Court Opinion

ID: 9613376
Source: CourtListenerOpinion
Date Created: 2023-08-22 04:16:29.963322+00
Date Added: 2024-06-11T09:06:54.802813
License: Public Domain

COOK, Circuit Judge,
concurring in the judgment.
While decisions from this circuit accept that we must analyze this brand of ERISA cases under the arbitrary and capricious standard of review, in practice we seem to stray improperly from that standard in favor of a more searching one. A handful of factors — such as supposedly contrary Social Security Administration (SSA) disability determinations, apparent conflicts of interest, and reliance on file reviews— colors our view of the administrators’ decisions. Our increased skepticism is unwarranted, and I write separately not to quibble over minor differences I might have with the majority’s analysis, but rather to explain why these factors should be less relevant to our analyses of these cases.
SSA Determinations
Our court has succumbed to the unfortunate temptation of continuing to equate Social Security and private insurance disability determinations, despite the Supreme Court’s clear and explicit warning *557not to do exactly that. In 2003, this court joined the Ninth Circuit in importing the SSA’s treating physician rule to ERISA cases, “requiring courts to defer to the opinions of a claimant’s treating physicians unless there is substantial evidence contradicting them.” Darland v. Fortis Benefits Ins. Co., 317 F.3d 516, 532 (6th Cir.2003). The court approved Ninth Circuit language finding the treating physician rule to be a “common sense requirement,” id. (quoting Regula v. Delta Family-Care Disability Survivorship Plan, 266 F.3d 1130, 1143 (9th Cir.2001)), but it failed to cite let alone explain the SSA regulation creating the treating physician rule, 20 C.F.R. § 404.1527(d)(2). Darland certainly did not explain, because it could not, why ERISA bound private insurance companies to regulations promulgated to govern the administration of a public benefit.
The Supreme Court overturned the judicially created ERISA treating physician rule just four months after this court issued Darland. See Black & Decker Disability Plan v. Nord, 538 U.S. 822, 123 S.Ct. 1965, 155 L.Ed.2d 1034 (2003). Writing for a unanimous court, Justice Ginsburg emphasized that “critical differences between the Social Security disability program and ERISA benefit plans caution against importing a treating physician rule from the former area into the latter.” Id. at 832-33, 123 S.Ct. 1965. The Court further noted that even “if a consultant engaged by a plan may have an ‘incentive’ to make a finding of ‘not disabled,’ so a treating physician, in a close case, may favor a finding of ‘disabled.’ ” Id. at 832, 123 S.Ct. 1965.
Darland also adopted the Seventh Circuit’s “penumbra rationale,” holding that the principles of judicial estoppel, if not the doctrine itself, apply to cases where the insurance company helps the claimant successfully petition the SSA for disability benefits and yet later denies that claimant LTD benefits. 317 F.3d at 529-30. One might think that the unanimous decision in Black & Decker explicitly overturning one aspect of Darland would give us pause as to the continuing vitality of the penumbra rationale. The Supreme Court explicitly warned courts not to equate the ERISA and Social Security regulatory regimes. See Black & Decker, 538 U.S. at 830, 123 S.Ct. 1965 (“The United States urges that the Court of Appeals ‘erred in equating the two [statutory regimes].’ We agree.” (quoting the Solicitor General’s amicus brief)). But our Glenn decision inexplicably held that comparing the Social Security disability standard to the private standard under review “is all the more relevant in the wake of’ Black & Decker’s holding that the treating physician rule “is not applicable in ERISA cases.” Glenn v. MetLife, 461 F.3d 660, 668 (6th Cir.2006).
Rather than attempting to salvage the penumbra rationale, I would read the Supreme Court’s holding in Black & Decker as denying support to the theoretical underpinnings of the penumbra rationale. Comparing disability standards to find es-toppel requires courts to effectively equate the two statutory regimes, and that is exactly what the Supreme Court counsels us against doing. But even without Black & Decker’s guidance, our court ought to distinguish between public and private “disability” determinations, for they are not the same.

Conflicts of Interest

The majority here does not analyze whether Kemper and Broadspire were acting under a conflict of interest but many cases in our circuit do evaluate such con-*558fliets.1 This line of argument stems from Justice O’Connor’s statement in a seminal 1989 ERISA decision: “Of course, if a benefit plan gives discretion to an administrator or fiduciary who is operating under a conflict of interest, that conflict must be weighed as a Tacto[r] in determining whether there is an abuse of discretion.’ ” Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115, 109 S.Ct. 948, 103 L.Ed.2d 80 (1989) (quoting Restatement (Second) of Trusts § 187 cmt. d (1959)). As other circuits have noted, “courts have struggled to give effect to this delphic statement, and to determine both what constitutes a conflict of interest and how a conflict should affect the scrutiny of an administrator’s decision to deny benefits.” Pinto v. Reliance Standard Life Ins. Co., 214 F.3d 377, 383 (3d Cir.2000), quoted by Denmark v. Liberty Life Assur. Co., 481 F.3d 16, 29 (1st Cir.2007).
In this circuit, we typically find a structural conflict of interest exists any time the entity paying benefits is also responsible for administering claims. See Miller v. Metro. Life Ins. Co., 925 F.2d 979, 984 (6th Cir.1991). It is not obvious to me why this must always be so, and other circuits have held that there is not an automatic conflict of interest in such situations. See, e.g., Davolt v. Executive Comm. of O’Reilly Auto., 206 F.3d 806, 809 (8th Cir.2000). ERISA was intended to govern the administration of private benefit plans, see 29 U.S.C. § 1001, and it seems odd to assume that companies would establish disability benefit plans only to deny benefits whenever possible. See Denmark, 481 F.3d at 29-30. We can safely assume that the employee’s interest is always to receive benefits when she asks for them. But we cannot assume the employer’s interest is to always deny benefits, which if true would greatly reduce the value of the benefit as an overall part of the employee’s compensation. And if that value were reduced, employees might seek additional compensation in other forms. It may, and often will, be in the employer’s financial interest to grant LTD benefits in some cases, especially the meritorious ones. I think we err, and misinterpret Justice O’Connor’s statement, when we create a structural conflict of interest based on the simplistic economic assumption that employers’ and employees’ interests will inevitably conflict.

File Reviews

Our circuit also seems troubled when administrators decline to have the claimant independently examined, see, e.g., Elliott v. Metro. Life Ins. Co., 473 F.3d 613, 621 (6th Cir.2006); Kalish v. Liberty Mutual/Liberty Life Assur. Co. of Boston, 419 F.3d 501, 509 (6th Cir.2005); Calvert v. Firstar Fin., Inc., 409 F.3d 286, 295 (6th Cir.2005), even though we find “nothing inherently objectionable about a file review by a qualified physician in the context of a benefits determination,” Calvert, 409 F.3d at 296. The Seventh Circuit recently found no
authority that generally prohibits the commonplace practice of doctors arriving at professional opinions after reviewing medical files. In such file reviews, doctors are fully able to evaluate medical information, balance the objective data against the subjective opinions of the treating physicians, and render an expert opinion without direct consultation. It is reasonable, therefore, for an *559administrator to rely on its doctors’ assessments of the file and to save the plan the financial burden of conducting repetitive tests and examinations.
Davis v. Unum Life Ins. Co., 444 F.3d 569, 577 (7th Cir.2006). It is odd to suggest that an administrator acts improperly by following standard practice in the health insurance industry, and I would follow the Seventh Circuit in not penalizing administrators who base their decisions on their experts’ file reviews.
Writing on a clean slate, I would not hold that the administrator’s decision was arbitrary and capricious. I cannot say that Bennett was deprived of the kind of contractually bargained-for benefit that ERISA was enacted to protect. But being bound by Sixth Circuit precedent until the Supreme Court or the en banc court rules otherwise, I concur in the judgment.

. As the majority opinion recognizes, the Supreme Court recently granted certiorari to review this issue in Glenn v. MetLife, 461 F.3d 660 (6th Cir.2006), cert. granted, 76 U.S.L.W. 3017, — U.S. —, 128 S.Ct. 1117, 169 L.Ed.2d 845, 2008 WL 161473 (U.S. Jan. 18, 2008) (No. 06-923).