Court Opinion

ID: 2973441
Source: CourtListenerOpinion
Date Created: 2015-09-22 17:02:26.524651+00
Date Added: 2024-06-11T11:43:45.821064
License: Public Domain

NOT RECOMMENDED FOR FULL-TEXT PUBLICATION
                           File Name: 06a0091n.06
                           Filed: February 6, 2006

                                            No. 04-6145

                           UNITED STATES COURT OF APPEALS
                                FOR THE SIXTH CIRCUIT

STACY MATHIS,                                      )
                                                   )
       Plaintiff-Appellee,                         )
                                                   )   ON APPEAL FROM THE UNITED
v.                                                 )   STATES DISTRICT COURT FOR THE
                                                   )   EASTERN DISTRICT OF TENNESSEE
MAHLE, INC.,                                       )
                                                   )
       Defendant-Appellant.                        )

       Before: CLAY and COOK, Circuit Judges; COOK, District Judge.*

       COOK, Circuit Judge. Stacy Mathis, an employee of Defendant Mahle, Inc., submitted

insurance claims under Mahle’s ERISA plan, seeking reimbursement for medical expenses related

to a gunshot wound to the face. Mahle’s third-party administrator denied Mathis’s claims, calling

the injury “self-inflicted.” Mathis sued Mahle, the party ultimately responsible for claims decisions,

for payment of his claims, disputing the “self-inflicted” label. The district court, conducting de novo

review, concluded that Mahle improperly denied Mathis’s claims. Because the district court should

have reviewed Mahle’s decision under the “arbitrary and capricious” standard and Mahle’s decision

survives such scrutiny, we reverse the judgment of the district court.

                                                   I

       *
       The Honorable Julian Abele Cook, Jr., United States District Judge for the Eastern District
of Michigan, sitting by designation.
No. 04-6145
Mathis v. Mahle, Inc.

       Mathis’s father admitted him to Lakeway Regional Hospital for treatment of a gunshot

wound to the face, and a nurse wrote in the “Initial Assessment Form” that “Father states that he shot

him self [sic] in his truck due to marital problems.” According to hospital reports, the bullet entered

Mathis’s face “under the chin” and exited “through his nasal region.” Lakeway transferred Mathis

to University of Tennessee (“UT”) Memorial Hospital. Two days later, once he regained his speech

abilities, hospital personnel requested that he consult a psychiatrist in the hospital. The psychiatrist

noted on the consultation form, “Patient states the event was accidental.              If evidence to

contrary—plz consult [illegible].”

       Mathis participated in Mahle’s self-funded health and dental insurance plan (the “Plan”).

The Plan authorized Acordia, a third-party administrator, to make initial claims decisions. An

insured could appeal Acordia’s initial decision to Mahle by submitting “a written request for review

. . . to [Mahle’s] Human Resources Office.” Mathis submitted claims for his medical and dental

expenses, and Acordia denied payment of Mahle’s claims. Acordia sent Mathis an “Explanation of

Benefits,” noting that the Plan excepted from coverage claims for “self-inflicted injury” and

describing the proper appeal procedure. Mathis contacted Carolyn Miner, Mahle’s employee benefit

coordinator, about the denial of his claims. Miner requested reconsideration by Acordia, faxing a

note from one of Mathis’s treating physicians, but Acordia continued to deny Mathis’s claims.

Mathis failed to submit a written request for review to Mahle’s human resources office.

                                                 -2-
No. 04-6145
Mathis v. Mahle, Inc.

       Mathis sued Mahle for payment on his claims. Mahle initially named Acordia as an

indispensible party, but the district court found Acordia to be “a third party administrator and . . .

not a proper party to th[e] lawsuit.” The court explained that, “[u]nder the terms of the Plan, Mahle

is the Plan Administrator of its fully self-funded Plan, and . . . Mahle retained the sole authority to

make final decisions regarding benefits.”

       After Mahle and Mathis cross-moved for summary judgment, the district court found the

administrative record to be inadequate and remanded the case “to the claims administrator to afford

the plaintiff a full and fair review, with complete medical records, by the appropriate named

fiduciary of the decision denying the claim.” Mahle then sent Mathis “an official, written denial of

the appeal of [his] claim for benefits.” The matter returned to the district court, which conducted

de novo review and granted Mathis summary judgment. Mahle appeals, arguing that the court

should have used a deferential “arbitrary and capricious” review standard.

                                                  II

       This court reviews de novo the district court’s decision to grant summary judgment on an

ERISA claim. Williams v. Int’l Paper Co., 227 F.3d 706, 710 (6th Cir. 2000). We also review de

novo the district court’s selection of a standard under which to review the plan administrator’s

decision. Hoover v. Provident Life & Accident Ins. Co., 290 F.3d 801, 807 (6th Cir. 2002).

                                                 -3-
No. 04-6145
Mathis v. Mahle, Inc.

        At the outset, we note the presence in this case of a readily-apparent conflict of interest.

Mahle self-funds its insurance plan and thus holds a direct financial interest in the denial of claims.

It also maintains discretion over the ultimate disposition of claims, creating the conflict of interest.

See Killian v. Healthsource Provident Adm’rs, Inc., 152 F.3d 514, 521 (6th Cir. 1998). We factor

this conflict into our review, although it does not change the review standard. Kalish v. Liberty

Mut./Liberty Life Assurance Co. of Boston, 419 F.3d 501, 506 (6th Cir. 2005).

                                  A. Appropriate Review Standard

        The district court announced, without any discussion of the appropriate review standard, that

it reviewed Mahle’s decision de novo. The Plan vests Mahle with discretion to determine eligibility

for benefits and construe the terms of the plan. Generally, where a plan confers discretion on an

administrator, the court “review[s] the denial of benefits only to determine if it was arbitrary and

capricious, and will uphold [the] decision if it is rational in light of the plan’s provisions.” Marks

v. Newcourt Credit Group, Inc., 342 F.3d 444, 456-57 (6th Cir. 2003) (quotations and citations

omitted).

        Even where a plan vests a party with discretion, however, this court conducts de novo review

of claims determinations where a party other than the one authorized by the plan in fact renders the

decision. Sanford v. Harvard Indus., Inc., 262 F.3d 590, 595-96 (6th Cir. 2001). Mathis contends

that Acordia, rather than Mahle, reviewed his claims, so that the district court properly conducted

de novo review. Mahle counters that it reviewed Mathis’s claims once it had proper notice of the

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No. 04-6145
Mathis v. Mahle, Inc.

appeal—specifically, after the court remanded the case for “a full and fair review . . . by the

appropriate named fiduciary.” Mathis responds that this compulsory review does not justify review

under the arbitrary and capricious standard.

        Mathis reasons that, although he failed to precisely follow the Plan’s appeals procedure, he

provided a de facto notice of appeal when he contacted Mahle’s employee benefits coordinator,

Miner. He asserts that Mahle, through Miner, delegated its review authority to Acordia when Miner

requested Acordia to review its decision. But a claimant “cannot seek to estop the application of an

unambiguous written provision in an ERISA plan.” Marks, 342 F.3d at 456 (holding, where

employer allegedly misrepresented facts so that employee would miss a claims deadline, that

employee was nonetheless bound by the deadline). The Plan unambiguously stated that “the

Participant . . . may make a written request for review of the denial [by] submitting such request to

Human Resources Office of the Employer,” and Mathis cannot avoid this provision.

        The district court, consistent with its holding that Acordia “perform[ed] purely ministerial

functions such as processing claims,” remanded Mathis’s claims to Mahle “to afford the plaintiff a

full and fair review, with complete medical records, by the appropriate named fiduciary.” After

Mahle denied Mathis’s claims, the district court reviewed Mahle’s decision. Because the Plan

identified Mahle as having “absolute discretion . . . to decid[e] all disputes of eligibility,” the district

court should have reviewed under the arbitrary and capricious standard. Cf. Stoll v. W. & S. Life Ins.

Co., 64 Fed. Appx. 986, 991 (6th Cir. 2003) (refusing to entertain plaintiff’s claim, unraised below,

                                                   -5-
No. 04-6145
Mathis v. Mahle, Inc.

of an improper decisionmaker because, although the initial decisionmaker was improper, the proper

decisionmaker “ultimately did review and reject” her claim after receiving a letter from the

plaintiff’s attorney).

                                 B. Review of Mahle’s Decision

        Having concluded that the district court employed an inappropriate standard of review in

this case, we now examine Mahle’s determination under the more deferential arbitrary and

capricious review standard. “‘When it is possible to offer a reasoned explanation, based on the

evidence, for a particular outcome, that outcome is not arbitrary or capricious.’” Gismondi v. United

Techs. Corp., 408 F.3d 295, 298 (6th Cir. 2005) (quoting Davis v. Ky. Fin. Co. Ret. Plan, 887 F.2d
689, 693 (6th Cir. 1989)). Mahle, in denying Mathis’s claims, asserted that his injuries were

intentional, and thus were “self-inflicted” within the meaning of the Plan. Mahle’s explanation for

why its decision was not arbitrary and capricious relies on the statements of hospital personnel and

of Mathis’s family. Mathis discounts those statements, calling the hospital-personnel statements

ambiguous and the family’s statements inconsistent.         Mathis then points to the consulting

psychiatrist’s report citing Mathis’s explanation that the gun accidentally discharged as he unloaded

it.

                                        1. Hospital Reports

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No. 04-6145
Mathis v. Mahle, Inc.

       A number of hospital reports describe Mathis’s injury as “self-inflicted.” The district court

found the hospital records’ use of this term to be ambiguous: “UT’s operative report describes the

injury as a ‘self-inflicted gunshot wound to the face’ but this report does not indicate whether the

gunshot wound was accidental or intentional. The ‘self-inflicted’ notation may simply have meant

that Mr. Mathis was not the victim of criminal assault.” An inspection of the record, however, casts

doubt on this conclusion. The operative report to which the district court referred was dictated by

the resident physician, Dr. Peter Chang. Mathis’s “Discharge Summary,” also dictated by Dr.

Chang, eliminates the ambiguity. There, Dr. Chang stated that Dr. Catron, the consulting

psychiatrist, “noted that the patient denies any self-infliction and that this was an accident and that

this was not a suicide attempt.” (Emphasis added.) Dr. Chang’s use of the term “self-infliction”

contrasts with his use of the term “accident.” Other reports dictated by Dr. Chang also describe

Mathis’s injuries as stemming from a “self-inflicted gunshot wound.”1

                                        2. Family Accounts

       Mathis’s family described his injury as intentional. A Lakeway Emergency Department

Nursing Assessment Record stated, “Mother came into ER. States son has shot himself.” A nurse

wrote in Lakeway’s “Initial Assessment Form” that “Father states that he shot him self [sic] in his

truck due to marital problems.” A police officer took statements of Lakeway emergency room

personnel and of Mathis’s family. Lakeway’s ER personnel recited to the officer their understanding

       1
        These reports were, of course, issued prior to the Discharge Summary, which describes Dr.
Catron’s consultation report.

                                                 -7-
No. 04-6145
Mathis v. Mahle, Inc.

of Mathis’s father’s account of events: Mathis was depressed over a recent divorce, went riding in

his truck, shot himself, wrecked the truck, returned to his father’s house, and his father drove him

to Lakeway. The father, mother, and brother’s account, as recorded by the officer, differs somewhat:

Mathis, who had been drinking at his grandfather’s house, was depressed because of his recent

divorce. He attempted to leave in his vehicle, but ran into a ditch on his grandfather’s property. He

returned to his grandfather’s house, became enraged, shot himself, and his father drove him to

Lakeway.

        Mathis calls the two descriptions of the events “facially inconsistent” as to the location of

the shooting and the timing of events. The hospital staff understood Mathis’s father to say that

Mathis shot himself in his truck and then wrecked the truck. Under the family’s account, the wreck

occurred first, and Mathis shot himself at his grandfather’s house.          These differences are

unsurprising, given the emergency situation at the time Mathis’s father described the events to the

hospital staff. By the time the officer interviewed Mathis’s family at the UT hospital, the situation

was more stable, and the events could be recounted in a more orderly, straightforward manner. The

apparent conflicts in the two stories do not justify a conclusion that Mahle acted unreasonably in

relying on them for its self-inflicted label.

                                     3. Location of the Wounds

        Finally, Mahle points to the location of Mathis’s wounds as supporting its decision. The

bullet entered underneath Mathis’s chin and exited through the nasal area. The location of the

                                                -8-
No. 04-6145
Mathis v. Mahle, Inc.

wounds comports with the family’s description of events—that Mathis “produced a 9mm pistol . .

. placed it under his chin and fired one round.”2 Mahle did not act unreasonably in discounting

Mathis’s accidental-discharge explanation, which would require that Mathis unloaded the weapon

with the gun’s nozzle pointed upward, directly below his chin as Mathis looked straight ahead on

a horizontal plane rather than looking down at the gun as he unloaded it.

                                        4. Mathis’s Evidence

       Mathis counters that other evidence supports his position. He argues, for instance, that Dr.

Catron accepted Mathis’s explanation without further inquiry. Mathis also directs the court to a

letter that his treating physician, Dr. Shanks, sent to Acordia. Dr. Shanks wrote that “Dr. Catron .

. . achieved an accurate history describing the injuries as the result of an accidental discharge of the

gun. He did not see anything to contradict the history given by the patient so he dismissed himself

from the care and did not recommend any treatment.” Dr. Catron’s consultation report, however,

merely indicates his reliance on Mathis’s explanation, without purporting to reach any medical

conclusions. The report reads in its entirety: “Patient states the event was accidental. If evidence

to contrary—plz consult [illegible] crisis. Thnx - /s/ Dr. Catron.” Nothing in Dr. Catron’s

consultation report or in Dr. Shanks’s letter indicates that either of them spoke with Mathis’s family

about the injury, nor does Dr. Catron’s report purport to have “achieved an accurate history.”

       2
         It remains unclear whether the family witnessed Mathis’s actions. Their description of the
events, as recorded by the officer, reads as a first-hand account. But Mathis’s treating physician at
UT hospital wrote in his letter to Acordia that “there were no witnesses.”

                                                 -9-
No. 04-6145
Mathis v. Mahle, Inc.

       Assuming the plausibility of Mathis’s explanation of his injuries, we must nonetheless defer

to Mahle so long as “‘it is possible to offer a reasoned explanation, based on the evidence’” for

Mahle’s decision. Gismondi, 408 F.3d at 298 (quoting Davis, 887 F.2d at 693). Here, the evidence

in the record provides a reasoned explanation for Mahle’s conclusion that Mathis’s injuries were

“self-inflicted” as the term is used in the Plan, and Mahle’s denial of benefits, therefore, cannot be

said to be arbitrary and capricious.

                                                 III

       Because the district court should have reviewed Mahle’s decision under the arbitrary and

capricious review standard, and because Mathis fails to convince the panel that Mahle’s decision

was arbitrary and capricious, we reverse the judgment of the district court and remand the case for

entry of judgment in favor of Mahle.

                                                - 10 -
No. 04-6145
Mathis v. Mahle, Inc.

       CLAY, Circuit Judge, dissenting. This case presents a startling example of arbitrary and

capricious behavior on the part of a plan administrator. In its decision to deny the medical claims

of Plaintiff Stacy Mathis, Defendant Mahle, Inc. unabashedly placed primary reliance on the

speculative statements of Plaintiff’s family members and the repetition of those statements in

subsequent medical reports. Defendant’s use of such unreliable evidence to justify its benefits

decision demonstrates irrationality that should not prevail in this Court. Therefore, I respectfully

dissent.

       As an initial matter, while I agree that this Court reviews Defendant’s administrative decision

under the arbitrary and capricious standard, I stress that we still have a responsibility to engage in

meaningful review of Defendant’s decision to insure the protection of members of the benefits plan.

“[M]erely because our review must be deferential does not mean our review must also be

inconsequential. While a benefits plan may vest discretion in the plan administrator, the federal

courts do not sit in review of the administrator’s decisions only for the purpose of rubber stamping

those decisions.” Moon v. UNUM Provident Corp., 405 F.3d 373, 379 (6th Cir. 2005). “Deferential

review is not no review, and deference need not be abject.” McDonald v. Western-Southern Life Ins.

Co., 347 F.3d 161, 172 (6th Cir. 2003). While this Court should rightfully defer to rational and

reasonable decisions, when a plan administrator bases its decision on unreliable evidence, we must

reject that decision. Glascoe v. Central States, SE SW Areas Pension Fund, No. 00-6430, 35 Fed.

App’x 121, 124-25 (6th Cir. Mar. 29, 2002) (unpublished opinion). See also Darrell Andrews

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Case No. 04-6145
Mathis v. Mahle, Inc.
Trucking, Inc. v. Fed. Motor Carrier Safety Admin., 296 F.3d 1120, 1134-35 (D.C. Cir. 2002)

(finding that agency use of unreliable evidence would constitute arbitrary and capricious behavior).

        Moreover, in deciding whether Defendant’s benefits decision was arbitrary or capricious,

we must consider the conflict of interest apparent when a plan administrator is also the payer of the

benefits under the plan. Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989) (“[T]hat

conflict must be weighed as a facto[r] in determining whether there is an abuse of discretion.”

(emphasis supplied) (internal quotations and citation omitted).) The majority’s opinion purports to

recognize its duty to consider this conflict, but it does not actually analyze the nature or extent of

the conflict in this case. Specifically, the majority in this case stated, “We factor this conflict into

our review,” yet it never so much as mentions this conflict again in its opinion. Plaintiff in this case

submitted over $40,000 in medical bills in claims that were denied by Defendant. Defendant’s

conflict, as one factor among several to be considered, must be viewed in light of the cost Defendant

was able to eliminate by rendering an adverse decision against Plaintiff.

        Turning now to the record, the evidence shows that Plaintiff was admitted to Lakeway

Regional Hospital with a single gunshot wound. Due to the nature of the wound, he was unable to

speak. When he was sufficiently healed, Plaintiff communicated to medical personnel that the

gunshot was the result of an accidental discharge while he was attempting to unload his handgun.

Plaintiff also stated that there were no witnesses to the accident. Plaintiff repeated this same version

of events in his application for short-term disability benefits.

                                                 - 12 -
Case No. 04-6145
Mathis v. Mahle, Inc.
        It is evident that Defendant improperly relied on Plaintiff’s family members’ speculative

statements as to how Plaintiff sustained the gunshot injury. While the majority opines that it is

“unclear” whether Plaintiff’s family members witnessed the events surrounding the injury, I believe

that it is fairly obvious that they did not see how Plaintiff’s injury occurred, nor did Plaintiff relay

any relevant information directly to his family after sustaining the injury. First, Plaintiff specifically

stated that there were no witnesses to the occurrence, and there is absolutely nothing in the record

to contradict this point. Second, not even Defendant asserts that Plaintiff’s family members

witnessed the gunshot. Third, the nature of Plaintiff’s injury prevented him from speaking after the

injury, so Plaintiff’s family members could not have learned what had happened from Plaintiff.

Fourth, Plaintiff’s family members recounted inherently conflicting versions of what had occurred.

One version, given by the father to Lakeway medical personnel, stated that Plaintiff shot himself

while driving, crashed his car, and then went to his father’s house, from which his father took him

to the hospital. The other version, given by the father, mother and brother to a police officer at the

University of Tennessee Hospital, stated that Plaintiff was drinking at his grandfather’s house, then

crashed his car in a ditch, went back to his grandfather’s house, and then shot himself in the house.

The fact that there is an inconsistent sequence of events and an inconsistent location of the actual

shooting confirms that, in fact, no one witnessed or otherwise had knowledge of the events

surrounding the gunshot. The majority attempts to explain away these inconsistencies by pointing

to the excitement surrounding this emergency situation. Certainly, in such a situation, small

inconsistencies in details should be forgiven; however, when the inconsistencies relate to where the

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Case No. 04-6145
Mathis v. Mahle, Inc.
injury occurred and how the injury took place, the very heart of the matter being disputed, I believe

it would be somewhat disingenuous to attribute these inconsistencies to the heat of the moment.

       Even assuming arguendo the truth of the majority’s statement that whether the family

members witnessed the occurrence is unclear, Defendant’s reliance on the family members’

statements would still be improper. If it is unclear whether the family members witnessed the

discharge of the gun, then their statements as to the occurrence would be unreliable. In other words,

the fact that there is a possibility that the family members actually had a basis for their statements

does not render their statements somehow reliable. Furthermore, it strains credibility to believe that

the family members actually witnessed events which transpired as Defendant alleges, and yet

Defendant never sought to present such information to buttress its position.

       Likewise, Defendant improperly relied on the Lakeway medical reports, which stated that

Plaintiff’s injury was self-inflicted.3 When Plaintiff was admitted to Lakeway Regional Hospital,

Plaintiff’s father immediately told hospital personnel that Plaintiff’s injury was self-inflicted, as

evidenced by the Initial Assessment Form. Considering that this form became a part of Plaintiff’s

medical file at Lakeway, it is no surprise that subsequent Lakeway medical records listed Plaintiff’s

injury as self-inflicted. The ultimate source of the self-inflicted information was Plaintiff’s father,

       3
         As the majority notes, the phrase “self-inflicted” is subject to a variety of interpretations.
I agree with the majority that the district court’s definition, “that [Plaintiff] was not the victim of
criminal assault,” is unreasonable and defies common usage. I also agree that the context of the
medical records shows that the phrase “self-inflicted” was meant in contradistinction to “accidental.”
Plaintiff is correct in his assessment “that the question at issue is whether [Plaintiff] intentionally
shot himself.” (Pl. Br. 15.)

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Case No. 04-6145
Mathis v. Mahle, Inc.
and Plaintiff’s father had no firsthand knowledge whatsoever regarding how Plaintiff’s injury took

place. Just as Plaintiff’s father’s statements about the discharge of the gun were unreliable, so too

were Lakeway’s subsequent memorializations of the father’s statements unreliable. In the same

vein, University of Tennessee Hospital medical records were unreliable to support the contention

that Plaintiff’s injury was self-inflicted; that hospital had received the tainted file from Lakeway,

and Plaintiff’s family members were also present at that hospital. While it is theoretically possible

that the doctors and nurses at the two hospitals made an independent assessment of the nature of

Plaintiff’s injury, the record below does not substantiate that they did so, and it is far more likely that

they merely continued to repeat the conjecture and speculation of Plaintiff’s family members.

        With the bulk of its case in doubt, Defendant has but one scrap of evidence that purportedly

indicates that Plaintiff’s injury was self-inflicted. Defendant argues, and the majority accepts, that

the nature of Plaintiff’s injury was more consistent with a suicide attempt than with the unloading

of a handgun. This type of conjecture is best suited for a firearms expert (though none was

provided), not a medical plan administrator or a reviewing court.

        In sum, Defendant’s decision was based almost entirely on unreliable or invented evidence.

Viewed in conjunction with Defendant’s conflict of interest, the record amply demonstrates that

Defendant’s decision to deny Plaintiff benefits was arbitrary and capricious. I would therefore

affirm the district court order requiring Defendant to pay Plaintiff’s medical claims.

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