NOT RECOMMENDED FOR PUBLICATION
File Name: 06a0304n.06
Filed: May 3, 2006
No. 05-3380
UNITED STATES COURT OF APPEALS
FOR THE SIXTH CIRCUIT
CHARLES BUCHANAN,
Plaintiff-Appellant,
v. On Appeal from the United
States District Court for the
AETNA LIFE INSURANCE COMPANY, Northern District of Ohio
Defendant-Appellee.
/
BEFORE: RYAN, CLAY, and GILMAN, Circuit Judges.
RYAN, Circuit Judge. The plaintiff, Charles Buchanan, appeals the district
court’s judgment in favor of the defendant, Aetna Life Insurance Company, on his ERISA
claim for disability benefits, and on Aetna’s counterclaim for reimbursement of benefits it
overpaid Buchanan. We AFFIRM the court’s judgment in favor of Aetna on Buchanan’s
claim, but REVERSE the grant of summary judgment in favor of Aetna on its counterclaim.
I.
Buchanan began working as a computer programmer for Progressive Casualty
Insurance Company in September 1996 and was a participant under Progressive’s
Managed Disability Benefits Plan, which was administered by Aetna. Under the plan, a
participant was eligible to receive disability benefits after a period of 24 months only if he
was “not able, solely because of disease or injury, to work at any reasonable occupation.”
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The plan defined “reasonable occupation” as “any gainful activity for which you are, or may
reasonably become, fitted by education, training or experience.”
An eligible plan participant received a monthly disability benefit equal to a
percentage of his monthly salary, and the plan permitted Aetna to reduce that monthly
benefit by “other income benefits,” which included Social Security Disability Insurance
(SSDI) benefits. The plan also provided that the participant was required to repay to Aetna
any overpayment of benefits that resulted from the receipt of other income benefits.
II.
In June 1997, Buchanan left work due to hypertension and syncope, and began to
receive monthly disability benefits from Aetna in October 1997. In addition, he began
receiving SSDI benefits in January 1998. Aetna claims it did not learn about Buchanan’s
SSDI payments until September 1999.
In a letter dated October 7, 1999, Aetna informed Buchanan that it had overpaid him
by a total of $15,120 as a result of his receiving SSDI benefits in addition to Aetna’s full
monthly benefit. In order to recover at least part of that overpayment, Aetna began to
withhold benefit payments, but Aetna alleges that approximately $11,000 remains unpaid.
In 2000, Aetna conducted a review of Buchanan’s claim and concluded that he was
no longer entitled to disability benefits because he had received benefits for more than 24
months, and the evidence showed that he was able to perform the duties of a reasonable
occupation as defined by the plan. In a letter dated July 2000, Aetna informed Buchanan
that his benefits were terminated effective May 31, 2000. Buchanan asked Aetna to
reconsider its decision, but, in a letter to Buchanan dated April 2, 2001, Aetna upheld its
original decision.
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Buchanan filed a claim in the federal district court to recover benefits under ERISA
§ 502(a)(1)(B), 29 U.S.C. § 1132(a)(1)(B), and Aetna filed a counterclaim under ERISA for
reimbursement of benefits it allegedly overpaid. Buchanan filed a motion to supplement
the administrative record with, among other things, a 1997 MRI film and report that Aetna
and its independent medical examiner had allegedly refused to accept. The district court
denied that motion. Both parties then filed motions for judgment, and the court granted
judgment in favor of Aetna on Buchanan’s claims and Aetna’s counterclaim.
III.
Traditional summary judgment concepts are inapposite to the adjudication of an
ERISA action for benefits, brought under 29 U.S.C. § 1132(a)(1)(B), because the district
court is limited to the evidence before the plan administrator at the time of its decision, and
therefore, the court does not adjudicate an ERISA action as it would other federal civil
litigation. See Wilkins v. Baptist Healthcare Sys., Inc., 150 F.3d 609, 617-19 (6th Cir.
1998). We review de novo the district court’s ruling regarding an ERISA plan
administrator’s denial of benefits, applying the same legal standard as the district court.
Whitaker v. Hartford Life & Acc. Ins. Co., 404 F.3d 947, 949 (6th Cir. 2005). When the plan
provides the administrator discretionary authority to determine eligibility for benefits, the
arbitrary and capricious standard of review applies. Id. The district court held that Aetna
had discretionary authority under the plan to determine benefit eligibility, and Buchanan
appears to agree. Therefore, we review Aetna’s decision denying benefits under the
arbitrary and capricious standard of review.
An administrator’s conflict of interest does not alter the standard of review; rather,
the court should take that conflict into account when determining whether the
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administrator’s decision was arbitrary and capricious. Peruzzi v. Summa Med. Plan, 137
F.3d 431, 433 (6th Cir. 1998). We must uphold Aetna’s decision “if it is the result of a
deliberate, principled reasoning process and if it is supported by substantial evidence.”
Baker v. United Mine Workers of Am. Health & Ret. Funds, 929 F.2d 1140, 1144 (6th Cir.
1991). Because Aetna was both the insurer and the plan administrator, it had a conflict of
interest.
Although the district court discussed traditional summary judgment standards at
some length, the court nevertheless properly applied the arbitrary and capricious standard
of review using the evidence available to Aetna at the time of its decision. The court
acknowledged Aetna’s conflict of interest and the requirement that it factor that conflict into
its review. The court then determined that Aetna did not act in an arbitrary and capricious
manner when it terminated Buchanan’s benefits because reports from two independent
medical examiners provided a “reasoned explanation” for Aetna’s decision.
Buchanan points out that, in a letter, his doctor stated: “The resulting disability
produced by this condition has produced a severe degree of cognitive impairment and
fatigability which I strongly feel makes him disabled from working. . . . I believe Mr.
Buchanan is disabled from his previous type of employment (and perhaps from many types
of meaningful employment).” (Emphasis added.) But the test, according to the plan
language, is whether Buchanan was able to work at a “reasonable occupation,” which is
defined in the plan as “any gainful activity.” (Emphasis added.) The record shows that two
independent medical examiners concluded that Buchanan could perform meaningful work.
Although Aetna’s April 2, 2001, letter upholding its original decision to terminate
Buchanan’s benefits indicates that Aetna reviewed a portion of medical records belonging
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to someone other than Buchanan, we respectfully disagree with our dissenting colleague’s
position that Aetna’s error rendered its decision arbitrary and capricious.
The April 2, 2001, letter contains an incorrect address and social security number,
and it states that there is “no record provided of the cardiac cath findings,” but that “[t]here
are clear reports . . . of panic attacks and anxiety disorder, which responded to Xanax.”
Buchanan insists that he has never received a cardiac catheter or taken Xanax to control
anxiety, and there is no evidence in the record suggesting he has.
The letter also references the two independent medical examinations Aetna ordered
and the letter from Buchanan’s doctor, which provide substantial evidence in support of
Aetna’s decision to terminate Buchanan’s disability benefits. There is also no indication
that Aetna’s mistake of reviewing a portion of medical records belonging to someone other
than Buchanan resulted in a selective, inadequate, or otherwise unprincipled review of
Buchanan’s medical records. Therefore, we agree with the district court that the record
contains substantial evidence supporting Aetna’s decision to terminate Buchanan’s
disability benefits and that Aetna employed “a deliberate, principled reasoning process” to
reach that decision.
We also conclude that the court did not err in denying Buchanan’s motion to
supplement the administrative record with, among other things, a 1997 MRI film and report
indicating that he suffered a stroke. The district court may consider evidence outside of the
administrative record only if “consideration of that evidence is necessary to resolve an
ERISA claimant’s procedural challenge to the administrator’s decision, such as an alleged
lack of due process afforded by the administrator or alleged bias on its part.” Wilkins, 150
F.3d at 618. Buchanan did not raise a procedural challenge to Aetna’s decision in his
(No. 05-3380) -6-
motion to supplement the record. He simply argued that “the record is flawed and not
developed properly,” and he offered no evidence in support of the motion beyond the mere
allegation that Aetna refused to accept the proper MRI film and report.
IV.
Traditional summary judgment concepts do apply to the adjudication of Aetna’s
counterclaim for reimbursement. We review the district court’s legal conclusions and its
grant of summary judgment in favor of Aetna de novo, using the same Fed. R. Civ. P. 56(c)
standard as the district court. Summary judgment is proper only where “the pleadings,
depositions, answers to interrogatories, and admissions on file, together with the affidavits,
if any, show that there is no genuine issue as to any material fact and that the moving party
is entitled to a judgment as a matter of law.” Fed. R. Civ. P. 56(c); Appalachian Res. Dev.
Corp. v. McCabe, 387 F.3d 461, 463 (6th Cir. 2004).
The parties do not dispute the facts. The terms of the plan clearly provide that
Buchanan is obligated to reimburse Aetna for the benefits it overpaid as a result of his
receipt of SSDI benefits. Buchanan argues only that the law does not provide Aetna with
a remedy. Unfortunately, we must agree. The Supreme Court’s decision in Great-West
Life & Annuity Insurance Co. v. Knudson, 534 U.S. 204 (2002), and our later decision in
Qualchoice, Inc. v. Rowland, 367 F.3d 638 (6th Cir. 2004), cert. denied, 125 S. Ct. 1639
(2005), prohibit Aetna from recovering the money it overpaid.
29 U.S.C. § 1132(a)(3) provides that an ERISA civil action may be brought:
by a participant, beneficiary, or fiduciary (A) to enjoin any act or
practice which violates any provision of this subchapter or the terms of the
plan, or (B) to obtain other appropriate equitable relief (i) to redress such
violations or (ii) to enforce any provisions of this subchapter or the terms of
the plan.
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(Emphasis added.) In Knudson, the Supreme Court held that the term “equitable relief” in
29 U.S.C. § 1132(a)(3) refers to the categories of relief typically available in equity.
Knudson, 534 U.S. at 209-10. The Court further explained that not all forms of restitution
were available in equity and that “a plaintiff could seek restitution in equity, . . . where
money or property identified as belonging in good conscience to the plaintiff could clearly
be traced to particular funds or property in the defendant’s possession.” Id. at 213.
The money Aetna claims it overpaid to Buchanan is not clearly traceable to particular
funds in his possession. Although Aetna characterizes its claim as one for unjust
enrichment, it actually seeks “legal relief—the imposition of personal liability . . . for a
contractual obligation to pay money.” Id. at 221. As we held in Qualchoice, “a plan
fiduciary’s action to enforce a plan-reimbursement provision is a legal action,” which 29
U.S.C. § 1132(a)(3) does not authorize. Qualchoice, 367 F.3d at 650.
V.
For these reasons, we AFFIRM the district court’s judgment in favor of Aetna on
Buchanan’s claim for benefits under 29 U.S.C. § 1132(a)(1)(B), and we REVERSE the
court’s grant of summary judgment in favor of Aetna on the counterclaim for reimbursement
of benefits it overpaid and REMAND to the district court.
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Clay, Circuit Judge, dissenting in part. I agree that the district court improperly
granted summary judgment to Defendant on Defendant’s recoupment of overpayments
claim. I disagree with the majority, however, that Defendant’s denial of benefits was the
result of a “deliberate, principled reasoning process” because the evidence clearly shows
that Defendant considered, in part, someone else’s medical records when it evaluated
Plaintiff’s case. I would therefore vacate the grant of summary judgment for Defendant on
Plaintiff’s denial of benefits claim and remand the case to the district court, with instructions
for further remand to the plan administrator for a proper consideration of Plaintiff’s claim for
benefits.
I.
BACKGROUND
On September 16, 1996 Plaintiff was hired by Progressive Insurance Co. as a
computer programmer/analyst. Plaintiff then enrolled in Progressive’s ERISA-governed
disability benefits plan, for which Defendant was the claims administrator.
Plaintiff had a history of hypertension, which Plaintiff alleges was under control until
February 1997, at which time Plaintiff underwent an appendectomy. Subsequent to the
appendectomy, Plaintiff's recovery was difficult and resulted in an increase in his
hypertension and a “cerebrovascular accident.” Plaintiff left work on June 5, 1997 due to
hypertension and syncope,1 and in October 1997 Plaintiff's treating physician diagnosed
1
syncope: a temporary suspension of consciousness due to generalized cerebral
ischemia (deficiency in blood). Dorland’s Illustrated Medical Dictionary 1514 (25th ed.
1974).
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the likely cause of the syncope as a stroke, or brain stem infarct,2 in early June 1997. After
performing an MRI to confirm the infarct, Plaintiff's physician, Dr. Grubb, diagnosed Plaintiff
with autonomic dysfunction resulting from damage to the brain stem area controlling
autonomic function. Plaintiff’s condition resulted in extreme migraines and fatigability, in
addition to syncopal episodes. Plaintiff applied for and received disability benefits
commencing in October 1997.
On October 7, 1999, Defendant requested reimbursement from Plaintiff for alleged
overpayments for the period of January 1, 1998 through September 30, 1999, during which
time Plaintiff was also receiving social security disability payments. Defendant alleged that
long term disability payments were offset under the plan to the extent of any social security
disability monies received.
After 24 months of disability, Plaintiff’s disability plan provided for continuing
payments only if a claimant “cannot perform all of the material duties of any gainful
occupation for which [claimant] [is] or may become reasonably fitted by training, education
or experience.” (J.A. at 201.) Defendant therefore undertook a review of Plaintiff’s
disability status in 2000. In a letter dated July 13, 2000, Defendant informed Plaintiff that
its review of Plaintiff's condition did not support Plaintiff's continued status as disabled.
Defendant stated that information provided by Plaintiff’s attending physician, a Dr. Grubb,
indicated that there was no objective information which supported Plaintiff's ongoing
disability. Defendant further noted that based on information from Dr. Grubb, it “appears
2
infarct: an area of coagulation necrosis in a tissue due to local ischemia resulting
from obstruction of circulation to the area. Dorland’s Illustrated Medical Dictionary, supra
note 1, at 778.
(No. 05-3380) - 10 -
your condition is under reasonable control and you would be able to perform the duties of
sitting, computer keyboarding [and] programming, and phone work.” (J.A. at 201.)
Defendant therefore terminated Plaintiff's disability benefits as of May 31, 2000.
On July 24, 2000 Plaintiff appealed Defendant's termination of benefits through
Defendant's administrative appeals procedure. Defendant submitted a letter from Dr.
Grubb which referenced the MRI confirming the brain stem stroke and repeating his
diagnosis of autonomic disorder manifesting in cognitive impairment, severe migraines, and
fatigability. The letter also stated Dr. Grubb’s opinion that Plaintiff “is disabled from his
previous employment (and perhaps from many types of meaningful employment ).” (J.A.
at 171.) Defendant then referred Plaintiff for evaluation by independent medical personnel
of the North American Medical Evaluations, Inc. Plaintiff was given a psychological
evaluation and a medical exam. The psychologist determined that Plaintiff performed in
the average range of cognitive function, exhibited mild impairment in some motor function,
exhibited mild depression, and showed difficulty in maintaining alertness. The psychological
report concluded that Plaintiff could return to work if given accommodations such as
frequent breaks to refresh alertness.
Plaintiff’s independent medical examination took place on November 21, 2000. In
the letter notifying Plaintiff of the medical appointment, Defendant invited Plaintiff to “obtain
and bring any medical records, X-ray films, MRI films and any test results to assist in this
evaluation.” (J.A. at 169.) Defendant alleges that Plaintiff produced no MRI showing his
brain stem infarct. Plaintiff alleges that Plaintiff brought the relevant MRI, dated September
29, 1997, with him to the medical evaluation, but that the physician refused to take the film
from Plaintiff, saying instead that the physician would procure the MRI from the hospital.
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Plaintiff further alleges that his wife sent a copy of the relevant MRI to Defendant at some
time.
The independent medical evaluation concluded that “[t]he patient has hypertension
and depression. There is no clearcut explanation of his episodic complaints. Of note,
however, I see no clearcut reason why this patient could not perform his previous
employment.” (J.A. at 151.) Earlier in the letter, the physician noted that Plaintiff took
Celexa for his depression. The physician further noted that while Plaintiff’s wife reported
to him an MRI revealing a stroke, the “official report . . . on the head MRI study obtained
through . . . Akron General Medical Center [dated] October 23, 1998 was negative except
for ‘mild bilateral maxillary and ethmoid sinusitis.’” (J.A. at 150.)
There is no indication in Plaintiff’s medical records from his treating physicians that
Celexa was described for depression. Rather, Celexa, while a popular antidepressant,
appears to have been prescribed by Dr. Grubb to address Plaintiff’s headaches and
extreme fatigue. (See J.A. at 190.) Nothing in Plaintiff’s medical records reveals a
diagnosis of depression by his attending physicians. (See J.A. at 223, Medical Provider
Statement by Dr. Grubb, noting diagnosis of syncope and autonomic disorder, but not
depression, and recording Celexa as a prescribed medication).)
In a letter dated April 2, 2001, Defendant denied Plaintiff’s appeal of the termination
of his disability benefits. The letter was addressed to Plaintiff, but contained the wrong
address and the wrong social security number. The letter summarized Defendant’s
assessment of Plaintiff's claim:
Your diagnosis is autonomic dysfunction syndrome, stroke secondary
to anesthesia during surgery and cervical pain.
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You have been out of work as a Computer Programmer/Analyst since
June 5, 1997 due to hypertension syncope. Office notes indicate that you
were told in October, 1997 that you may have had a stroke over the summer.
Rehabilitation followed your case with the onsite individual from October
1997. In June, 1998, it appeared that you were released to return to work but
you developed panic attacks therefore a psychiatric referral was made. You
had medication changes that made you ill that psychiatric referral was
cancelled and was not rescheduled. Other notes indicate that you had a
cardiac cath[eter] on August 4, 1999 with discharge on August 5, 1999 with
possible surgery indicated, but no surgery was noted. On February 15, 2000
notes your doctor reported that you have had no recent syncopal episodes
and your blood pressure was well controlled. You stated you may possibly
have sleep apnea but sleep studies were normal.
There are numerous reports from you and your wife regarding your
symptoms but there is very little objective medical information. The objective
information that is present was all provided in the first 2 years of your
disability. There is no clinical record provided to substantiate seizure
disorder, no MRI report confirming a stroke and no record provided of cardiac
cath findings. There are clear reports from your doctor’s officer of panic
attacks and anxiety disorders, which responded to Xanax. There have been
no observable, objective tests, which substantiate total disability to any
reasonable occupation.
You reported you were unable to drive due to severity of fatigue and
sleepiness, but surveillance is reported to clearly document otherwise.3
(J.A. at 374-75.)
There is no indication in Plaintiff’s medical records that Plaintiff ever received a
cardiac catheter or was ever even referred for such a procedure, and Plaintiff denies
undergoing any. Plaintiff further alleges that the denial letter references medications that
Plaintiff never took. Plaintiff’s address was, at all relevant times, 372 East Cassell Ave.,
Barberton, OH 44203. The letter was addressed to Plaintiff at 6020 Periwinkle Dale,
3
Defendant had Plaintiff surveilled on May 11, 13, and 15, 2000. The surveillance
reports indicated that Plaintiff was observed on May 11 operating a Mazda pick-up three
times, and on May 13 he operated the same truck for a single trip to the local middle
school. (J.A. at 198-200.)
(No. 05-3380) - 13 -
Seneca, SC 29672. Plaintiff’s social security number is xxx-xx-2752. The letter referenced
social security number xxx-xx-6220. (full social security numbers omitted for confidentiality
purposes)
II.
ANALYSIS
A. The District Court Erred by Refusing to Permit Wilkins Discovery
This Court reviews the district court’s decision on whether to permit discovery
beyond the administrative record de novo. Cf. Putney v. Medical Mut., 111 Fed. Appx. 803,
806 (6th Cir. 2004) (unpublished opinion).
Plaintiff argues that the district court should have granted Plaintiff’s motion to either
supplement the administrative record or remand for correction because Defendant violated
Plaintiff's procedural due process rights when it refused to consider the September 27,
1997 MRI. Plaintiff presents evidence that the MRI had been available to Defendant
(Plaintiff's wife having proffered the MRI to the physician performing the independent
medical evaluation) in the form of an affidavit from Plaintiff and Plaintiff’s wife; the affidavit
had the referenced MRI attached. (See J.A. at 48-50.) Defendant asserts in briefs to this
Court that the MRI's lack of presence in the administrative record proves its unavailability
to Defendant, but puts forth no evidence, save the state of the administrative record itself,
in support of that assertion.
In Wilkins, this Court clarified when and to what extent a district court may go
beyond the administrative record in reviewing an ERISA administrator’s decision. Wilkins
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v. Baptist Healthcare Sys., Inc., 150 F.3d 609, 618-19 (6th Cir. 1998). This Court instructed
district courts to follow a two-step process in adjudicating an ERISA benefit action:
1. As to the merits of the action, the district court should conduct a de
novo [or arbitrary and capricious] review based solely upon the administrative
record, and render findings of fact and conclusions of law accordingly. The
district court may consider the parties’ arguments concerning the proper
analysis of the evidentiary materials contained in the administrative record,
but may not admit or consider any evidence not presented to the
administrator.
2. The district court may consider evidence outside of the administrative
record only if that evidence is offered in support of a procedural challenge to
the administrator’s decision, such as an alleged lack of due process afforded
by the administrator or alleged bias on its part. This also means that any
prehearing discovery at the district court level should be limited to such
procedural challenges.
Id.
Plaintiff has alleged a procedural violation by Defendant. If true, the procedural
violation is significant, for it wrongfully precluded the only fully objective medical evidence
of the cause of Plaintiff's condition from appearing in the administrative record. Under
Wilkins, the district court should have permitted discovery to the extent the parties could
adduce evidence as to whether Defendant had the September 1997 MRI available to it
when ruling on Plaintiff’s claim for continued benefits.
Should discovery have revealed that Defendant did have the MRI available to it, the
district court could have followed one of two recourses. First, the district court could have
permitted the parties to supplement the administrative record with the MRI and any relevant
medical interpretations of the MRI. Id. Second, and perhaps more appropriately, the
district court could have remanded the case to the administrator. Vanderklok v. Provident
Life & Accident Ins. Co., 956 F.2d 610, 619 (6th Cir. 1992). While remand is appropriate
(No. 05-3380) - 15 -
only in those cases where some useful purpose would be served from remand, the
inclusion of the MRI in the administrative record, as the only objective evidence of the
cause of Plaintiff's condition, is central to the benefits determination and therefore justifies
such remand. See Kent v. United of Omaha Life Ins. Co., 96 F.3d 803, 807-08 (6th Cir.
1996).
B. The District Court Erred in Granting Summary Judgment to Defendants on
Plaintiff's Claim for Benefits
1. Standard of Review
In an ERISA benefits case, this Court reviews de novo a district court's decision on
the administrative record. See Spangler v. Lockheed Martin Energy Sys., 313 F.3d 356,
361 (6th Cir. 2002). The general rule is to review a plan administrator’s denial of ERISA
benefits de novo. Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989).
However, where, as is the case here, a plan vests the administrator with complete
discretion in making eligibility determinations, such determinations will stand unless they
are arbitrary or capricious. Id.4 A benefit denial is arbitrary and capricious if the
administrative record cannot support the rationale of the benefits denial as a “reasoned
explanation.” See Moon v. Unum Provident Corp., 405 F.3d 373, 381 (6th Cir. 2005). The
“explanation must be consistent with the quantity and quality of the medical evidence that
is available on the record.” Id. (internal quotation and citation omitted).
4
Plaintiff argues that the district court did not properly consider Defendant’s conflict
of interest insofar as Defendant is both the claims administrator and the insurer. This Court
has repeatedly held that such a conflict of interest does not change the standard of review,
but is factored into the analysis going to whether the administrator’s decision was arbitrary
and capricious. See Darland v. Fortis Benefits Ins. Co., 317 F.3d 516, 527 (6th Cir. 2003).
(No. 05-3380) - 16 -
Absent a procedural challenge, the review of the courts is confined to the
administrative record as it existed on the date of the administrator's decision. See Wilkins,
150 F.3d at 615. If the administrative record so limited supports the administrator's action
as a "reasoned" decision, the decision is not arbitrary or capricious. Williams v. Int’l Paper
Co., 227 F.3d 706, 712 (6th Cir. 2000). As this Court has recently observed, however, “the
arbitrary-and-capricious . . . standard does not require us merely to rubber stamp the
administrator’s decision.” Jones v. Metro. Life Ins. Co., 385 F.3d 654, 661 (6th Cir. 2004).
Indeed, “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).
2. Significant References to Medical Records Other Than Plaintiff’s Renders the
Administrator’s Denial Arbitrary and Capricious
Defendant’s decision is unsupported by the record because Defendant’s denial letter
contains such egregious errors going both to Plaintiff’s identify and Plaintiff's medical
records that Defendant's decision can only be arbitrary and capricious.
By all indications, Defendant considered someone else's medical records in
conjunction with Plaintiff's records in making its 2001 benefits determination. The April 2,
2001 denial letter referenced the wrong address, the wrong social security number, and
included references to medical treatments and conditions which Plaintiff never had,
including a heart catheter, depression, and a number of drug prescriptions. Few
administrator decisions could be more “arbitrary and capricious” than a denial of benefits
in partial reliance on the medical records of someone else.
A Fourth Circuit district court has dealt with just such an administrator's decision and
concluded that a benefits decision based, in part, on medical records not belonging to the
(No. 05-3380) - 17 -
claimant revealed a decision process so flawed that it was “unprincipled and
unreasonable.” See Watson v. Unum Provident Corp., 185 F. Supp. 2d 579, 586 (D. Md.
2002). This Court has always required that the record support the reasoning of an
administrator’s decision. See Moon, 405 F.3d 373, 378 (6th Cir. 2005). Someone else’s
medical records cannot support a “reasoned decision” going to Plaintiff’s claim for benefits.
Summary judgment for Defendant was improper.
I therefore dissent from the majority’s affirmance of the district court’s summary
judgment for Defendant on Plaintiff’s denial of benefits claim.