Court Opinion

ID: 8410450
Source: CourtListenerOpinion
Date Created: 2022-11-02 18:03:53.621292+00
Date Added: 2024-06-11T16:47:46.485027
License: Public Domain

HOWARD, Circuit Judge,
dissenting.
For essentially the reasons stated by Judge Lipez, I agree that we ought to reexamine our approach to reviewing an administrator’s denial of benefits under a plan governed by the Employee Retirement Income Security Act, 29 U.S.C. § 1001 et seq. (“ERISA”), when those benefits stand to be paid out of the administrator’s own assets. I think, however, that, even under the standard of review now in place, we should reverse the decision by Liberty Life Assurance Company (“Liberty”) to deny long-term disability benefits to Diane Denmark. In my view, the denial “was ‘unreasonable in light of the information available’ to Liberty at the time of its decision.” Cook v. Liberty Life Assurance Co., 320 F.3d 11, 18 (1st Cir.2003) (quoting Pari-Fasano v. ITT Hartford Life & Acc. Ins. Co., 230 F.3d 415, 419 (1st Cir.2000)). As my view does not depend on whether a higher level of scrutiny is applied to the report of the outside physician who reviewed Denmark’s file for Liberty, Dr. John Bomalaski, see infra note 4, I do not reach whether the district court permissibly applied a higher level of scrutiny as a sanction for Liberty’s refusal to provide discovery on whether Dr. Bo-malaski’s employer routinely approved Liberty’s benefit decisions.
As Judge Lipez’s lead opinion observes, Liberty does not dispute that Denmark has fibromyalgia, but only that the condition rendered her disabled under the terms of the plan when she stopped working in October 2001. Around that time, Denmark’s treating physician rated her as having a “severe limitation of functional capacity” and being “incapable of physical activity,” while her rheumatologist called her “disabled by exhaustion and myalgia which makes it difficult for her to stay at work for any appreciable amount of time.” At her employer’s insistence, Denmark then obtained a third opinion, in the form of an independent medical examination conducted by Dr. Peter Schur (“the IME”). Schur found that Denmark was “clearly disabled, not only from work, but from being able to take care of her household.” While he expressed hope that changes to Denmark’s drug regime and increased exercise “will improve matters so that she can get her stamina back and get back to work,” he concluded that “until that is accomplished, which may take months, she is clearly disabled.”
In spite of this consensus among the doctors who had examined Denmark, Liberty concluded that she was not, in fact, disabled because “there was no significant change in [her] condition” on the date she stopped working. This'rationale, however, bears no relationship to any requirement for long-term disability benefits imposed by the plan itself. Instead, it amounts to an argument that, because Denmark has suffered from fibromyalgia since at least 1996 but continued working nonetheless, she cannot rely on fibromyalgia as a reason for not working in 2001 unless she can show that her condition has worsened. The argument does not survive even minimal scrutiny.
As a number of other courts have recognized, there is no “logical incompatibility between working full time and being disabled from working full time. A desperate person might force himself to work despite an illness that everyone agreed was totally *42disabling. Yet even a desperate person might not be able to maintain the necessary level of effort indefinitely.” Hawkins v. First Union Long-Term Disability Plan, 326 F.3d 914, 918 (7th Cir.2003) (citations omitted); accord Seitz v. Metro. Life Ins. Co., 433 F.3d 647, 651 (8th Cir.2006); Lasser v. Reliance Std. Life Ins. Co., 344 F.3d 381, 392 (3d Cir.2003); Marecek v. BellSouth Telecomms., Inc., 49 F.3d 702, 706 (11th Cir.1995). In addition to its appeal as a matter of human experience, this reasoning also furthers an important policy objective, namely that “[a] disabled person should not be punished for heroic efforts to work by being held to have forfeited his entitlement to disability benefits should he stop working.” Hawkins, 326 F.3d at 918.
Rather than engaging this line of authority here, the lead opinion sidesteps the issue, concluding that, because Denmark herself asserted that her condition had worsened at the time she stopped working, Liberty was entitled to rely on her failure to support that assertion in denying her claim. Under the plan, however, Denmark’s entitlement to long-term disability payments does not depend on whether her fibromyalgia had intensified around the time she stopped working. It depends on whether she was then “unable to perform the Material and Substantial Duties of [her] Own Occupation.” Denmark’s treating physicians, as well the independent doctor hired by her employer, all concluded that she was. Liberty could not have reasonably reached the opposite conclusion based on Denmark’s failure to prove a fact that is inessential, and logically unconnected, to her contractual right to long-term disability benefits.
The lead opinion also downplays the importance of this factor to Liberty’s ultimate decision, focusing instead on the asserted absence of objective evidence of Denmark’s inability to work. But the lack of a change in Denmark’s condition at the time she stopped working was the sole explanation the insurer gave for denying both short-term and long-term disability benefits.19 In any event, Denmark presented objective evidence of her inability to work in the form of the IME, where Dr. Schur observed “tender points all over,” a decreased range of motion in the shoulders and hips, and “back discomfort” during an extensive physical examination.
The lead opinion treats this as “some objective evidence of [Denmark’s] physical restrictions,” but concludes that “it does not demonstrate objectively her inability to work because the evaluation does not specifically relate those restrictions either to the physical requirements of the job or to her overall stamina ” (emphasis added). As this passage recognizes, a condition that saps a claimant of her energy would make her unable to perform the duties of nearly any occupation. See, e.g., Rose v. Shalala, 34 F.3d 13, 19 (1st Cir.1994). Dr. Sehur’s report characterizes Denmark’s fi-bromyalgia in precisely that way: he endorses a course of treatment “to try and cut down on pain and help her sleep ... so that she isn’t so tired and, hopefully, can get some of her stamina back,” but opines that, “until that is accomplished, which may take months, she is clearly disabled not only from work, but from being able to take care of her household.” The IME therefore expressly relates the objective manifestations of Denmark’s condition— *43the pain Dr. Schur observed in various points throughout her body — to her inability to work.20
In light of this diagnosis, our decision in Boardman v. Prudential Ins. Co. of Am., 337 F.3d 9 (1st Cir.2003), does not support the outcome reached by the majority. In Boardman, we upheld the insurer’s denial of long-term disability benefits to the claimant based on two factors: “(1) the absence of adequate evidence in [her] medical records indicating that [her] condition imposed limitation on her ability to perform the material and substantial duties of her own occupation ... and (2) the evidence to the contrary provided in the [IME] reports.... ” Id. at 17. Here, in stark contrast, the IME unequivocally concludes, based on objective observations, that Denmark is disabled, and that conclusion squares with the opinions of her treating physicians.
Liberty’s contrary finding, then, much more closely resembles the decision we overturned in Cook. There, as here, the physician who had examined the claimant opined that she was disabled from fatigue,21 but Liberty relied on purported defects in the opinion — identified by an in-house analyst who had not examined the claimant — to conclude otherwise. 320 F.3d at 20-23. In criticizing this approach, we suggested that an insurer who doubts a treating doctor’s diagnosis ordinarily should seek a second opinion, either in the form of peer review or an IME. Id. at 23. Here, of course, the IME confirmed the diagnoses of Denmark’s treating physicians. So Liberty reached the contrary conclusion based on purported defects in the IME identified by an in-house analyst who had not examined Denmark — using, in essence, the same approach we took such a dim view of in Cook.22
Furthermore, Liberty’s efforts to discount the IME do not hold up, even under our deferential standard of review. In seeking to diminish Dr. Schur’s conclusion that Denmark is disabled, Liberty’s in-house nurse argued that “since an IME provides an examination on a specific date in time, its scope is limited on that inferences to the status of conditions 6 months previous cannot be accurately assessed.” Under this logic, however, a medical examination — which, by its nature, always occurs “on a specific date in time” — can never “accurately assess” the patient’s condition prior to having walked into the examination room. Either that premise is demonstrably false, or a patient is subjected to a pointless exercise every time she undergoes an IME. Cf. Cook, 320 F.3d at 23. Liberty’s reasons for spurning Dr. Schur’s opinion here, then, are no more supportable than its reasons for spurning *44the treating doctor’s opinion in Cook.23
I recognize, as we did in Cook, the possibility of “cases where the opinion of the claimant’s treating physician can be rejected without reliance on any contradictory medical evidence developed by the plan administrator.” 320 F.3d at 23. But rejecting the opinions of the claimant’s treating physicians, and the corroborating view of an independent medical examiner, ought to require a considerably stronger justification than the one relied on here.24 Accordingly, I would overturn Liberty’s denial of long-term disability benefits to Denmark, even under our present standard of review.

. Liberty's letter reaffirming its denial of long-term disability benefits does cite the absence of “support of a severity of impairment that would preclude Ms. Denmark from performing her own occupational job duties,” but, as the lead opinion observes, a contemporaneous explanation in Liberty’s case log again notes the "limited evidence to support a need to cease working.”

. The lead opinion devalues Dr. Schur’s report based on its view that it does not speak to the current level of Denmark's fatigue or its effect on her ability to do her job. But, again, the report states that Denmark’s fatigue has left her unable to work or to care for her household. I do not know how the report could have described the level of fatigue any more clearly, or pertinently.

. The claimant in Cook suffered from asthma, chronic fatigue syndrome, and fibromyal-gia. 320 F.3d at 15.

.Liberty also subjected the IME to peer review by Dr. Bomalaski, who concluded that ''[t]he clinical medical evidence does not clearly support severe impairment because as noted, the diagnosis of fibromyalgia remains in question....” As Judge Lipez notes, this conclusion is irrelevant because Liberty has never contested the diagnosis itself. The closest Dr. Bomalaski's report comes to supporting Liberty's position that Denmark is not disabled is its observation that "[l]imitations of ability to function are difficult to assess...." The report therefore does little to bolster Liberty's decision.

. The lead opinion finds Liberty’s criticism of the IME "not unreasonable given that Dr. Schur himself had limited his evaluation to 'the time being.’ ” While Dr. Schur’s report indeed contains the phrase "at least for the time being,” it is clearly not intended to limit Dr. Schur's opinion retrospectively, but prospectively: in both the paragraph immediately preceding the phrase and the sentence immediately following it, Dr. Schur suggests interventions for Denmark that "hopefully will improve matters, so that she can get her stamina back and get back to work.” Accordingly, I do not see how the phrase "for the time being” can reasonably be read to support Liberty’s exceedingly narrow view of Dr. Schur's opinion.

. While Liberty also relied on its surveillance of Denmark to support its decision, I agree with the district court that this evidence does not speak to whether she can consistently work full days as her job requires. Denmark was observed leaving her house on only two of the four days she was being watched and, even then, was out for only a few hours.