Tumbleston that her claim for LTD bene-
fits was being approved. The Plan clearly states that disability claims
for nervous and mental diseases are limited to two years, and Tum-
bleston was made aware at the time her claim was accepted that her
benefits were scheduled to terminate after 24 months. At no time
thereafter did Tumbleston seek or obtain benefits in whole or in part
for a physical disability resulting from her lumbosacral disc disease
or any other physical malady. In every update requested and received
by the Plan Administrator thereafter, Tumbleston and Dr. Bell both
held firm in their opinion that Tumbleston’s disability was related to
her depression and anxiety, and Dr. Bell held firm in his opinion that
Tumbleston had no physical limitations or restrictions even after she
was released from the care of her orthopaedist.

   In sum, Tumbleston’s argument fails on two levels. First, the
record is utterly devoid of any indication that the Plan Administrator
tried to improperly limit her benefits by classifying Tumbleston’s
claim as one for disability resulting from a nervous or mental condi-
tion, as opposed to a physical disability, or tried to hide that classifi-
cation from Tumbleston. On the contrary, Tumbleston and her family
physician classified her disability as resulting from major depression
and anxiety from the outset, and we see no indication that her claim
should have been interpreted as one arising from anything other than
her nervous or mental diagnoses. Second, we find no abuse of discre-
tion in the Plan Administrator’s determination, rendered at the conclu-
sion of the 24-month period and based upon the reports of Drs. Bell
and Hassler, that Tumbleston had failed to demonstrate that she was
totally and permanently disabled as a result of her physical maladies
alone. See Booth, 201 F.3d at 345 ("[I]t is not an abuse of discretion
10                 TUMBLESTON v. A.O. SMITH CORP.
for a plan fiduciary to deny benefits where conflicting medical reports
were presented.") (internal quotation marks and ellipsis omitted)).

   To conclude, we agree with the district court’s determination that
the Plan Administrator did not abuse its discretion by terminating
Tumbleston’s LTD benefits under the provisions of the Plan which
limit such benefits to 24 months in circumstances such as these. The
Plan provides that LTD benefits for a "nervous or mental" disease are
limited to a 24-month period. Tumbleston was found to be totally dis-
abled from "major depression and anxiety" arising from "job stress"
and an inability to successfully engage in interpersonal relationships
necessary to perform her employment duties, conditions which fall
easily within the ordinary meaning of a "nervous or mental disease,"
and Tumbleston drew LTD benefits for the entire 24-month period.
After the 24 months had passed, the Plan Administrator reasonably
concluded that Tumbleston had not demonstrated that she was physi-
cally disabled from "performing any and every duty of every occupa-
tion for which [she was] qualified," J.A. 37, and denied her claim for
continued benefits. Applying the modified abuse of discretion stan-
dard to the record before us, we are satisfied that the Plan Administra-
tor’s denial of LTD benefits was not an abuse of discretion.

                                  III.

   For the foregoing reasons, the judgment of the district court is
affirmed.

                                                           AFFIRMED