Court Opinion

ID: 7214758
Source: CourtListenerOpinion
Date Created: 2022-07-25 00:19:36.657166+00
Date Added: 2024-06-11T16:16:58.588926
License: Public Domain

FUENTES, Circuit Judge,
dissenting.
FUENTES, Circuit Judge.
Although I concur with the Court’s analysis as set forth in Parts I — III, I disagree with the conclusions drawn in Parts IV and V. After reviewing the record, I believe the District Court properly applied our instructions in Pinto v. Reliance Standard Life Ins. Co., 214 F.3d 377 (3d Cir. 2000), when it determined the relevant standard of review. I also believe the District Court’s decision to grant summary judgment in favor of Reliance was appropriate on the record before it. For these reasons, I respectfully dissent.
In Pinto, we recognized that when an insurance company is both administrator and funder of a benefits plan, heightened scrutiny is required. See id. at 387. As the majority also noted, the appropriate degree of scrutiny to be applied varies along a sliding scale, “according different degrees of deference.... ” Id. at 391. The degree of deference will depend in any given case on the presence of conflict, bias, or procedural irregularities on the part of the insurer that would weigh in favor of greater skepticism. The point that bears repeating here, however, is that Pinto intentionally preserved the status quo with respect to the burden allocation — that is, plaintiff continues to bear the burden of establishing a conflict, bias, or procedural irregularity sufficient to trigger more skeptical review. See id. at 392 (“We think the best way to ‘consider’ these potentially relevant factors (in this case, the structural conflict of interest) is to use them to heighten our degree of scrutiny, without actually shifting the burden away from the plaintiff.”) (emphasis added).
As the District Court noted, plaintiff Joseph Weinberger (‘Weinberger”) failed to produce any evidence below that would substantiate a conflict or bias that would trigger a high degree of skepticism in reviewing the denial of Weinberger’s benefits. Instead, it appears that Weinberger is attempting to argue on appeal, for the first time, that Reliance’s review process was infected with procedural irregularities. After reviewing the record, however, these purported irregularities do not appear altogether irregular. For instance, Weinberger claims that it is suspicious that Reliance has no mechanism for reviewing its denial of benefits even though the Social Security Administration (“SSA”) awarded disability benefits to Weinberger. For this proposition, Weinberger relies on Pinto. I believe that Weinberger has misconstrued the factual similarity between his case and Pinto. In Pinto, we found an irregularity in part because although Reliance had initially based its denial on SSA’s rejection of the plaintiffs claim, it later refused to review its denial when the SSA reversed its own determination. Id. at 393. Here, Weinberger has failed to prove *559that SSA’s decision was in any way relevant to Reliance’s. Furthermore, after a thorough review of the record, I find that none of the documents cited by Weinberger support his contention that the SSA determination should inform the review of Weinberger’s separate claim for benefits from Reliance. Rather, the only probative document relating to the SSA determination is the report of Dr. Mark Friedman discussing an October 20, 1999 medical examination. App. at 99. Dr. Friedman’s report merely records his observations about Weinberger’s condition as of that date, without giving any indication that Weinberger’s “disability” manifested itself before April 29, 1999 — the date of Weinberger’s termination. Without a showing of the standards applied by SSA, the time frame for its decision, and the bases for its decision, Weinberger cannot rely on a third party’s determination to inform Reliance’s.
Second, Weinberger claims that Reliance’s review was irregular because it selectively relied on portions of the medical record while it ignored the parts that support his claim for benefits. I fail to see how the record supports such a conclusion. Rather, the record reflects that Reliance relied primarily on the reports of Dr. Margery Mark, Weinberger’s treating physician. The relevant aspects of Dr. Mark’s reports overwhelmingly indicate that Weinberger had the ability to perform most, if not all, of the functions required in a sedentary occupation and that he was able to continue most activities associated with daily living. While there are statements regarding neurological impairment, this hardly renders Reliance’s review irregular. It appears that Reliance attempted to make an informed decision based on all of the evidence submitted by Weinberger.
Third, Weinberger claims that Reliance’s review was tainted by its failure to obtain an independent medical evaluation. While the failure to obtain an independent medical evaluation may be relevant to the limited issue of the propriety of the review process, I fail to see how that omission is at all relevant here, where there was a well-documented medical record as evidenced by Dr. Mark’s reports. Weinberger has not shown that an independent medical evaluation would have contributed anything to the review process.
Finally, the majority notes that it was unusual for Reliance to employ the Department of Labor’s Description of Occupational Titles (“DOT”), as opposed to the job descriptions submitted by Weinberger which more accurately reflect the requirements of his position. While I recognize that Reliance’s decision to employ the DOT was curious, I am not certain that it rises to the level of a procedural irregularity that would warrant skeptical review. Furthermore, in light of my reading of Pinto, the burden still rested with Weinberger to show that the use of the DOT tainted the review process in some material way. As the District Court noted, however, the DOT’s and Weinberger’s descriptions were not entirely inconsistent and both acknowledged that Weinberger’s position was largely sedentary. To be sure, Reliance did not perform a flawless review in this case. I do not believe, however, that the imperfections here resulted in the type of bias or conflict that Pinto requires for more skeptical review of an administrator’s decision.
For these reasons, I find that Weinberger failed to establish that a high degree of skepticism was warranted in this case and that the District Court properly determined that it could reverse Reliance’s denial of benefits only if the denial was arbitrary and capricious. Along the slid*560ing scale, the District Court appropriately-accorded Reliance’s decision a moderate degree of deference. In light of this standard, I also find that the District Court properly granted summary judgment in favor of Reliance, as its decision was supported by the record. Accordingly, I would affirm the judgment of the District Court.