United States Court of Appeals,
Fifth Circuit.
No. 94-40474
(Summary Calendar).
Cynthia SWEATMAN, Plaintiff-Appellant,
v.
COMMERCIAL UNION INSURANCE CO., et al., Defendants-Appellees.
Dec. 9, 1994.
Appeal from the United States District Court for the Western
District of Louisiana.
Before SMITH, EMILIO M. GARZA and PARKER, Circuit Judges.
EMILIO M. GARZA, Circuit Judge:
After Metropolitan Life Insurance Company ("MetLife") denied
Cynthia Sweatman's claim for disability benefits, Sweatman brought
an action under ERISA, 29 U.S.C. § 1132(a)(1)(B) (1988), seeking
district court review of MetLife's determination. The court upheld
MetLife's decision, and Sweatman appeals. We AFFIRM.
I
Cynthia Sweatman worked for Commercial Union Insurance Co.
("Commercial Union") for nineteen years as a claims adjuster, a job
that required her to climb ladders, inspect roofs, and crawl under
houses. When Sweatman stopped working for Commercial Union, she
timely submitted a statement of claim for benefits under Commercial
Union's Long Term Disability Plan ("the Plan"). Sweatman claimed
that her medical condition (listed as rheumatoid arthritis and/or
1
fibrositis) rendered her unable to perform any of her job duties.1
Under the terms of the Plan, Sweatman was eligible for
long-term disability benefits if she was totally disabled. The
Plan defines "total disability" as follows:
"Total Disability" means that during the first 24 months of
disability you are unable because of sickness or accident to
perform the duties of your own occupation for any employer.
Thereafter, "total disability" means the inability to perform
any occupation for which you are fitted by training,
education, or experience.
Record on Appeal, vol. 1, at 48. As claims administrator for the
Plan,2 MetLife sought to determine whether Sweatman was in fact
"totally disabled." Shirley Darvasi, a claim reviewer employed by
MetLife, attempted to gather Sweatman's medical records from her
various physicians. At first, this task proved difficult. Dr.
Burda, the physician who completed the Attending Physician
Statement accompanying Sweatman's disability claim, did not
promptly produce Sweatman's complete medical records.
To expedite its review of Sweatman's claim, MetLife sent the
records it had received to Underwriting Medical Actuarial
Consultants, Inc. ("UMAC"). Dr. Peter Blendonhy, a board certified
physiatrist retained by UMAC, reviewed Sweatman's medical records
and concluded that they did "not support limitations on work or
physical activity." After UMAC's peer review board, the
1
Pending determination of her disability claim, Sweatman
received a percentage of her salary under Commercial Union's
"salary continuation plan," which provided for such payments "in
the event of an illness or accident resulting in [the] inability
to work."
2
In addition to acting as claims administrator, MetLife
insured the plan.
2
"Physician's Roundtable," reviewed and concurred with Dr.
Blendonhy's opinion, UMAC sent MetLife a report summarizing its
findings. The report pointed to numerous deficiencies in
Sweatman's medical records and noted that the diagnosis of
rheumatoid arthritis had not been established according to the
American Rheumatism Association's criteria.
Even after receiving UMAC's report, MetLife continued its
efforts to obtain Sweatman's complete medical records. After
repeatedly contacting the physicians listed on Sweatman's
disability claim, MetLife was able to gather additional records.
Because these records had not been considered by UMAC in its first
review, MetLife forwarded the additional records to UMAC for a
second review. Dr. Dwyer, an orthopedic surgeon, reviewed the
complete records and concluded that they did not support the
physical limitations that Sweatman claimed. After its Physician's
Roundtable reviewed and concurred with Dr. Dwyer's opinion, UMAC
issued a second report summarizing its findings. Specifically,
UMAC found that Sweatman's lab work refuted a diagnosis of
rheumatoid arthritis. UMAC also concluded that "the diagnosis of
fibromyositis or fibromyalgia, if accepted, is certainly not
substantiated to the degree that would disable Sweatman."
MetLife also hired Equifax Services ("Equifax") to investigate
Sweatman's claim. An investigator working for Equifax interviewed
Sweatman's neighbors and a local merchant who operated a business
across the street from that of Sweatman's husband. None of these
sources knew of Sweatman's disability. The neighbors reported that
3
Sweatman was taking care of her husband, who was confined to a
wheelchair after suffering a stroke, on a full-time basis. The
investigator also interviewed Sweatman and reported that she "moved
about with no apparent restrictions or obvious signs of
impairments."
Based on Sweatman's medical records, the two UMAC reports, the
Equifax claim investigation, and its own employment-related
information, Darvasi recommended in writing to her supervisor Allen
Carson, a MetLife unit claims manager, that Sweatman's disability
claim be denied. Carson reviewed the claim file and agreed that
Sweatman was not totally disabled within the meaning of the Plan.
MetLife then informed Sweatman by letter of the denial and
explained its reasons for denying her claim. MetLife also
explained that Sweatman could request reconsideration of her claim.
When Sweatman requested review of the denial, MetLife
forwarded her file to Laura Sullivan, a "procedure analyst" at
MetLife who had not been involved in the prior decision to deny
Sweatman's claim. Sullivan reviewed the file and upheld the
original determination. Consequently, MetLife informed Sweatman by
letter of its decision to uphold the earlier denial.
Sweatman filed suit under ERISA, 29 U.S.C. § 1132(a)(1)(B)
seeking district court review of MetLife's disability
determination.3 After a bench trial submitted on pleadings,
3
29 U.S.C. § 1132(a)(1)(B) provides that "[a] civil action
may be brought ... by a participant or beneficiary ... to recover
benefits due to him under the terms of his plan, to enforce his
rights under the terms of the plan, or to clarify his rights to
future benefits under the terms of the plan."
4
depositions, and the administrative record, the court held that
MetLife did not abuse its discretion when it denied Sweatman's
claim and entered judgment against Sweatman. Sweatman now appeals,
alleging: (1) that the district court erroneously applied an abuse
of discretion standard of review to MetLife's determination; and
(2) that even if "abuse of discretion" was the proper standard,
MetLife abused its discretion in determining that Sweatman was not
"totally disabled."
II
A
Sweatman argues that the district court erroneously applied
an abuse of discretion standard of review to MetLife's denial of
her claim. In the Fifth Circuit, the proper standard for district
court review of a plan administrator's benefit determination is
governed by the Supreme Court's decision in Firestone Tire and
Rubber Co. v. Bruch, 489 U.S. 101, 109 S.Ct. 948, 103 L.Ed.2d 80
(1989), and our decision in Pierre v. Connecticut General Life
Insurance Co., 932 F.2d 1552 (5th Cir.), cert. denied, --- U.S. ---
-, 112 S.Ct. 453, 116 L.Ed.2d 470 (1991). In Bruch, the Court held
that "a denial of benefits challenged under § 1132(a)(1)(B) is to
be reviewed under a de novo standard unless the benefit plan gives
the plan administrator or fiduciary discretionary authority to
determine eligibility for benefits or to construe the terms of the
plan." 489 U.S. at 115, 109 S.Ct. at 956-57. In Pierre, we held
"that for factual determinations under ERISA plans, the abuse of
discretion standard of review is the appropriate standard." 932
5
F.2d at 1562.4 Consequently, district courts in the Fifth Circuit
review under an abuse of discretion standard a plan administrator's
factual determinations and determinations made pursuant to a plan
that gives the administrator discretionary authority to determine
eligibility or interpret the terms of the plan.
Sweatman concedes that MetLife's determination that she was
not disabled was "more factual in nature than interpretive in
nature," and therefore is ordinarily subject to abuse of discretion
review by the district court under Pierre. However, she argues
that two special circumstances in her case warrant heightened
scrutiny of MetLife's decision.
1
First, she argues that because she was deprived of the "full
and fair review" of her claim required by ERISA, 29 U.S.C. §
1133(2) (1988), the district court should have reviewed MetLife's
decision de novo. We do not reach this issue5 because in this case
MetLife conducted a "full and fair review" of Sweatman's claim.
Section 1133(2) provides that "every employee benefit plan
shall ... afford a reasonable opportunity to any participant whose
4
We recently reaffirmed this standard in Southern Farm
Bureau Life Insurance Co. v. Moore, 993 F.2d 98, 101 (5th
Cir.1993).
5
Sweatman cites no authority for the proposition that
noncompliance with § 1133(2) would warrant heightened scrutiny of
MetLife's disability determination. In Weaver v. Phoenix Home
Life Mutual Insurance Co., 990 F.2d 154 (4th Cir.1993), the
Fourth Circuit held that a plan administrator's noncompliance
with § 1133(1) was evidence of abuse of discretion, but the court
did not apply a heightened standard of review. See id. at 158-
59.
6
claim for benefits has been denied for a full and fair review by
the appropriate named fiduciary of the decision denying the
claim."6 Other circuits have explained that "full and fair review
means "knowing what evidence the decision-maker relied upon, having
an opportunity to address the accuracy and reliability of the
evidence, and having the decision-maker consider the evidence
presented by both parties prior to reaching and rendering his
decision.' " Sage v. Automation, Inc. Pension Plan & Trust, 845
F.2d 885, 893-94 (10th Cir.1988) (quoting Grossmuller v.
International Union Local 813, 715 F.2d 853, 858 n. 5 (3d
Cir.1983)).
Sweatman argues that MetLife's review of her claim was
inadequate because "the word "review' contemplates an examination
and evaluation of the file by someone other than the various people
who initially denied the claim." This argument is both legally and
factually inaccurate. The word "review" does not connote
examination by a second party. Instead, "review" means "to view,
6
The Department of Labor's regulations further elaborate on
the "full and fair review" requirement of 29 U.S.C. § 1133(2):
Every plan shall establish and maintain a procedure by
which a claimant or his duly authorized representative
has a reasonable opportunity to appeal a denied claim
to an appropriate named fiduciary or to a person
designated by such fiduciary, and under which a full
and fair review of the claim and its denial may be
obtained. Every such procedure shall include but not
be limited to provisions that a claimant or his duly
authorized representative may: (i) Request a review
upon written application to the plan; (ii) Review
pertinent documents; and (iii) Submit issues and
comments in writing.
29 C.F.R. § 2560.503-1(g) (1993).
7
look at, or look over again." The Random House College Dictionary
1130 (Rev. ed. 1980); see also Black's Law Dictionary 1320 (6th
ed. 1990) ("Review. To re-examine judicially or administratively.
A reconsideration; second view or examination; revision;
consideration for purposes of correction."). We have found no case
law supporting Sweatman's interpretation of "review" as it appears
in § 1133(2). To the contrary, courts have held that a plan
administrator's reconsideration of its prior decision satisfies §
1133(2). See, e.g., Brown v. Retirement Comm., 797 F.2d 521, 534-
35 (7th Cir.1986) (committee's review of its own decision
"satisfied the section 1133 requirement of a full and fair review
by the appropriate named fiduciary"), cert. denied, 479 U.S. 1094,
107 S.Ct. 1311, 94 L.Ed.2d 165 (1987); see also Davidson v.
Prudential Ins. Co., 953 F.2d 1093, 1096 (8th Cir.1992)
(Prudential's reconsideration of permanent disability claim three
times was "full and fair review").
Furthermore, even if § 1133(2) required review by a second
decision-maker, MetLife's procedure did involve such review. As
Sweatman acknowledges in her brief, Laura Sullivan, who was not
involved in the original disability determination, reviewed
Sweatman's file and the recommendations of Shirley Darvasi, "the
original claim reviewer." We cannot agree that a second review of
the recommendations of an "original reviewer" does not amount to a
"review" as contemplated by § 1133(2).7
7
Sweatman also argues that Sullivan could not have
adequately reviewed Sweatman's claim because "Paragraph 6 of her
affidavit states that, "based upon my ERISA review of MetLife's
8
Sweatman has not pointed to any other procedural deficiency in
MetLife's review of her claim. Therefore, we hold that the
district court properly declined Sweatman's request that it review
MetLife's decision with heightened scrutiny on the grounds that
MetLife failed to comply with § 1133(2).
2
Sweatman also argues that MetLife's inherent conflict of
interest as plan administrator and benefit insurer warranted
heightened scrutiny by the district court. We have previously
held, however, that a conflict of interest does not change the
standard of review. Salley v. DuPont de Nemours & Co., 966 F.2d
1011, 1014 (5th Cir.1992). Instead, the district court should
weigh any potential conflict of interest in its determination of
whether the plan administrator abused its discretion. Id.;
Haubold v. Intermedics, Inc., 11 F.3d 1333, 1337 (5th Cir.1994).8
denial decision, MetLife again determined that Ms. Sweatman was
not totally disabled from performing her job and, therefore,
upheld the decision to deny benefits.' " This statement is
inaccurate, according to Sweatman, because Drs. Dwyer and
Blendonhy "did not base their decisions upon any conclusion that
she wasn't disabled but, in fact, denied the claim because they
did not believe there were sufficient records of medical findings
to support the disability opinion offered by plaintiff's treating
physicians." This argument assumes that UMAC played a greater
role than it actually did in MetLife's disability determination
process. MetLife asked Drs. Dwyer and Blendonhy to review
Sweatman's medical records to ascertain whether the documents
supported Sweatman's claimed physical limitations. With the
benefit of these opinions, MetLife, the plan administrator, made
the ultimate determination that Sweatman was not totally
disabled. See infra part II.B.2.
8
See also Duhon v. Texaco, Inc., 15 F.3d 1302, 1306 (5th
Cir.1994) (plan administrator's possible conflict of interest did
not change abuse of discretion standard of review); Callahan v.
Rouge Steel Co., 941 F.2d 456, 459 (6th Cir.1991) (conflict of
9
In this case, the district court properly reviewed MetLife's
decision under the abuse of discretion standard, weighing MetLife's
conflict of interest as a factor in that review.
B
Sweatman argues in the alternative that even if the court
applied the proper standard of review, it erroneously concluded
that MetLife did not abuse its discretion. Both parties cast our
standard of review on appeal as whether the district court's
"finding" was erroneous. However, Sweatman attacks not the
district court's findings of fact, but rather the district court's
holding that the plan administrator's denial of benefits was not an
abuse of discretion. The posture of this case requires us to
clarify the proper standard of review on appeal from a district
court's review of a denial of benefits under § 1132(a)(1)(B).
1
The Supreme Court's holding in Bruch that "a denial of
benefits challenged under § 1132(a)(1)(B) is to be reviewed under
a de novo standard unless the benefit plan gives the plan
administrator or fiduciary discretionary authority to determine
interest is a factor to be considered in determining whether plan
administrator abused its discretion); Brown v. Blue Cross & Blue
Shield, 898 F.2d 1556, 1563 (11th Cir.1990) (arbitrary and
capricious standard applies to case in which administrator is
insurer, but application of the standard is shaped by the
circumstances of the inherent conflict of interest), cert.
denied, 498 U.S. 1040, 111 S.Ct. 712, 112 L.Ed.2d 701 (1991).
Contra Bogue v. Ampex Corp., 976 F.2d 1319, 1325 (9th Cir.1992)
("This court has confirmed that less deference applies when the
administrator's decision involves a "serious conflict' between
the administrator and the employee."), cert. denied, --- U.S. ---
-, 113 S.Ct. 1847, 123 L.Ed.2d 471 (1993).
10
eligibility for benefits or to construe the terms of the plan," 489
U.S. at 115, 109 S.Ct. at 956-57, describes the district court's
standard of review—not that of the Court of Appeals.9 Plaintiffs
who file suit under § 1132(a)(1)(B) to challenge denials of
benefits do so in district court, and the district court reviews
the plan administrator's decision. Then, if a party appeals the
district court's judgment, we review its decision. On appeal, our
standard of review for district court decisions reviewing plan
administrators' eligibility determinations is guided by the
principles that typically guide our standard of review. Namely, we
review questions of law de novo and set aside factual
determinations only if clearly erroneous. Odom v. Frank, 3 F.3d
839, 843 (5th Cir.1993). Consistent with these principles, we
review a district court's determination of whether a plan
administrator abused its discretion—a mixed question of law and
fact—de novo.10 Our review of the district court's holding will
then require us to apply Bruch and Pierre to determine what
9
Similarly, our holding in Pierre "that for factual
determinations under ERISA plans, the abuse of discretion
standard of review is the appropriate standard," 932 F.2d at
1562, also describes the district court's standard of review.
10
Cf. Phillips v. Alaska Hotel & Restaurant Employees
Pension Fund, 944 F.2d 509, 515 (9th Cir.1991) (question whether
pension plan trustees acted arbitrarily and capriciously is mixed
question of law and fact; ultimate conclusions are reviewed de
novo while underlying facts are reviewed for clear error), cert.
denied, --- U.S. ----, 112 S.Ct. 1942, 118 L.Ed.2d 548 (1992);
Brown v. Blue Cross & Blue Shield, 898 F.2d 1556, 1559 (11th
Cir.1990) (clarifying that district court's holding on question
of whether plan administrator's determination was arbitrary and
capricious is a matter of law subject to de novo review), cert.
denied, 498 U.S. 1040, 111 S.Ct. 712, 112 L.Ed.2d 701 (1991).
11
standard of review applies to the plan administrator's decision.
See Sandoval v. Aetna Life and Casualty Ins. Co., 967 F.2d 377, 380
(10th Cir.1992) ("The district court's holding that the
administrator's decision was not arbitrary and capricious is a
legal conclusion. Hence, our review of the district court's
decision, although not the underlying administrator's decision, is
plenary.").
Previous cases in this circuit have applied the proper
standard of review for potentially conflicting reasons. In some
cases, we have applied the Bruch and Pierre tests to determine our
standard of review of the plan administrator's decision. For
example, in Vasseur v. Halliburton Co., 950 F.2d 1002 (5th
Cir.1992), we explained that "[b]ecause the applicable plan gives
the plan administrator discretion to construe plan terms, the
arbitrary and capricious standard applies," id. at 1006, and held
that "[t]he plan administrator's decision ... was not arbitrary and
capricious." Id. at 1007.11 While these cases properly review the
district court's decision de novo, they only implicitly recognize
the fact that as a court of appeals we review the district court's
decision and not the plan administrator's determination directly.12
11
Accord Salley v. E.I. DuPont de Nemours & Co., 966 F.2d
1011, 1014 (5th Cir.1992); Batchelor v. IBEW, Local 861 Pension
and Retirement Fund, 877 F.2d 441, 442-43 (5th Cir.1989).
12
The one case in which we did recognize the fact that on
appeal we review a district court's decision reviewing a plan
administrator's determination is Cathey v. Dow Chemical Co.
Medical Care Program, 907 F.2d 554 (5th Cir.1990), cert. denied,
498 U.S. 1087, 111 S.Ct. 964, 112 L.Ed.2d 1051 (1991). There we
explained: "Accordingly, the New Plan cannot be read as granting
discretion expressly, and thus we will review de novo the
12
Other decisions have applied the Bruch standard to determine
our standard of review of the district court 's decision. In
Schultz v. Metropolitan Life Ins. Co., 872 F.2d 676 (5th Cir.1989),
we explained our standard as follows: "Neither party has pointed
to any provision in the Plan which gives the administrator
discretionary authority to determine benefit eligibility or to
construe the plan terms. Accordingly, the district court's review
of the administrator's denial of the Schultz claim will be tested
here based on a de novo standard." Id. at 678; accord Wise v. El
Paso Natural Gas Co., 986 F.2d 929 (5th Cir.1993) (citing Schultz,
872 F.2d at 678), cert. denied, --- U.S. ----, 114 S.Ct. 196, 126
L.Ed.2d 154 (1993). These cases also apply the proper standard—de
novo review of the district court's decision—but they imply that if
a plan does give the plan administrator discretion, then we would
review the district court's decision under an abuse of discretion
standard. However, this implication is inconsistent with the
general rule in this circuit that we review mixed questions of law
and fact de novo. E.g., United States v. Faubion, 19 F.3d 226, 228
(5th Cir.1994).
Finally, some cases have suggested that all actions brought
under 29 U.S.C. § 1132(a)(1)(B) are reviewed de novo on appeal.
See, e.g., Godwin v. Sun Life Assur. Co., 980 F.2d 323, 329 (5th
Cir.1992) ("Because this is an action brought under 29 U.S.C. §
fiduciary's denial of Cathey's nursing claims here. Having the
benefit of prior judicial review, however, we will not upset the
district court's factual determinations unless they are clearly
erroneous." Id. at 560.
13
1132(a)(1)(B), we review de novo the district court's decision.")
(citing Bruch, 489 U.S. at 115, 109 S.Ct. at 956); Jones v. Sonat,
Inc. Employee Benefit Plan Admin. Comm., 997 F.2d 113, 115 (5th
Cir.1993) (same) (citing Goodwin, 980 F.2d at 329). Again, while
these cases reach the proper result—de novo review of the district
court's decision upholding or overruling the plan administrator's
decision—they are potentially misleading because our standard of
review does not derive from § 1132(a)(1)(B).13 Furthermore, we
apply the "clearly erroneous" standard to a district court's
findings of fact in an action under § 1132(a)(1)(B). Cathey, 907
F.2d at 560.
In sum, while none of our cases have applied an incorrect
standard of review to a district court's decision in a §
1132(a)(1)(B) case, their conflicting explanations of the
applicable standard of review warrant clarification. The Supreme
Court's decision in Bruch and our decision in Pierre determine the
proper standard of review in a § 1132(a)(1)(B) action for review of
a plan administrator's determination of benefits. On appeal from
a district court's judgment in a § 1132(a)(1)(B) case, our
traditional standards of review apply, and we review de novo the
district court's holding on the question of whether the plan
administrator abused its discretion or properly denied a claim for
13
As we explained in Wise v. El Paso Natural Gas Co., 986
F.2d 929 (5th Cir.1993), "[a]lthough it is a "comprehensive and
reticulated statute,' ... ERISA fails to set out the applicable
standard of review for actions under § 1132(a)(1)(B) challenging
benefit eligibility determinations." Id. at 933 (quoting Nachman
Corp. v. PBGC, 446 U.S. 359, 361, 100 S.Ct. 1723, 1726, 64
L.Ed.2d 354 (1980)).
14
benefits. However, we will set aside the district court's factual
findings underlying its review of the plan administrator's
determination only if clearly erroneous.
2
The parties in this case agree that Sweatman asked the
district court to review MetLife's factual determination that she
was not permanently disabled. The district court held that MetLife
did not abuse its discretion, a holding we review de novo. See
supra part II.B.1. Consequently, under Pierre, we must determine
whether MetLife's decision amounted to an abuse of its discretion.
932 F.2d at 1562. "In applying the abuse of discretion standard,
we analyze whether the plan administrator acted arbitrarily or
capriciously." Salley v. E.I. DuPont de Nemours & Co., 966 F.2d
1011, 1014 (5th Cir.1992).
Sweatman essentially argues that MetLife made the wrong
decision because it attached insufficient weight to her doctors'
opinions and too much weight to the results of its own
investigation, which Sweatman alleges was deficient. MetLife
considered all of the medical records Sweatman submitted in support
of her disability claim, contracted independent medical consultants
to evaluate those records and determine whether they supported her
physical limitations,14 hired an investigator to interview and
14
Sweatman argues that because Drs. Blendonhy and Dwyer
review twenty to thirty files per month for UMAC, they are
"financially dependent upon UMAC [which, Sweatman argues, is in
turn financially dependent on MetLife] and ... by no means
"independent' or "impartial.' " This argument lacks merit.
First, UMAC's doctors are independent consultants because MetLife
hires UMAC on a contractual basis. Second, even assuming the
15
investigate Sweatman, and reviewed the entire administrative record
twice.
The record generated by these evaluations contains ample
evidence to support MetLife's finding that Sweatman was not
permanently disabled. Specifically, the UMAC reports explained
that Sweatman's own medical records did not support a diagnosis of
rheumatoid arthritis. UMAC's second report found that "the
diagnosis of fibromyositis or fibromyalgia, if accepted, is
certainly not substantiated to the degree that would disable
Sweatman." After reviewing the record and considering MetLife's
issue were relevant, Sweatman points to no evidence in the record
that proves that Drs. Dwyer and Blendonhy are "financially
dependent" on UMAC or that UMAC depends on MetLife. The number
of files they review per month proves nothing about their
financial status. Finally, we note that the only way for MetLife
to satisfy Sweatman's standard for impartiality would be to seek
physicians willing to volunteer their time to review the medical
files of disability claimants.
Sweatman also argues that Dr. Blendonhy's opinion is
worthless because he did not review all of Sweatman's
medical records. It is true that Dr. Blendonhy examined
only those records that Sweatman had submitted to MetLife at
the time of his review. However, when Sweatman submitted
additional records, some of which filled gaps identified by
Dr. Blendonhy, MetLife resubmitted the complete records for
UMAC's consideration. Sweatman does not dispute that Dr.
Dwyer based his opinion on all of the records Sweatman
submitted to MetLife. Consequently, even if Dr. Blendonhy's
opinion were based on an insufficient record, Dr. Dwyer's
opinion and MetLife's ultimate benefit determination were
based on Sweatman's complete medical records.
Sweatman also contends that UMAC's "Physician's
Roundtable" has no evidentiary value whatsoever, and in fact
"is nothing more than a bucket of whitewash which is
legitimated by the professional degrees of those that
participate." However, Sweatman's characterization of
UMAC's peer review process does not change the fact that
UMAC's report contains ample evidence supporting MetLife's
determination.
16
dual role as plan administrator and insurer, we agree with the
district court that MetLife's disability determination was not an
abuse of discretion. See Donato v. Metropolitan Life Ins. Co., 19
F.3d 375, 380 (7th Cir.1994) (MetLife's denial of benefits was not
arbitrary and capricious when its "decision simply came down to a
permissible choice between the position of UMAC, MetLife's
independent medical consultant, and the position of [the claimant's
physicians].").
Citing our decision in Salley, Sweatman argues that MetLife
abused its discretion because it failed to obtain necessary
information and selectively relied on only part of her treating
physicians' diagnoses. In Salley, the plaintiff, a teenager with
a history of emotional disabilities, drug abuse, and depression,
had been admitted to a hospital three times for psychiatric care.
966 F.2d at 1012. After she had been hospitalized for almost a
month during her third admission, Salley's treating psychiatrist,
Dr. Blundell, found that her condition had improved dramatically.
Id. at 1013. However, he concluded she should remain as an
inpatient until a suitable environment could be found to avoid a
regression to her previous behavior. Id. DuPont ultimately
terminated Salley's inpatient hospitalization benefits based on a
determination by Preferred Health Care ("Preferred") that continued
hospitalization was not medically necessary. Id. Preferred's case
manager Ron Schlegel and its psychiatrist Dr. Ahluwalia had spoken
with Dr. Blundell about Salley's improved condition, examined the
medical records of Salley's first admission, and concluded that
17
continued hospitalization was not medically necessary. Id. We
held that:
[A]lthough DuPont followed the prescribed procedures, it
abused its discretion in relying upon the Schlegel and Dr.
Ahluwalia recommendation to terminate [Salley's] benefits.
Because they chose to follow Dr. Blundell's diagnosis,
Schlegel and Dr. Ahluwalia were required, absent independent
inquiry, to follow all his advice, not just part of it. If
they decided to deviate from his diagnosis, they were required
to investigate further the medical necessity of in-patient
hospitalization. Whether this investigation included an
examination of [Salley] or an analysis of hospital records
depended on the particulars of each case. At the very least,
however, administrators relying on hospital records obviously
must review the most recent records. The case administrator
and the physician conceded at trial that they did not do so.
Id. at 1015-16 (emphasis added). In this case, MetLife
investigated Sweatman's condition and analyzed all of her hospital
records. When Sweatman submitted additional records after Dr.
Blendonhy's review, MetLife sought another opinion from UMAC
regarding whether her records supported the physical limitations
found by her treating physicians. Furthermore, MetLife did not
rely on Sweatman's physicians' diagnoses only to ignore their
advised treatment. Rather, MetLife denied Sweatman's claim for
disability benefits based on the opinions of Drs. Dwyer and
Blendonhy disagreeing with those of Sweatman's physicians.
Finally, we note that Salley involved a determination of "medical
necessity" and not a claim for disability benefits.
Sweatman also argues that because she received a percentage
of her salary under Commercial Union's "salary continuation plan,"
she is entitled to a presumption of total disability, and that
MetLife did not rebut this presumption with evidence of a change in
her condition. Sweatman cites no authority for such a rule, and we
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see no need to create one in this case. Furthermore, there is no
evidence in the record that payments under the salary continuation
plan depend on a finding of total disability. The parties
stipulated at trial that a beneficiary is entitled to such benefits
"in the event of an illness or accident resulting in [the]
inability to work." However, the terms of the salary continuation
plan are not contained in the record, and the Long Term Disability
Plan makes no reference to such benefits.
The remainder of Sweatman's arguments simply overstate UMAC's
role in MetLife's disability determination. Sweatman argues that
MetLife abused its discretion because Drs. Blendonhy and Dwyer were
not asked whether Sweatman was "totally disabled" but rather only
whether her medical records supported the physical limitations she
claimed. Sweatman also argues that Drs. Dwyer and Blendonhy were
not qualified to determine whether she was "totally disabled"
within the meaning of the Plan because they were not familiar with
what her occupation entailed. Both of these arguments are beside
the point because MetLife, not Drs. Dwyer and Blendonhy, was
responsible for the ultimate determination of whether Sweatman was
"totally disabled." MetLife consulted the UMAC physicians only on
the question of whether Sweatman's own records supported the
physical limitations that she claimed.15 In fact, had MetLife
15
Sweatman also argues that Drs. Dwyer and Blendonhy were
not qualified to render their opinions because they do not
practice in Louisiana where Sweatman was diagnosed and do not
specialize in the same areas as her primary treating physicians.
These arguments similarly assume too great a role for UMAC's
physicians. Drs. Blendonhy and Dwyer were asked to determine
only whether the contents of Sweatman's medical records supported
19
delegated its decision to grant or deny disability benefits to
UMAC, it might have run afoul of its fiduciary duty under the Plan.
Cf. Salley, 966 F.2d at 1014 ("As long as a company maintains the
ultimate decision on denial of benefits, it can be beneficial for
it to have experienced agents assist in the determination.").
In sum, in light of the ample evidence supporting MetLife's
"total disability" determination, and recognizing MetLife's dual
role as claims administrator and insurer, we hold that the district
court properly upheld MetLife's denial of Sweatman's claim.
III
For the foregoing reasons, we AFFIRM.
her claimed physical limitations. Sweatman fails to show that
Drs. Blendonhy and Dwyer were not qualified to make this limited
determination.
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