Court Opinion

ID: 72516
Source: CourtListenerOpinion
Date Created: 2010-04-26 07:33:06+00
Date Added: 2024-06-11T17:21:11.396247
License: Public Domain

United States Court of Appeals,

                                         Eleventh Circuit.

                                           No. 96-8299.

                          Jacqueline PARAMORE, Plaintiff-Appellant,

                                                 v.

                             DELTA AIR LINES, INC., Defendant,

           Delta Family-Care Disability and Survivorship Plan, Defendant-Appellee.

                                           Dec. 2, 1997.

Appeal from the United States District Court for the Northern District of Georgia. (No. 1:94-CV-
1539-JEC), Julie E. Carnes, Judge.

Before BIRCH, Circuit Judge, and HILL and FARRIS*, Senior Circuit Judges.

       BIRCH, Circuit Judge:

       Jacqueline Paramore, a former flight attendant for Delta Air Lines, Inc. ("Delta"), filed this

action under the Employee Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. §

1132(1)(b) and (e), in which she sought an award of long-term disability benefits pursuant to the

Delta Family Care Disability and Survivorship Plan ("the Plan"). Paramore contended that the

Administrative Committee, acting in its capacity as administrator and fiduciary, violated the terms

of the Plan and the governing federal law embodied in ERISA by denying the requested benefits.

The district court determined that the Administrative Committee's decision to deny long-term

disability benefits was neither arbitrary nor capricious and granted summary judgment in favor of

Delta. For the reasons that follow, we conclude that the "arbitrary and capricious" standard of

review is the appropriate standard by which to evaluate a plan administrator's factual findings in

   *
    Honorable Jerome Farris, Senior U.S. Circuit Judge for the Ninth Circuit, sitting by
designation.
cases involving the denial of benefits under ERISA. We further conclude that the district court

properly applied this standard of review to the facts of this case in upholding the Administrative

Committee's decision. We therefore affirm.

                                        I. BACKGROUND

       For the limited purpose of resolving the issues presented in this appeal, the following facts

are found to be undisputed: Jacqueline Paramore worked for approximately eleven years as a flight

attendant for Delta. In 1991, while performing her job during the course of a flight, Paramore was

involved in an incident that resulted in injury to her neck and shoulder. After an initial period of

recuperation at home, Paramore returned to work sporadically for approximately one year.

Paramore subsequently sought and received short-term disability benefits pursuant to the Plan; these

benefits were awarded based on certifications from two treating physicians, Dr. Kenneth Lazarus

and Dr. Patricia Tewes, who affirmed that Paramore had experienced a cervical strain. Paramore

next requested long-term disability benefits and sought certification for such benefits from Dr.

Tewes. Dr. Tewes, however, indicated that Paramore could perform some light clerical work.

Based on Dr. Tewes' observations, the request for long-term disability benefits was denied.

       In accordance with the Plan's procedural framework, Paramore appealed this decision to the

Administrative Subcommittee ("the Subcommittee").            Paramore specifically requested the

Subcommittee to afford greater weight to the opinion of Dr. Lazarus, her treating physician, rather

than Dr. Tewes, to whom she had been referred. At the Subcommittee's request, Paramore also was

examined by Dr. Nicol, who withheld his opinion concerning Paramore's long-term prognosis

pending further tests; Dr. Nicol did note his initial impressions of Paramore's condition as follows:

       Difficult to know exactly what's going on with this lady. She has symptoms of cervical
       strain and sprain, but no focal organic neurological deficits and, in fact, she has some
       "deficits" that would lead me to believe that there is a very large functional component to
       her disorder at the present time.
Exh. 11 at 3. Dr. Lazarus forwarded to the Subcommittee a letter stating his belief that Paramore

would be "unable to work in any capacity on even a part-time basis" and that her condition likely

would "continue indefinitely despite maximum treatment." Exh. 12. Paramore also received a

psychological examination by Dr. Wright, who rendered the following findings:

       Psychological testing results with this patient suggest considerable stress, but very little
       subjective psychological discomfort. Most of her stress and psychological pressures are
       being diverted into somatic symptoms, and she is quite preoccupied with her somatic
       processes while attempting to deny and repress any subjective psychological discomfort.
       I could not rule out the possibility of a conversion disorder. She has developed most of the
       classic signs of "chronic pain syndrome." Test indications regarding cognitive and
       intellectual abilities show the patient to be functioning within the bright-normal range with
       no problems. There were indications of organic brain dysfunction on testing.

Exh. 17. Pursuant to these observations, Dr. Wright recommended that Paramore would benefit

from psychotherapy in addition to any other treatment she was receiving for chronic pain. Dr. Nicol

subsequently wrote to the Subcommittee after reviewing both Dr. Wright's report and the results of

the tests he previously had ordered. With respect to psychological aspects of Paramore's condition,

Dr. Nicol stated: "I don't think that Ms. Paramore is suffering from any major physical disability,

but psychosomatic aspects of her illness have supervened and are causing the majority of her

problems at the present time." Exh. 20. In a separate letter, Dr. Nicol stated, in pertinent part:

                At the present time it would be my professional opinion that she is disabled, but I
       can't say as a result of demonstrable injury, because there was no demonstrable injury, at
       least from a purely physical standpoint. I think there probably is demonstrable injury from
       a psychological standpoint.

              I hope that this answers your questions satisfactorily. I hope that you will be able to
       get Ms. Paramore some ongoing psychological help so that she will [be] able to get back to
       work full time in the not too distant future as a flight attendant once these other issues have
       been addressed.

Exh. 21. Dr. Nicol further observed that although Paramore, in his view, was not capable of

performing her customary job on a full time basis without limitations, she nonetheless was

physically capable of performing sedentary work. See id.
       On the same date on which Dr. Nicol filed his report with the Subcommittee, Dr. Tewes

notified the Subcommittee that Paramore was no longer under her care and that Dr. Lazarus should

make any further decisions regarding her capacity to work. Dr. Lazarus subsequently wrote a letter

to a Subcommittee representative concerning Paramore's case and stated:

       With regard to Ms. Paramore's disability status, I believe that it would be appropriate for Ms.
       Paramore to return to some sort of sedentary work activity. I think this would be helpful to
       her, both with regard to her self-esteem and her recovery from her injury.... [I]n an
       appropriately supportive environment, I believe that Mrs. Paramore could and should return
       to some form of sedentary work.

Exh. 27.

       After reviewing the doctors' submissions, the Subcommittee affirmed the denial of benefits

and determined that Paramore's entitlement to disability benefits terminated as of November 14,

1992. Paramore appealed this decision to the Administrative Committee. Shortly thereafter, Dr.

Lazarus wrote to the Administrative Committee a letter stating, in relevant part:

       I have been the treating physician for Mrs. Paramore and have been primarily responsible
       for her care. Decisions on her benefit status were apparently made with reference to forms
       filled out from other treating physicians, despite the fact that I have been the primary treating
       physician in this case. I am not certain on what basis the other physicians made their
       determination. It is my opinion that Mrs. Paramore was unable to return to any sort of
       gainful employment, even on a part-time basis prior to February 22, 1993. From that time
       forward, however, I do believe she has been capable of part-time sedentary work.

Exh. 33. The Administrative Committee determined, "[b]ased on information obtained from Dr.

Tewes and from independent examinations performed by Dr. Nicol and Dr. Wright, Ms. Paramore

could perform some type of work; ..." Exh. 46 at 3. Consistent with this determination, the

Administrative Committee decided that Paramore's disability benefits were correctly denied as of

November 14, 1992.

                                         II. DISCUSSION

       The district court's grant of summary judgment is subject to plenary review. See Canadyne-
Georgia Corp. v. Continental Ins. Co., 999 F.2d 1547, 1554 (11th Cir.1993). We therefore apply

the same legal standards as those controlling the district court. Id. The standard that properly should

have governed the district court's evaluation of the Administrative Committee's findings, however,

is disputed by the parties. Paramore contends that, although the Administrative Committee's

interpretation of the Plan's terms are subject to an arbitrary and capricious standard of review, the

court should have reviewed the Administrative Committee's factual determinations de novo. Delta

responds that the court appropriately examined the propriety of the Administrative Committee's

factual and interpretive conclusions solely to ascertain whether the denial of benefits in this instance

constituted either an abuse of discretion or an arbitrary and capricious resolution of Paramore's

claim.

         ERISA does not provide a standard to review decisions of a plan administrator. In Firestone

Tire and Rubber Co. v. Bruch, 489 U.S. 101, 109 S.Ct. 948, 103 L.Ed.2d 80 (1989), the Supreme

Court looked to the principles underlying trust law as largely defining the role and responsibilities

of a plan fiduciary or administrator;1 more specifically, the Court reasoned that, "where discretion

is conferred upon the trustee with respect to the exercise of a power, its exercise is not subject to

control by the court except to prevent an abuse by the trustee of his discretion." Id. at 111, 109 S.Ct.

at 954 (internal citation and quotation marks omitted). Applying these principles, the Court

established a range of standards that pertain to benefits determinations under ERISA:

         a denial of benefits challenged under § 1132(a)(1)(B) is to be reviewed under a de novo

   1
    Our discussion of the standard of review refers primarily to the proper level of deference
afforded a plan administrator; our conclusions in this regard obtain with equal force, however,
to plan fiduciaries. We previously have noted that the Supreme Court's treatment in Firestone of
the possible standards of review that might apply to determinations rendered under
ERISA-governed plans "applies equally to the decisions of fiduciaries and the plan
administrator." Brown v. Blue Cross & Blue Shield of Ala., 898 F.2d 1556, 1560 (11th
Cir.1990).
       standard unless the benefit plan gives the administrator or fiduciary discretionary authority
       to determine eligibility for benefits or to construe the terms of the plan.... Of course, if a
       benefit plan gives discretion to an administrator or fiduciary who is operating under a
       conflict of interest, that conflict must be weighed as a facto[r] in determining whether there
       is an abuse of discretion.

Firestone, 489 U.S. at 115, 109 S.Ct. at 956-57 (citations and quotation marks omitted).

       Consistent with the Court's directive in Firestone, we have adopted three standards of review

for plan interpretations: (1) de novo, applicable where the plan administrator is not afforded

discretion, (2) arbitrary and capricious when the plan grants the administrator discretion, and (3)

heightened arbitrary and capricious where there is a conflict of interest. Buckley v. Metropolitan

Life, 115 F.3d 936, 939 (11th Cir.), rehearing denied, --- F.3d ---- (11th Cir.1997) (citing Marecek

v. BellSouth Services, Inc., 49 F.3d 702, 705 (11th Cir.1995)).

       Paramore and Delta agree that the plan at issue in this case affords the Administrative

Committee discretion to construe the Plan's terms. For instance, the Plan expressly mandates that

eligibility for disability benefits "shall be determined by the Administrative Committee or its

designees," R1-1, Exh. A at 23, and confers on the Administrative Committee the power

       [t]o interpret the Plan, and decide all questions of eligibility of any Eligible Family Member
       to participate in the Plan or to receive benefits under it, its interpretation thereof in good faith
       to be final and conclusive; [t]o determine the amount, manner, and time of payment of
       benefits which shall be payable to any Employee or Dependent, ... [and] to decide all
       questions concerning the Plan; ...

Id. at 48-49.

       Neither party contends that the Administrative Committee's interpretation of the plan's terms

is at issue here; rather, the parties ask us to decide what constitutes the proper standard of review

with respect to the Administrative Committee's factual determinations as incorporated in its ultimate

conclusion that Paramore was not entitled to long-term disability benefits.

         Our court has not yet conclusively stated the standard applicable to an ERISA plan
administrator's factual findings. Significantly, we consistently have applied the arbitrary and

capricious standard to eligibility determinations—without necessarily distinguishing the factual from

the legal, interpretive bases of those decisions—in all instances in which a plan vested the

administrator or fiduciary with discretion to interpret the plan's terms or to resolve questions of

eligibility. See, e.g., Hunt v. Hawthorne Assoc., Inc., 119 F.3d 888, 912 (11th Cir.1997) ("The

arbitrary and capricious standard is the appropriate standard of review in this case because the Plan

contains express language conferring discretionary authority upon the administrator to construe its

terms."); Shannon v. Jack Eckerd Corp., 113 F.3d 208, 210 (11th Cir.1997) ("Denial of benefits

under an ERISA plan that gives the plan administrator discretionary authority to determine

eligibility for benefits or to construe the terms of the plan is reviewed by the district court for abuse

of that discretion."); Jett v. Blue Cross and Blue Shield of Alabama, 890 F.2d 1137, 1139 (11th

Cir.1989) ("The plan in this case does give the administrator of the plan discretionary authority to

determine eligibility for benefits and to construe the plan's terms.... Accordingly, the arbitrary and

capricious standard of review applies here.") (internal citations, markings, and quotation marks

omitted).2 Indeed, in only one case have we differentiated explicitly between an administrator's plan

interpretations and fact-based findings; our resolution of that case, however, rendered a decision

regarding the standard of review with respect to factual determinations to be unnecessary. See

Marecek, 49 F.3d at 707 ("We decline to decide which standard of review should be applied for

   2
    It is worth noting that our decisions involving the review of administrative decisions under
ERISA-governed plans do not distinguish between the terms "arbitrary and capricious" and
"abuse of discretion." See Jett, 890 F.2d at 1139 ("When conducting a review of an ERISA
benefits denial under an arbitrary and capricious standard (sometimes used interchangeably with
an abuse of discretion standard), the function of the court is to determine whether there was a
reasonable basis for the decision...."). Although we hereinafter refer to the proper standard of
review regarding the Administrative Committee's factual findings by the term "arbitrary and
capricious," we recognize that, for purposes of evaluating a plan determination, there is no
substantive distinction between the terms "arbitrary and capricious" and "abuse of discretion."
factual findings by a plan administrator as BellSouth's decision does not survive the most deferential

standard of review.").

       Other circuits that have addressed the question of the level of deference to which factual

findings of an ERISA plan administrator are due uniformly have held that, where the plan confers

discretionary authority to determine eligibility and to construe the plan's terms, the arbitrary and

capricious standard of review applies. See, e.g., Rowan v. Unum Life Ins. Co. of America, 119 F.3d

433, 436 (6th Cir.1997) ("The de novo standard of review applies only when the plan does not

explicitly vest fact-finding discretion in the plan administrator."); Mitchell v. Eastman Kodak Co.,

113 F.3d 433, 438-39 (3rd Cir.1997) (where broad discretion afforded plan administrator was

undisputed, court applied Supreme Court's analysis in Firestone and held that "the appropriate

standard of review ... depends on whether the terms of this Plan grant the Administrator discretion

to act as a finder of facts.... [W]e conclude that the Plan Administrator's decision to deny ...

[long-term disability] benefits should be reviewed under an arbitrary and capricious standard.")

(citations and quotation marks omitted).3 Cf. Pierre v. Connecticut Gen. Life Ins. Co., 932 F.2d

1552, 1562 (5th Cir.1991) (holding that, regardless of discretionary authority of plan administrator

to interpret terms of plan, "for factual determinations under ERISA plans, the abuse of discretion

   3
    Interestingly, the Sixth Circuit has voted to rehear en banc a case involving the denial of
benefits under an ERISA plan. In its order granting en banc rehearing, the court expressly noted
that it would consider and resolve the following issue:

               Whether the decision of the U.S. Supreme Court in Firestone ..., setting the
               standards for the review of an administrator's discretion in making ERISA plan
               decisions, encompasses decisions both of fact and of law, or whether the Supreme
               Court's decision should be limited only to setting standards with regard to an
               administrator's decisions of legal interpretation, while allowing unfettered
               discretion in all cases with respect to factual decisions.

       Perez v. Aetna Life Ins. Co., 106 F.3d 146 (6th Cir.1997) (en banc ).
standard of review is the appropriate standard; that is, federal courts owe due deference to an

administrator's factual conclusions that reflect a reasonable and impartial judgment.").

       As noted, an examination of our own decisional law reveals that we consistently have upheld

application of the abuse of discretion standard of review to determinations involving both plan

interpretations and factual findings under ERISA. The consistency of our decisions in this arena

strongly suggests that our court has interpreted the Supreme Court's analytical framework in

Firestone, particularly in regard to the application of trust law principles to the level of deference

due an administrator or fiduciary, to mean that, where an ERISA plan grants discretion to a plan

administrator to interpret the express terms of the plan or to determine eligibility for benefits, we

review both the administrator's construction of the plan and concomitant factual findings with

respect to each case under an arbitrary and capricious standard of review. See Buckley, 115 F.3d at

939 ("Given that the ... Plan at issue here vests the administrator with discretion, the district court

properly employed the arbitrary and capricious guidelines in judging the administrator's factual

conclusions."). We are cognizant of the fact that other circuits to have decided this issue similarly

have found the arbitrary and capricious standard to obtain when the plan unambiguously affords

discretionary authority on the administrator. We further find persuasive the Third Circuit's

observation in Mitchell that " "application' of the Plan, like judicial "application' of the law, must

encompass the resolution of factual disputes as well as the interpretation of the governing provisions

of the Plan." Mitchell, 113 F.3d at 439.

       Thus, where the plan affords the administrator discretion, the administrator's fact-based

determinations will not be disturbed if reasonable based on the information known to the

administrator at the time the decision was rendered. See Hunt, 119 F.3d at 912 ("Under the arbitrary

and capricious standard of review, the court seeks "to determine whether there was a reasonable
basis for the [administrator's] decision, based upon the facts as known to the administrator at the

time the decision was made.' ") (quoting Jett, 890 F.2d at 1139).

        Applying this standard of review to the facts presented in this case, we conclude that the

Administrative Committee's decision to deny Paramore's request for long-term disability benefits

was reasonable based on the facts known to the Administrative Committee at all times relevant to

this action. Under the Plan at issue, an employee may qualify for long-term disability benefits if the

following conditions are met:

       The Employee shall be eligible for Long Term Disability provided he is disabled at that time
       as a result of demonstrable injury or disease (including mental or nervous disorders) which
       will continuously and totally prevent him from engaging in any occupation whatsoever for
       compensation or profit, including part-time work, but not including work performed in
       connection with a rehabilitation program approved by the Administrative Committee.... The
       Employee shall be eligible for Long Term Disability benefits so long as he remains disabled
       in accordance with this subsection and Section 4.01.

R1-1, Exh. A at 21.

       As described earlier, the Administrative Committee initially received conflicted information

from Dr. Tewes, indicating that Paramore was capable of sedentary work, and Dr. Lazarus, stating

that Paramore's condition was likely to require long-term disability due to her pain disorder. In an

attempt to gather further information, the Administrative Committee sought evaluations from several

other physicians, including a neurologist, Dr. Nicol, and a psychologist, Dr. Wright. Although these

doctors' medical evaluations both contained sporadic, internally inconsistent statements concerning

both   the   degree   to   which    Paramore     suffered   from    a   physiological—rather     than

stress-related—condition and the degree to which she was capable of returning to work on some

basis,4 the Administrative Committee's function was to evaluate the various reports in tandem and

   4
    For instance, Dr. Nicol's report stated both that "[a]t the present time it would be my
professional opinion that [Paramore] is disabled" and that "I hope you will be able to get Ms
Paramore some ongoing psychological help so that she will [be] able to get back to work full
render a determination as to Paramore's ability to engage "in any occupation whatsoever for

compensation or profit, including part-time work." See R1-1, Exh. A at 21. We cannot say that the

Administrative Committee's appraisal of the available medical information was unreasonable or

inconsistent with the data with which the Committee had been provided. Stated differently, we

conclude that there existed a reasonable basis to support the Administrative Committee's factual

determination that, based on the administrative record examined in its entirety, Paramore was not

entitled to long-term disability benefits.5 The Administrative Committee's decision to deny benefits

in this case thus was neither arbitrary nor capricious.

                                        III. CONCLUSION

       Paramore asks that we reverse the district court's order granting summary judgment in favor

of Delta. Paramore contends that the district court applied an incorrect standard of review in

evaluating the Administrative Committee's factual determinations and improperly found these

determinations to be supported by the record. We conclude that (1) where an ERISA-governed plan

confers discretion on an administrator to interpret plan terms and decide eligibility for benefits, we

time in the not too distant future ... ". Exh. 21. Dr. Wright similarly noted that "[p]sychological
testing results with this patient suggest considerable stress, but very little subjective
psychological discomfort," while at the same time observed, "I could not rule out the possibility
of a conversion disorder .... [and] there were indications of organic brain dysfunction on testing."
Exh. 17.
   5
    We find unpersuasive Paramore's assertion that the district court should have given greater
weight to the Social Security Administration's determination that Paramore was totally disabled.
Although a court may consider this information in reviewing a plan administrator's decision
regarding eligibility for benefits under an ERISA-governed plan, see Kirwan v. Marriott Corp.,
10 F.3d 784, 790 n. 32 (11th Cir.1994), an award of benefits by the Social Security
Administration is not dispositive of the issue before us, particularly given the measure of
deference that we afford a plan administrator's decision. Moreover, as noted by Delta, the
decision of the Social Security Administration to award benefits was rendered after the
Administrative Committee denied Paramore benefits; that determination consequently was not
available to the Administrative Committee during the relevant time frame.
review the administrator's fact-based conclusions regarding eligibility to determine whether these

conclusions are arbitrary or capricious and (2) although the medical reports submitted to the

Administrative Committee in this case were not a model of clarity, the Administrative Committee's

overall evaluation of these reports was rational. Its factual determinations, therefore, were neither

arbitrary nor capricious. The district court's order granting summary judgment in favor of Delta is

AFFIRMED.