Court Opinion

ID: 4655991
Source: CourtListenerOpinion
Date Created: 2021-01-29 20:00:40.57053+00
Date Added: 2024-06-11T08:00:33.236315
License: Public Domain

USCA11 Case: 19-14643   Date Filed: 01/29/2021   Page: 1 of 11

                                                        [DO NOT PUBLISH]

            IN THE UNITED STATES COURT OF APPEALS

                    FOR THE ELEVENTH CIRCUIT
                      ________________________

                            No. 19-14643
                      ________________________

               D.C. Docket No. 8:18-cv-02281-CEH-TGW

AMY WRIGHT,

                                             Plaintiff - Appellant,

                                  versus

RELIANCE STANDARD LIFE
INSURANCE COMPANY,
a Foreign Corporation,

                                             Defendant - Appellee.

                      ________________________

               Appeal from the United States District Court
                   for the Middle District of Florida
                     ________________________

                           (January 29, 2021)

Before MARTIN, NEWSOM, and BRANCH, Circuit Judges.

PER CURIAM:
         USCA11 Case: 19-14643       Date Filed: 01/29/2021    Page: 2 of 11

      In this case, we are asked to review an ERISA plan administrator’s denial of

benefits. After Amy Wright stopped working in 2017, she made two claims with

her insurer for benefits that would accrue to her only if she could prove that she

was disabled. Wright provided a wide range of medical evidence with mixed

indicators of disability. Treating physicians disagreed as to whether she was

disabled. Ultimately, her plan administrator denied both claims because it

determined that her evidence was insufficient to establish disability. Because we

review only whether the denial was arbitrary and capricious, we will affirm.

                                          I

       Amy Wright worked as the vice president of health information services at

Integrity Health Care. Wright’s job entailed light physical exertion. Integrity

provided Wright with two policies through Reliance Standard Life Insurance:

(1) long-term disability insurance, and (2) life insurance. Both plans were at all

times subject to the requirements of the Employment Retirement Income Security

Act of 1974.

      The Reliance long-term disability policy guaranteed payments to Wright if,

due to injury or sickness, she couldn’t “perform the substantial and material duties

of [her job]” for 90 consecutive days. The Reliance life-insurance policy waived

Wright’s premium obligations for a year if she “bec[ame] totally disabled” for at

least six months. The life-insurance policy defined “total disability” as the

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“complete inability to engage in any type of work for wage or profit for which [she

was] suited by education, training, or experience.” Importantly, both policies gave

Reliance the “discretionary authority to interpret” their terms and “to determine

eligibility for benefits.”

       As she was still working during the spring and early summer of 2017,

Wright sought medical care several times and missed some work due to recurring

physical and mental health problems.

       On August 7, 2017, Wright stopped working. She brought claims for

benefits under the long-term disability policy and for a waiver of premiums under

the life-insurance policy. After she stopped working, Wright sought medical care

multiple times per month for four months. The medical reports arising from those

months presented a mixed picture of health. On the one hand, Wright complained

of pain and fatigue and was diagnosed with a constellation of health problems,

including fibromyalgia, dysautonomia, and Postural Orthostatic Tachycardia

syndrome. On the other hand, repeated physical exams found her to exhibit normal

strength, range of motion, and neurological and psychological condition.1

1
 The details of Wright’s medical conditions are known to the parties and were thoroughly
described in the district court’s opinion.
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      On December 21, 2017, Reliance denied Wright’s long-term disability

claim. It explained that the medical evidence was somewhat inconsistent with her

proffered diagnoses and in any event didn’t establish disability.

      Wright continued to seek medical care in the following months as her

waiver-of-premium claim under her life-insurance policy remained pending. The

medical visits continued to present a mixed picture. Her strength, appearance, and

neurological exam results were normal, and she was exercising twice a week with

a doctor’s recommendation to increase that regimen.

      On May 11, 2018, Reliance denied Wright’s waiver-of-premium claim under

her life-insurance policy. It explained that, based on the medical evidence

presented, Wright hadn’t established that she was incapable of performing work

for which she was suited by education, training, or experience. Wright

administratively appealed both claim denials.

      While Reliance was considering Wright’s appeals, Wright visited her own

preferred independent doctor and Reliance’s preferred independent doctor for

further evaluation. Wright’s preferred independent doctor, Dr. Pamela Noel,

diagnosed Wright with more than a dozen medical ailments and concluded that

Wright was “totally and permanently disabled.” Reliance’s preferred independent

doctor, Dr. Robert Martinez, acknowledged Wright’s wide-ranging concerns and

reported symptoms. He administered physical and neurological exams and found

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         USCA11 Case: 19-14643        Date Filed: 01/29/2021    Page: 5 of 11

everything to be normal except some limitations to Wright’s range of motion and

an unsteady gait. He opined that Wright’s reported symptoms didn’t correspond to

the physical examination and that she was capable of “full-time work duties and

activities.” Finally, Reliance asked another doctor, Dr. Donald Tan-Fog Lee, to

review Wright’s medical records. He concluded that, with some accommodations

and limitations on her physical exertion, Wright could work a normal schedule.

      In late 2018, Reliance denied both of Wright’s administrative appeals. It

explained that its independent appeal unit had reviewed the claims and the new

evidence and concluded that the initial denials were appropriate.

      Wright sued Reliance in federal district court under ERISA, which provides

that a civil action may be brought “by a . . . beneficiary” to “recover benefits due to

[her] under the terms of [her] plan, to enforce [her] rights under the terms of the

plan, or to clarify [her] rights to future benefits under the terms of the plan.” 29

U.S.C. § 1132(a)(1)(B). In her complaint, Wright requested an order conferring

long-term disability benefit payments, a declaration that she was entitled to long-

term disability benefit payments, and a declaration that she was entitled to a waiver

of premiums under her life-insurance policy.

      Reliance filed a motion for summary judgment arguing that Wright had

failed to prove she was disabled under either policy and that substantial evidence in

the record supported the conclusion that its claim denials weren’t arbitrary and

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         USCA11 Case: 19-14643       Date Filed: 01/29/2021   Page: 6 of 11

capricious. Wright filed a motion for summary judgment arguing that Reliance’s

denials were arbitrary and capricious. She reasoned that her conditions didn’t

admit of objective evidence but that Reliance ignored the relevant medical

evidence—including multiple doctors who opined she was disabled—in favor of

its own experts who misunderstood the standard for disability.

      The district court entered judgment for Reliance. It surveyed the medical

evidence and explained that, for a number of reasons, Reliance’s claim denials

weren’t arbitrary and capricious. It explained that Reliance reasonably weighed

the competing evidence regarding Wright’s disability and that many test results

and medical reports suggested that Wright’s health was relatively normal and that

she was functioning well enough to work. It also noted internal contradictions in

Wright’s evidence—such as one doctor simultaneously claiming that Wright was

so dysfunctional as to be possibly bedridden while also recommending to her a

vigorous exercise program with few limitations. The court also concluded that

Reliance’s conflict of interest as both administrator and payor of claims didn’t

render its decision arbitrary and capricious given the “overwhelming support in the

medical evidence that [Wright’s] condition is not as debilitating as claimed.”

      Wright timely appealed.

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         USCA11 Case: 19-14643       Date Filed: 01/29/2021    Page: 7 of 11

                                          II

      We review a district court’s summary-judgment decision de novo.

Blankenship v. Metro. Life Ins. Co., 644 F.3d 1350, 1354, 1354 n.4 (11th Cir.

2011) (per curiam). In the ERISA context, when a policy vests an administrator

with discretion, we may hold for the claimant only if we conclude that the

administrator’s denial was “arbitrary and capricious.” Id. at 1355. When, as here,

the administrator has a financial stake in its own decision, we must take that

conflict of interest into account when determining whether the denial was arbitrary

and capricious. Id. Our review is limited to the material available to Reliance

when it made its decision. Id. at 1354.

      Wright presents two arguments on appeal, which we will consider in turn.

                                          A

      First and centrally, Wright argues that Reliance arbitrarily and capriciously

denied both her claims. Wright bears the burden of proving that Reliance’s claim

denials were arbitrary and capricious. See Doyle v. Liberty Life Assur. Co. of

Boston, 542 F.3d 1352, 1360–62 (11th Cir. 2008). Wright’s first claim—for long-

term disability—required her to prove that, for the 90-day “elimination period”

from August 7 through November 5, 2017, she was totally disabled. She was

totally disabled if she “[could] not perform the substantial and material duties of

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[her] regular occupation.”

      Wright’s second claim—for a waiver of life-insurance premiums—required

her to prove that, for six months from August 7, 2017 to February 7, 2018, she had

the “complete inability to engage in any type of work for wage or profit for which

[she was] suited by education, training, or experience.”

      Reliance didn’t arbitrarily and capriciously deny either claim. Although

Wright’s own preferred doctors asserted that she was unable to work, they

repeatedly noted that her gait, range of motion, strength, and many other physical

conditions were normal during that period. She complained of a wide range of

symptoms and ailments, but doctors noted that she was exercising and seemed to

think they could prescribe her even more rigorous exercise programs. And while

some doctors said that she was totally disabled, others—like Dr. Martinez and Dr.

Tan-Fog Lee —said she was able to work.

      We must consider Reliance’s conflict of interest as a factor in deciding

whether it arbitrarily and capriciously denied the claims. Metro. Life Ins. Co. v.

Glenn, 554 U.S. 105, 108 (2008). It was undeniably in Reliance’s short-term

interest to deny Wright’s claims. But as another panel of this Court has explained,

“the presence of a structural conflict of interest [is] an unremarkable fact in today’s

marketplace.” Blankenship, 644 F.3d at 1356; see also Glenn, 554 U.S. at 120

(Roberts, C.J., concurring) (noting that a “conflict of interest . . . is a common

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feature of ERISA plans”). Wright didn’t demonstrate that Reliance’s run-of-the-

mill conflict rendered its denials arbitrary and capricious.

      Wright relies heavily on Oliver v. Coca Cola Co., where we held that a

discretion-vested administrator wrongfully denied a disability claim where it

demanded “objective evidence” of the claimant’s chronic pain. 497 F.3d 1181

(11th Cir. 2007), reh’g granted, opinion vacated in part on other grounds, 506

F.3d 1316 (11th Cir. 2007), and adhered to in relevant part on reh’g, 546 F.3d

1353 (11th Cir. 2008). But unlike this case, in Oliver (1) the claimant presented

more rigorous evidence of disability, as he was in a car crash, experienced

subsequent severe headaches and neck pain, tested positive for a spinal nerve

disorder, couldn’t sleep, had right-arm pain that wasn’t responding to medication,

and was on heavy doses of painkillers; and (2) the only doctors to conclude the

claimant wasn’t disabled never saw him in person. See id. at 1187–92. We

emphasized that Oliver was not a case of “conflicting, reliable evidence,” but

rather one-sided evidence of disability that the administrator simply ignored. Id. at

1199. By contrast, Reliance denied Wright’s claim based on conflicting, reliable

evidence, including from Dr. Martinez, who treated her in person and concluded

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          USCA11 Case: 19-14643           Date Filed: 01/29/2021       Page: 10 of 11

she wasn’t disabled.2

                                                B

       Second, Wright argues that the district court erred because in its opinion

granting summary judgment, it briefly discussed Wright’s medical history from

before the time that she claimed to be disabled. The district court’s discussion of

Wright’s earlier medical history doesn’t constitute reversible error. First, it’s

reasonable to discuss Wright’s past medical history to contextualize her medical

developments during the period of claimed disability. Second, in the ERISA

context, we must determine for ourselves whether the district court’s conclusion

was supported by the administrative record regardless of how it arrived there. See

2
  The other six published Eleventh Circuit cases that Wright cites in support of her argument
regarding claim denial are less pertinent. Capone v. Aetna Life Insurance Co. concerns the
conditions under which a denial is wrong but not arbitrary and capricious. See 592 F.3d 1189
(11th Cir. 2010). In Shaw v. Connecticut General Life Insurance Co., we said in dictum that
although administrators can’t arbitrarily refuse to credit a claimant’s reliable evidence, the
district court erred by giving too much credit to the claimant’s favored physician. See 353 F.3d
1276, 1287 (11th Cir. 2003). Here, Reliance didn’t fully credit Wright’s evidence for the simple
reason that it was contradicted by other evidence. Florence Nightingale Nursing Service, Inc. v.
Blue Cross/Blue Shield of Alabama and Tippitt v. Reliance Standard Life Insurance Co. stand
for the proposition that administrators can’t change the terms of their policy. 41 F.3d 1476,
1483–84 (11th Cir. 1995); 457 F.3d 1227 (11th Cir. 2006). Here, Reliance didn’t change the
terms of its policy. In Godfrey v. BellSouth Telecommunications, Inc., our summary of the
procedural history paraphrased the district court’s holding that the administrator’s physician
wrongly rejected evidence where he didn’t examine the claimant personally or seek the treatment
notes of the claimant’s doctors. 89 F.3d 755, 758 (11th Cir. 1996). Here, Reliance’s preferred
physicians examined Wright and sought the treatment notes of her doctors. And in Melech v.
Life Insurance Co. of North America, we held that an administrator couldn’t base its decision on
an administrative record that didn’t contain key findings from a parallel social security benefits
proceeding. 739 F.3d 663 (11th Cir. 2014). Here, Wright doesn’t point to analogous
circumstances.

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Blankenship, 644 F.3d at 1354. We’ve done that, and we conclude the district

court was correct to conclude that Reliance’s denials of Wrights claims weren’t

arbitrary and capricious.

                                        III

      Accordingly, we AFFIRM.

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