Gothard v. Metropolitan Life Insurance

United States Court of Appeals
Fifth Circuit
F I L E D
IN THE UNITED STATES COURT OF APPEALS
June 27, 2007
FOR THE FIFTH CIRCUIT
Charles R. Fulbruge III
Clerk
No. 06-50386
c/w 06-50564

SUSAN GOTHARD,

Plaintiff-Appellee,

versus

METROPOLITAN LIFE INSURANCE CO.;
BUSINESS MEN’S ASSURANCE COMPANY OF AMERICA,

Defendants-Appellants.

Appeals from the United States District Court
For the Western District of Texas

Before HIGGINBOTHAM, DAVIS, and WIENER, Circuit Judges.

PATRICK E. HIGGINBOTHAM, Circuit Judge:

Susan Gothard sued her disability-plan fiduciary, MetLife, for

terminating her long-term disability payments. The district court

granted Gothard's motion for summary judgment, ruling that MetLife

abused its discretion because its decision was not supported by

substantial evidence. We must reverse because we conclude that it

was.

I

A

Susan Gothard worked as a legal secretary until she injured

her back on Feburary 6, 2001. She had surgery for a herniated
disc, but her recovery was cut short by a car accident, which made

her injury permanent. On May 4, 2001 she applied for long-term

disability benefits, was approved, and collected benefits until

MetLife terminated them in July 2003, finding that she could

perform sedentary work. Gothard filed this suit in federal

district court, and on cross-motions for summary judgment, the

district court held that MetLife’s decision to terminate her

benefits was arbitrary and capricious.

B

After her surgery, Gothard was under the care of Dr. Hunley

Chapman. On November 26, 2002, Dr. Chapman examined Gothard and

found that she would never return to work. He noted that she

reported pain as 8 out of 10, that it came on suddenly, that it was

better while she was lying down or had her legs elevated, and that

it was worse while sitting in a soft chair, walking for more than

10 minutes, or standing for more than five minutes. He noted a 50%

limitation in her lumbar range of motion. Dr. Chapman also

completed an assessment for MetLife. He reported that Gothard

could not lift over 10 pounds, but that she could do any of the

following activities for up to 33% of the time: bend, sit, drive,

push/pull, stand, walk, climb, craw, and squat/stoop. In the

“other limitation” section he noted that Gothard should not do any

long-term sitting or standing.

Upon reviewing this medical report, the MetLife case manager

notified Gothard that her file was being refered to a Nurse

2
Consultant for review because, in the case manager’s opinion,

Gothard should have been able to return to work as a legal

secretary. The Nurse consultant agreed, noting that even though

Gothard had been awarded SSI benefits, her medical file did not

support her claim that she couldn’t perform sedentary work.

Indeed, Dr. Chapman had noted that Gothard might be a candidate for

evaluation by the Texas Rehabilitation Commission.

MetLife’s decision to terminate Gothard’s benefits was soon

put on hold. In late January of 2003, Gothard received an epidural

steroid injection, and MetLife decided to wait for the updated

medical records. Those records indicated that Gothard had

progressed and responded to treatment. Dr. Chapman removed the

limitation on lifting up to 10 pounds, stating that Gothard could

occasionally, up to 33% of the time, carry up to 10 pounds. He

also reduced her medication, from six prescriptions to two. He

reiterated his 33% restriction on bending and sitting and standing.

In the same report, Dr. Chapman noted that Gothard could “never”

return to work. A few months later, in April of 2003, Gothard

reported that her pain was only of moderate discomfort, that it

came on gradually, and that it was better when she was sitting.

The plan’s definition of disability is time dependant, and May

8, 2003 was an important transition date under the plan. For the

first 24 months of benefits, disability is defined as when “the

insured cannot perform the essential duties of his or her regular

3
occupation on a full-time basis.” After 24 months, disability is

defined as when “the insured cannot perform the essential duties of

any occupation for which he or she is reasonably fitted by

training, education, or experience on a full-time basis.”

After May 8, 2003, MetLife conducted a labor market survey to

determine whether any jobs were available for Gothard. The survey

classified Gothard as a “secretary,” using the Department of

Labor’s Dictionary of Occupational Titles. The survey reported

that

all of the employers contacted regarding possible
sedentary jobs indicated sedentary work requirements with
no greater lifting than 10 lbs. And primarily sitting,
although this type of job would allow for change in
position. All of the positions would require occasional
bending (accommodations could be made).

MetLife concluded from this survey that Gothard could work several

jobs in the Waco area based on her training, education, and

experience. MetLife terminated Gothard’s LTD benefits in a letter

dated July 21, 2003.

Gothard filed an administrative appeal. Her record was

reviewed by Dr. Amy Hopkins, who found that Gothard’s medical file

contained no objective support for the proposition that Gothard was

unable to perform sedentary work. Dr. Hopkins reported that

Repeated exams by Dr. Chapman were notable only for LS
junction tenderness and reduced LS [range of motion].
There was not objective evidence of any radiculopathy,
neuropathy, myopathy, or plexopathy. Dr. Chapman also
noted on both 11/26/02 and 1/17/03 that [Gothard] had a
sedentary work capacity. Since [Gothard’s] own

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 occupation was sedentary, there was no objective support
in this file for [Gothard’s] inability to perform the
material duties of her own occupation.

Indeed, according to Dr. Hopkins’s review of the medical records,

there was nothing preventing Gothard from returning to her own

occupation. That is, Dr. Hopkins opined that nothing in the

medical record supported any restrictions on sitting, walking,

standing, or bending. Based on this opinion, on March 22, 2004,

MetLife upheld its own decision to terminate Gothard’s benefits.

Gothard then filed this lawsuit in federal district court, and the

district court granted Gothard’s cross motion for summary judgment.

II

A

MetLife is the plan fiduciary, vested with the discretionary

authority to determine disability claims under the plan. As such,

a district court may reverse MetLife’s decision regarding benefits

only for an abuse of discretion that yields an arbitrary and

capricious decision.1 A decision is arbitrary only if “made

without a rational connection between the known facts and the

decision or between the found facts and the evidence.”2 Our

standard of review is informed by MetLife’s conflict of interest,

for it is both the insurer and administrator of the disability

1
Meditrust Financial Services Corp. v. Sterling Chemicals, Inc., 168 F.3d
211, 214–15 (5th Cir. 1999); Vega v. National Life Ins. Services, 188 F.3d 287,
295 (5th Cir. 1999) (en banc).
2
Bellaire, 97 F.3d at 828-29.

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plan.3 We therefore apply a “sliding scale standard” and accord

MetLife’s decision less than full deference,4 reviewing the

district court’s grant of summary judgment de novo.5

B

MetLife urges this court to reverse, arguing that it did not

abuse its discretion in terminating benefits because there is

substantial evidence that Gothard could do sedentary work. Gothard

responds that, according to her treating doctor’s orders, she can

only sit for up to 33% of the work day, too little time for full-

time sedentary work. Gothard also notes that her treating doctor

opined that she could “never” return to work.

There is substantial evidence in support of Metlife’s

conclusion. Its labor market survey adopted the 33% sitting

limitation that was proposed by Gothard’s treating physician. The

survey found that even though sedentary jobs primarily involve

sitting, such sedentary jobs “would allow for change in position”

and that though all of the positions would require occasional

bending, “accommodations could be made.”

Even if this were not the case, the report of MetLife’s

consulting physician still provides substantial evidence in support

of MetLife’s decision. The Supreme Court has held that “plan

3
Id. at 295–97.
4
Id.
5
Baker v. Metropolitan Life Ins., 364 F.3d 624, 628 (5th Cir. 2004).

6
administrators are not obliged to accord special deference to the

opinions of treating physicians.”6 Accordingly, this court has

held that an administrator does not abuse its discretion when it

relies on the medical opinion of a consulting physician whose

opinion conflicts with the claimant’s treating physician.7 This is

so even if the consulting physician only reviews medical records

and never physically examines the claimant, taxing to credibility

though it may be.8

Dr. Hopkins reviewed the same medical records as the treating

physician and reached a different conclusion, opining that the

medical records did not support any restrictions that would prevent

Gothard from working as secretary. This conclusion, reached from

a desk in Connecticut, is in plain conflict with the treating

physician’s note that Gothard could “never” return to work. Yet

plan fiduciaries are allowed to adopt one of two competing medical

views, a rule which resolves this appeal in favor of MetLife.

We do not hold that a plan fiduciary has no obligation to

consider the basis of the expert opinion on which they are relying

at summary judgment, or that a fiduciary may rely on an opinion

that is in plain conflict with medical records. That is not this

6
Black & Decker Disability Plan v. Nord, 538 U.S. at 831.

7
Gooden v. Provident Life, 250 F.3d 329, 335 n.9 (5th Cir. 2001); MediTrust
v. Fin. Servs. Corp. v. Sterling Chems, 168 F.3d 211, 213 (5th Cir. 1999);
Sweatman v. Commercial Union Ins., 39 F.3d 594, 597 (5th Cir. 1994).
8
Id.

7
case. Dr. Hopkins opinion can be arguably supported by the medical

record, two assessments by Dr. Chapman, and the office visit notes.

Further, the labor market survey conducted by MetLife indicates

that sedentary jobs, requiring less than 33% sitting without change

of position, are available in the Waco labor market. We cannot say

that this finding is sustained by our experience or that it does

not conflict with our own judgment of what is required of a legal

secretary, yet the relevant question, by the terms of the plan, is

whether Gothard is “suited for any occupation for which he or she

is reasonably fitted by training, education, or experience on a

full-time basis.” MetLife’s decision may not be correct, but we

cannot say that it was arbitrary.9 The judgment of the district

court is REVERSED and REMANDED with instructions to enter judgment

in favor of MetLife.

9
We are not persuaded by MetLife’s suggestion that the district court gave
undo weight to a finding of disability under the federal social security scheme.

8