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Roumeliote v. Long Term Disability Plan For Employees of Worthington Industries

January 23, 2007


The opinion of the court was delivered by: Judge Gregory L. Frost

Magistrate Judge King


In this Employee Retirement Income Security Act ("ERISA") action, Plaintiff Kim Roumeliote ("Plaintiff"), appeals from the denial of her application for long-term disability benefits under a plan administered by Unum Life Insurance Company of America ("Unum") to Worthington Industries. The parties have filed cross-motions for judgment on the administrative record, and briefing on those motions is now complete. (Docs. # 16, 20, 22, 23.) For the reasons that follow, the Court DENIES Plaintiff's motion (Doc. # 16) and GRANTS Unum's motion (Doc. # 20).

A. Background

Unum is the long-term disability insurer for the Worthington Industries Group Disability Plan ("the Plan"). Plaintiff was covered by the terms of the Plan while she worked for over three years as a commuter programmer at Worthington Industries. In 2003, Plaintiff received a negative employment evaluation and was put on probation. In August of 2003, Plaintiff stopped working and filed a claim for short-term disability due to sleep apnea, narcolepsy, and an inability to concentrate. Plaintiff, however, has never undergone cognitive testing. Based on these reported symptoms, Plaintiff was paid short-term disability for initially two months, and then pursuant to a behavioral medical review for an additional six weeks.

Once her short-term disability benefits came to an end, Plaintiff applied for long-term disability benefits. Plaintiff based her claim for long-term disability on complaints of fibromyalgia, narcolepsy, sleep apnea, pituitary insufficiency, carpal tunnel syndrome, depression, and anxiety. After gathering and reviewing Plaintiff's medical records, Unum informed Plaintiff in its February 26, 2004 letter that it granted Plaintiff's long-term disability for six weeks. Unum specifically granted these benefits, however, to cover Plaintiff's carpal tunnel syndrome and proposed surgery. Unum further informed Plaintiff that it would continue to monitor Plaintiff's medical condition with periodic updates. After an on-going evaluation, Unum determined that Plaintiff no longer met the definition of "disabled" under the policy, and informed Plaintiff that she was no longer eligible to receive benefits under the policy. Rather, Plaintiff would be required to return to work.

On December 23, 2004, Plaintiff filed an appeal with Unum. After noting that she needed to supplement her current medical file, Plaintiff sent Unum a letter containing additional medical information. The information included a statement from Plaintiff explaining why she could no longer perform her job and a letter from her sleep physician, Dr. Clark. Dr. Clark's letter stated that Plaintiff was unable to fulfill her job requirements and contained general medical studies not specific to Plaintiff, which posited that obstructive sleep apnea could affect cognitive functions. Plaintiff's appeal reveals that Plaintiff is morbidly obese and experiences chronic fatigue, apnea, narcolepsy, and fibromyalgia, all of which are worsened by stress, anxiety and depression that she suffers. She argues that her illnesses affect her cognitive functions and thereby prevent her from performing her duties as a computer programmer.*fn1 After a thorough review of Plaintiff's appeal, Unum denied Plaintiff's appeal for long-term disability benefits. Subsequently, Plaintiff asserts a single claim in this Court under 29 U.S.C. § 1132(a)(1)(B), which "gives a participant the right to bring a civil action 'to recover benefits due to [her] under the terms of [her] plan, to enforce [her] rights under the terms of the plan, or to clarify [her] rights to future benefits under the terms of the plan.' " Creech v. Unum Life Ins. Co. of N. Am., No. 05-5074, 2006 WL 41186, at *2 (6th Cir. Jan. 9, 2006).

B. Analysis

1. Standard Involved

It is well settled 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 administrator or fiduciary discretionary authority to determine eligibility for benefits or to construe the terms of the plan." Kalish v. Liberty Mutual/Liberty Life Assur. Co. of Boston, 419 F.3d 501, 505-06 (6th Cir. 2005) (citing Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989)); see also Calvert v. Firstar Finance. Inc., 409 F.3d 286, 291-92 (6th Cir. 2005). If the plan provides the administrator with discretion, then "the highly deferential arbitrary and capricious standard of review is appropriate." Borda v. Hardy, Lewis, Pollard, & Page, P.C., 138 F.3d 1062, 1066 (6th Cir. 1998); see also Calvert, 409 F.3d at 291-92.

Both sides agree that the arbitrary and capricious standard applies in the instant case. (Doc. # 20, at 12; Doc. # 22, at 1.) The Sixth Circuit has explained that, in determining whether this standard applies, a court should remain cognizant that a plan is not required to use certain magic words to create discretionary authority for a plan administrator in administering the plan. Johnson v. Eaton Corp., 970 F.2d 1569, 1572 at n.2 (6th Cir. 1992). What is required is "a clear grant of discretion [to the administrator]." Wulf v. Quantum Chemical Corp., 26 F.3d 1368, 1373 (6th Cir. 1994), cert. denied, 513 U.S. 1058 (1994). Because the plan involved here provides that "[w]hen making a benefit determination under the policy, UNUM has discretionary authority to determine your eligibility for benefits and to interpret the terms and provisions of the policy" (Rec. at 189), the Court agrees with the parties that the arbitrary and capricious standard applies.*fn2 See Evans v. Unumprovident Corp., 434 F.3d 866, 876 (6th Cir. 2006) (construing identical language and concluding that "[t]he plan at issue clearly and unambiguously grants discretionary authority to defendant in its administration of the plan and determination of claims for benefits").

The arbitrary and capricious standard is a "difficult one for the claimant to overcome." Nance v. Sun Life Assurance Co. of Canada, 294 F.3d 1263, 1269 (10th Cir. 2002); see also Davis v. Ky. Fin. Cos. Ret. Plan, 887 F.2d 689, 693 (6th Cir. 1989) (noting that "the arbitrary and capricious standard is the least demanding form of judicial review"). This standard, however, "does not require [the Court] merely to rubber stamp the administrator's decision." Jones v. Metropolitan Life Ins. Co., 385 F.3d 654, 661 (6th Cir. 2004) (citing McDonald v. Western-Southern Life Ins. Co., 347 F.3d 161, 172 (6th Cir. 2003)). Rather, under the arbitrary and capricious standard, a plan administrator's decision will not be deemed arbitrary and capricious so long as "it is possible to offer a reasoned explanation, based on the evidence, for a particular outcome." Davis, 887 F.2d at 693. A court must therefore "review the quantity and quality of the medical evidence and the opinions on both sides of the issues." Jones, 385 F.3d at 661. In other words, the Court will uphold a benefit determination unless it is not grounded on any reasonable basis. Nance, 294 F.3d at 1269; see also Yeager v. Reliance Standard Life Ins. Co., 88 F.3d 376, 381 (6th Cir. 1996) (stating that a benefit determination will be upheld if it is "rational in light of the plan's provisions.")

In evaluating the record, then, the Court is required to consider only the facts known to the plan administrator at the time the final decision was made to deny disability benefits. Moon v. Unum Provident Corp., 405 F.3d 373, 378 (6th Cir. 2005); see also Miller v. Metropolitan Life Ins. Co., 925 F.2d 979, 986 (6th Cir. 1991). The Court is also required to remain cognizant of the potential inherent conflict of interest that arises when an insurer such as that Unum acts as both the decision maker on a claim and the potential payor of that claim. Calvert, 409 F.3d at 292 ("[t]he 'possible conflict of interest' inherent in this situation 'should be taken into account as a factor in determining whether [Unum's] decision was arbitrary and capricious.' "(quoting Davis, 887 F.2d at 694).

Applying the arbitrary and capricious standard to review of the administrative record, this Court recognizes certain guidelines that the Sixth Circuit has set forth with regard to review of benefit determinations. As long as a plan administrator offers a reasonable explanation based upon the evidence for its decision, it may choose to rely upon the medical opinion of one doctor over that of another doctor. See Evans v. Unumprovident Corp., 434 F.3d 866, 877 (6th Cir. 2006). Also, the Supreme Court has held that in the ERISA context that "Courts have no warrant to require administrators automatically to accord special weight to the opinions of a claimant's physician; nor may courts impose on plan administrators a discrete burden of explanation when they credit reliable evidence that conflicts with a treating physician's evaluation." Evans, 434 F.3d at 877 (quoting Black & Decker Disability Plan v. Nord, 538 U.S. 822, 834). Furthermore, despite Plaintiff's contention that "Unum did no testing, [and] employed no outside physicians or sleep experts to review plaintiff's medical records" a plan administrator is not required to conduct a physical examination or hire an outside physician. See Calvert, 409 F.3d at 295. A plan administrator's reliance on a file review does not standing alone require the conclusion that the administrator acted improperly, rather it constitutes yet another element in the equation of ...

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