Court Opinion

ID: 866105
Source: CourtListenerOpinion
Date Created: 2013-04-29 19:46:15.036534+00
Date Added: 2024-06-11T09:06:43.224143
License: Public Domain

Case: 12-15864         Date Filed: 04/29/2013   Page: 1 of 7

                                                                      [DO NOT PUBLISH]

                   IN THE UNITED STATES COURT OF APPEALS

                               FOR THE ELEVENTH CIRCUIT
                                 ________________________

                                        No. 12-15864
                                    Non-Argument Calendar
                                  ________________________

                             D.C. Docket No. 9:11-cv-81091-KLR

PATRICIA HERRING,

llllllllllllllllllllllllllllllllllllllllPlaintiff - Appellant,

versus

AETNA LIFE INSURANCE COMPANY,

llllllllllllllllllllllllllllllllllllllllDefendant - Appellee.
                                       ________________________

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

                                          (April 29, 2013)

Before TJOFLAT, WILSON and PRYOR, Circuit Judges.

PER CURIAM:
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      In this appeal, Patricia Herring challenges the district court’s grant of Aetna

Life Insurance Company’s (Aetna) motion for summary judgment. Because

Herring has not shown reversible error, we affirm.

                                          I.

      Herring worked as an accounts payable clerk for Alphastaff, Inc. Through

Alphastaff, Herring was eligible to receive long term disability (LTD) benefits as a

participant in an employee welfare benefit plan under a group insurance policy

issued by Aetna. Aetna served as the plan’s claim administrator, meaning it had

discretionary authority to determine whether Herring was entitled to benefits under

the terms of the policy.

      In March 2009, Herring ceased work and underwent coronary artery bypass

surgery. Subsequently, she applied for LTD benefits. Under the policy, LTD

benefits were payable for a period of “total disability.” The policy defines total

disability as: (1) one who is not able to perform the material duties of her

occupation; or (2) one who is not able to work at any reasonable occupation.

Reasonable occupation is defined as “any gainful activity for which [one is], or

may reasonably become, fitted by education, training, or experience.” A

reasonable occupation includes “sedentary work,” where standing and walking are

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required only occasionally. A period of total disability ends when one ceases to be

totally disabled or fails to give proof of her continued total disability.

      Aetna approved Herring’s claim for LTD benefits effective June 27, 2009.

On August 31, 2009, Aetna notified Herring that as of June 27, 2010, her eligibility

for continued benefits would be contingent upon evidence that she was totally

disabled. In July 2010, at Aetna’s request, Dr. Josef Hudec performed an

Independent Medical Examination (IME), and concluded that Herring was capable

of working. A Vocational Rehabilitation Consultant (VRC), who was employed

by Aetna, reviewed Dr. Hudec’s findings, and identified five sedentary occupations

Herring could perform, as well as the local employers for each occupation. In

August 2010, in light of the IME and the VRC’s findings, Aetna terminated

Herring’s LTD benefits on the grounds that Herring could perform a “reasonable

occupation,” as defined under the policy.

      Herring appealed Aetna’s termination decision. In her appeal, Herring

included a letter from her treating cardiologist, Tobia Palma, stating that Herring

was totally disabled and had “no ability to work.” In evaluating the appeal, Aetna

hired three physicians to review Herring’s medical records. Two of the three

doctors concluded that Herring was capable of sedentary work and not totally

disabled. The third physician offered a more restrictive view of Herring’s physical

capabilities. His review was consistent with the comments made by Dr. Joshua

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Levy, a physiatrist referred by Herring’s family practitioner and assigned by Aetna

to offer his medical opinion on the results of the IME. Dr. Levy agreed that

Herring was able to work; however, he noted that she was capable of working

fewer hours per day with more restrictive limitations on the tasks she could

perform.

        After considering the reports of all 3 physicians, Aetna affirmed its decision

to terminate Herring’s benefits and issued its final decision by letter dated June 30,

2011.

                                            II.

        The Employee Retirement Income Security Act (ERISA) itself does not

provide a standard for courts to review the benefits determinations of plan

administrators or fiduciaries. Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101,

109, 109 S. Ct. 948, 953 (1989). With Firestone and Metropolitan Life Insurance

Company v. Glenn, 544 U.S. 105, 128 S. Ct. 2343 (2008), as guides, however, this

circuit has formulated a multi-step framework for courts reviewing an ERISA plan

administrator’s benefits decisions:

        (1) Apply the de novo standard to determine whether the claim
            administrator’s benefits-denial decision is “wrong” (i.e., the court
            disagrees with the administrator's decision); if it is not, then end the
            inquiry and affirm the decision.

        (2) If the administrator’s decision in fact is “de novo wrong,” then determine
            whether he was vested with discretion in reviewing claims; if not, end
            judicial inquiry and reverse the decision.
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      (3) If the administrator’s decision is “de novo wrong” and he was vested
          with discretion in reviewing claims, then determine whether “reasonable”
          grounds supported it (hence, review his decision under the more
          deferential arbitrary and capricious standard).

      (4) If no reasonable grounds exist, then end the inquiry and reverse the
          administrator’s decision; if reasonable grounds do exist, then determine
          if he operated under a conflict of interest.

      (5) If there is no conflict, then end the inquiry and affirm the decision.

      (6) If there is a conflict, the conflict should merely be a factor for the court
          to take into account when determining whether an administrator’s
          decision was arbitrary and capricious.

Blankenship v. Metro. Life Ins. Co., 644 F.3d 1350, 1355 (11th Cir.) (per curiam),

cert. denied, 132 S. Ct. 849 (2011).

      Under this framework, Herring bears the burden of proving that she is

disabled and that Aetna’s decision is wrong. Glazer v. Reliance Standard Life Ins.

Co., 524 F.3d 1241, 1247 (11th Cir. 2008). If Herring satisfies this burden, she

then must demonstrate that Aetna’s decision to deny her LTD benefits was

arbitrary and capricious; that is, she must show that had no reasonable grounds

support Aetna’s decision. Id. at 1246.

      The district court found that Aetna was not “de novo wrong.” We agree.

Herring’s LTD benefits were payable for a period of “total disability.” A period of

total disability ends when one is not totally disabled or fails to supply proof of her

continued total disability. Here, Herring has not shown proof of her continued

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disability. Two reviewing physicians considered the medical evidence and found

Herring was capable of sedentary work. Their findings were consistent with the

IME performed by Dr. Hudec, who also found that Herring was capable of

sedentary work. This evidence was considered in conjunction with the VRC

report, which identified sedentary occupations available to Herring in her

geographical area. See Richey v. Hartford Life & Acc. Ins. Co., 608 F. Supp. 2d

1306, 1312 (M.D. Fla. 2009) (finding that “the use of vocational evidence in

conjunction with medical evidence is an effective method of reaching an informed

decision as to a claimant’s work capability”).

      Even if Aetna’s decision had been “de novo wrong,” because Aetna had

discretion to determine whether Herring was entitled to LTD benefits under the

policy, Herring bears the burden of showing that Aetna’s decision was arbitrary

and capricious. See Glazer, 524 F.3d at 1246. She cannot. While one of the

reviewing physicians agreed with Dr. Levy that Herring was restricted in her

performance of sedentary work, it was not unreasonable for Aetna to rely on the

findings of the other two reviewing physicians, in conjunction with the IME and

the VRC. See Blankenship, 644 F.3d at 1356 (holding that a termination decision

was not unreasonable where it “relied upon the advice of several independent

medical professionals” and found that the claimant failed to provide conclusive

medical evidence of disability). While it is true that Dr. Parma, Herring’s treating

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physician, determined the exact opposite—that Herring was totally disabled and

could not work—his conclusion does not automatically qualify Aetna’s termination

decision as arbitrary and capricious. Aetna “need not accord extra respect to the

opinions of a claimant’s treating physicians.” Id. Accordingly, the district court

properly granted Aetna’s motion for summary judgment. 1

       AFFIRMED.

       1
        In light of our decision affirming the district court, Aetna’s motion to strike portions of
Herring’s reply brief is denied as moot.
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