Court Opinion

ID: 9496730
Source: CourtListenerOpinion
Date Created: 2023-08-05 16:34:04.607444+00
Date Added: 2024-06-11T17:57:46.026404
License: Public Domain

WILLIAMS, Circuit Judge,
concurring in the judgment:
Although I agree with the majority’s ultimate conclusion that MetLife abused *313its discretion by improperly failing to consider whether Evans was totally disabled while he was actively at work, I write separately to note my disagreement with the majority’s characterization of Met-Life’s actions and the Plan’s requirements.
I.
Robert Evans, as an employee of Bab-cock & Wilcox Co., was covered by its Long Term Disability Plan (Plan), administered and insured by Metropolitan Life (MetLife). The Plan provided benefits for employees who were “Totally Disabled.” (J.A. at 74.) Total disability “means that, due to an Injury or Sickness,” an employee:
1. [is] completely and continuously unable to perform each of the material duties of [his] regular job; and
2. require[s] the regular care and attendance of a Doctor.
(J.A. at 74.)
The Plan also states that “[w]hen [Met-Life] receive[s] proof that [an employee is] Totally Disabled, [it] will pay a Monthly Benefit in accordance with the SCHEDULE OF BENEFITS.” (J.A. at 74.) The Plan included an Elimination Period, defined as “the number of consecutive days of Total Disability before Long Term Disability Benefits become payable.”1 (J.A. at 73.) The Elimination Period begins “on the first day of Total Disability,” but allows for “[l]imited interruption,” which is defined as returns to work of “up to 30 days” that would not restart the period. (J.A. at 73.)
Availability of the benefits under the Plan ends “on the date ... employment ends.” (J.A. at 78.) Employment ends, for purposes of the Plan, “when [an employee] cease[s] Active Work.”- (J.A. at 78.) An employee is actively at work when he is “performing all of the material duties of [his] job with the Employer where these duties are normally carried out.” (J.A. at 73.) The Plan permits “the Employer [to] deem employment to continue for certain absences [for purposes of the Plan].” (J.A. at 78.) ’ As relevant here, absences for “Sickness or Injury,” may be counted as active work under the Plan for “[t]he period determined in accordance with the Employer’s general practice.” (J.A. at 79.) The Plan also permits an employee on a “Leave of Absence” to be deemed actively at work and eligible for benefits with the caveat that “the period will not be longer than two months following the date the leave of absence ... begins.” (J.A. at 79.) Thus, under the terms of the Plan, an individual could remain on his employer’s payroll but still be ineligible for the Plan’s benefits because he was not actively at work.
On October 19, 2000, MetLife issued its first ’ denial of Evans’s request for LTD benefits, which was made “effective [as of] August 9, 2000.” (J.A. at 120-21) (the October 19 denial). At no point in that October 19 denial letter did MetLife state that Evans “quit work” on December 2, 1999. To the contrary, the October 19 denial referred to medical records from as late as June 2000 and thus does not warrant a finding that MetLife limited its review of Evans’s claim to his status on December 2, 1999.
In response to the October 19 denial, Evans’s attorney submitted a letter on December 6, 2000, stating that “Mr. Evans is totally and permanently disabled and has been so since December 2, 1999.” (J.A. at 97.) The letter noted that the Social Security Administration determined that Evans was totally disabled under its rules as of December 2, 1999. The letter also re*314ferred to correspondences by Dr. Wright, Evans’s primary care physician, and Dr. Owens, Evans’s psychologist, stating that Evans was disabled as of about August 2000. Thus, after that letter from Evans’s attorney, MetLife had before it two different dates on which Evans’s disability may have begun: December 2, 1999 and August 1, 2000.
As the majority notes, MetLife conducted a review of the October 19 denial, and, on March 7, 2001, issued a letter upholding the denial of Evans’s claim. It was in this letter that MetLife, for the first time, limited its review of Evans’s claim to whether he was totally disabled as of December 2, 1999.
II.
I concur in the majority’s holding that MetLife abused its discretion when handling Evans’s request to review the October 19 denial.2 When determining if a plan administrator has abused its discretion we are required to consider “the language of the plan.” Booth v. Wal-Mart Stores, Inc., 201 F.3d 335, 342 (4th Cir.2001). Here, MetLife’s first duty under the Plan was to determine the period during which Evans was actively at work and thus eligible to receive the Plan’s benefits. After MetLife made that determination, it was obliged to decide whether Evans had submitted “proof that [he was] Totally Disabled” during that period. (J.A. at 74.) Only after making such a finding, was MetLife permitted to determine the date of onset of total disability in order to start the Elimination Period.
On appeal, MetLife argues that Evans’ Elimination Period began on December 2, 1999 when he took leave from work.3 Met-Life also argues that Evans was never totally disabled. The Plan does not allow MetLife to make these arguments in that order or simultaneously. If Evans did not submit proof that he was totally disabled, then the Elimination Period never began and Evans’s few days of work in June and July cannot be viewed as limited interruptions of the Elimination Period, as MetLife contends. Although MetLife never questioned whether Evans was actively at work and eligible for the Plan’s benefits, it was not permitted to determine whether Evans was disabled as of a specific date absent first finding that, due to injury or sickness, Evans was completely, and continuously unable to perform each of the material duties of his job and was under the regular care and attendance of a physician. I thus agree with the majority that MetLife abused its discretion in conducting its review of the October 19 denial.4
I disagree, however, with my colleagues’ statement that MetLife “refused” to consider Evans’s evidence.5 Both Evans and *315MetLife consistently have failed to focus on the requirements of the Plan during this litigation. I do not believe that Met-Life “refused” to consider evidence, but I do believe that MetLife failed in its responsibility to interpret the Plan’s language and apply it to the facts as it found them.
I also wish to emphasize that my colleagues do not shift the burden of proving a claimant’s case to MetLife. As we have explained, “[an administrator] must treat each claimant with procedural fairness, but ... it is not its duty to affirmatively aid claimants in proving their claims.” Ellis v. Metropolitan Life Ins. Co., 126 F.3d 228, 236 (4th Cir.1997). By definition, a plan administrator is a passive entity that accepts claims and does not actively seek them. A plan administrator has a duty to conduct a full and fair review of benefit applications “that takes into account all comments, documents, records, and other information submitted by the claimant relating to the claim.” 29 C.F.R. § 2560.503—1(h)(2)(iv) (2003). Here, Evans, in requesting a review of the October 19 denial, included opinions from two physicians stating that he was disabled as of August 2000. Absent a finding that Evans was not actively at work and thus ineligible for the Plan’s benefits as of that date, MetLife was required, in conducting a full and fair review of Evans’s claim, to consider that evidence and to determine whether it indicated that Evans was in fact totally disabled, and, if so, when that disability began. MetLife did not follow this process in conducting a review of its October 19 denial, and, by failing to do so, it abused its discretion.
III.
For the foregoing reasons, I concur separately in the judgment of the majority vacating the district court’s grant of summary judgment in favor of MetLife and remanding the case to MetLife for further review.

. The parties agree that the Elimination Period for Evans was six months.

. Evans conceded in his Reply Brief (Reply Br. at 3), and I agree, that MetLife did not abuse its discretion in denying the original claim on October 19, 2000.

. Notably, MetLife does not argue that Evans was not actively at work and, accordingly, we assume that Evans was an eligible participant prior to filing his claim for benefits on August 9, 2000.

. I do not suggest, nor do I read my colleagues' opinion as suggesting, that MetLife would abuse its discretion by denying Evans's claim on remand. As noted, the Plan's benefits only apply to individuals who become disabled while they are actively at work, or deemed to be actively at work while ill or on leave of absence. MetLife has yet to make a finding of whether Evans was actively at work after December 2, 1999.

.Whether Evans’s proof "established” his disability as of August 2000 is a determination for MetLife to make on remand. Our inquiry is whether MetLife abused its discretion, i.e., whether MetLife’s decision was "the result of a deliberate, principled reasoning process and [was] supported by substantial evidence.” *315Brogan v. Holland, 105 F.3d 158, 161 (4th Cir.1997) (internal quotation marks omitted).