Tuesday, October 27, 2009

Eleventh Circuit Affirms Summary Judgment To Plan In ERISA Long Term Disability Case

In Trina Gipson v. Administrative Committee of Delta Airlines, Inc., et al (09-11748), the Eleventh Circuit affirmed the district court's grant of summary judgment to Delta's administrative plan in an ERISA long term disability dispute.

The court outlined the facts as follows:
Gipson worked for Delta as a reservation agent until April 1995, when she requested and received short-term disability benefits due to fibromyalgia, depression, and headaches. In October 1995, she began to receive long-term disability benefits.  In 2001, the Plan transferred review of Gipson’s case to Aetna, which initiated a reassessment and traced Gipson’s medical history. Aetna continued to gather medical information over the next few years until it denied long-term disability benefits in 2004.
The district court granted the Committee’s summary judgment motion. The district court first determined that it would not consider materials not presented to the Committee. The court then concluded that the Committee’s decision was not “wrong,” as Gipson had not shown she was entitled to benefits. The court reviewed the medical records and agreed that Singh’s reports were conclusory and lacked any objective findings to support the conclusion that Gipson was unable to work. The court also concluded that the fact that Gipson received Social Security benefits was not dispositive because the rules applicable to such determinations did not apply to ERISA claims.
In the opinion, the court provided an extensive review of the factual backgroud in the opinion which is not copied here.

The first issue the court addressed was the standard of review:
Where, as here, an ERISA plan endows the plan administrator with discretion to determine eligibility for plan benefits, we review the administrator’s decision under a deferential standard. Firestone Tire and Rubber Co. v. Bruch, 489 U.S. 101, 111, 109 S.Ct. 948, 103 L.Ed.2d 80 (1989). We will reverse the plan administrator’s decision only if it was arbitrary and capricious.
The court then affirmed the district court's refusal to consider evidence not presented to the plan administrator:
We agree with the district court that the additional evidence was not properly before it. Our law is clear; even under the first step of the analysis, where the court determines whether the administrator was wrong under a “de novo” standard, “[w]e are limited to the record that was before [the administrator] when it made its decision.” Glazer v. Reliance Standard Life Ins., 524 F.3d 1241, 1247 (11th Cir. 2008). Thus, the district court properly rejected the additional evidence Gipson submitted.
Objective Medical Evidence:
The Committee, faced with conflicting medical evidence, determined that Gipson was able to engage in some level of employment. Gipson has not shown that this determination was arbitrary and capricious. “Under the arbitrary and capricious standard of review, the plan administrator’s decision to deny benefits must be upheld so long as there is a ‘reasonable basis’ for the decision.” Oliver v. Coca Cola Co., 497 F.3d 1181, vacated in part on petition for reh’g, 506 F.3d 1316 (11th Cir. 2007). Here, Selvey and Friedman gave thorough and detailed reasons for their medical opinions. In contrast, Singh’s opinion was conclusory, with no rationale. In light of these conflicting opinions, the Committee’s decision was not arbitrary and capricious.
As to the weight to be given to the treating physician's opinion:
A plan administrator has no obligation to give a treating physician’s opinion more weight. See Black & Decker Disability Plan v. Nord, 538 U.S. 822, 834 (2003). Here, the treating physician’s opinion was conclusory and failed to provide any basis for the decision that Gipson was unable to work. In contrast, the opinions of Selvey and Friedman contradicted Singh’s opinion and explained why Gipson was capable of some level of work. Moreover, the other physicians who treated Gipson opined that she required other medication and psychotherapy, all of which Gipson refused. This non-compliance further supports the Committee’s conclusion that benefits were not warranted.
Finally, with regard to a prior payment for the long term disability:
First, Levinson does not stand for the proposition that one payment of benefits forever binds the company. In any event, we find the facts of Levinson distinguishable for the simple reason that, unlike Levinson, the medical evidence in this case was not one-sided; there was ample evidence from which the Committee could conclude Gipson was not disabled. Under the terms of the Plan, Gipson was required to show an ongoing disability. We agree with the Committee and the district court that Gipson failed to meet this burden.


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