Abston v. Sedgwick Claims Management Services Inc, 3:16-cv-00037

Background

Plaintiff Tammy Abston, a SunTrust Area Manager/Branch Manager, received SSDI and long-term disability (LTD) benefits beginning August 2013 based on diagnoses including lupus, psoriasis, psoriatic arthritis, and fibromyalgia.
SunTrust’s LTD plan, governed by ERISA, defines "total disability" differently after 24 months (change in definition, CID): claimant must be unable to perform any occupation for which she is reasonably fitted and earn at least 60% of pre-disability earnings.
Sedgwick (plan administrator) reviewed Abston’s file prior to the CID date and retained independent rheumatologists (Dr. Marwah and, on appeal, Dr. Barry) to evaluate continued entitlement.
The consultants concluded Abston could perform her job (or any similar job) without restrictions; Sedgwick therefore discontinued LTD benefits.
Abston challenged the denial, arguing Sedgwick failed to consider her entire SSA file and improperly discounted her treating physician Dr. McLain’s opinions.
The district court reviewed under Eleventh Circuit ERISA standards, found Sedgwick’s decision de novo correct (and alternatively supported by reasonable grounds), and granted summary judgment for defendants.

Issues

Issue	Plaintiff's Argument	Defendant's Argument	Held
Whether Sedgwick’s denial of continued LTD benefits was incorrect under the plan definition (de novo review)	Abston contended the medical record (including SSA decision and Dr. McLain’s opinions) showed continued disability under the CID	Sedgwick relied on independent rheumatology reviews finding no restrictions that would prevent work and argued the record did not support continued disability	Court held Sedgwick’s denial was de novo correct — independent reviews supported conclusion that Abston could perform her occupation
Whether greater weight must be given to treating physician’s opinions	Dr. McLain’s opinions should control or be given special weight	Defendant argued no special weight is required for treating physicians in ERISA benefit determinations	Court held no special weight required; Sedgwick permissibly credited independent reviewers over treating physician
Whether SSDI approval required remand or compelled a different result	Abston argued Sedgwick failed to adequately consider SSA/SSDI file and Melech requires remand when administrative record was incomplete	Sedgwick noted SSDI approval is not dispositive under ERISA and its review considered relevant medical evidence available when it decided	Court distinguished Melech and held SSA approval not conclusive; no remand required
Whether a conflict of interest tainted Sedgwick’s decision	Abston implied procedural unfairness and possible conflict (financial interest)	Defendants showed benefits are paid from a trust; Sedgwick had no financial stake in outcomes	Court held no conflict of interest and thus no reducing-of-deference adjustment necessary

Key Cases Cited

Leahy v. Raytheon Co., 315 F.3d 11 (1st Cir. 2002) (discussing appellate-style review of administrative ERISA decisions)
Williams v. Bellsouth Telecommunications, Inc., 373 F.3d 1132 (11th Cir. 2004) (articulating Eleventh Circuit six-step ERISA review framework)
Blankenship v. Metro. Life Ins. Co., 644 F.3d 1350 (11th Cir. 2011) (review limited to materials before administrator at time decision was made)
Black & Decker Disability Plan v. Nord, 538 U.S. 822 (U.S. 2003) (no automatic special weight to treating physician opinions in ERISA cases)
Melech v. Life Ins. Co. of N. Am., 739 F.3d 663 (11th Cir. 2014) (failure to consider SSA file can require remand; distinguishable where SSA decision pending or record incomplete)
Gilley v. Monsanto Co., 490 F.3d 848 (11th Cir. 2007) (trust-funded plans reduce or eliminate conflict-of-interest concerns)