Amanda Foster v. Principal Life Insurance Co.
920 F.3d 298
5th Cir.2019Background
- Amanda Foster, a healthcare attorney, stopped working in 2013 alleging intractable migraines and claimed long-term disability (LTD) under her employer’s ERISA-governed group policy administered and insured by Principal Life Insurance Company.
- The policy defines “disabled” under an Own-Occupation standard: inability to perform one or more substantial and material duties of the member’s specialty as performed for the policyholder.
- Principal provisionally paid benefits, then reviewed medical records, surveillance, and multiple independent reviewers (neurologists and psychologists) and terminated LTD benefits effective December 9, 2014, citing normal objective tests, surveillance, blog activity, and expert opinions that Foster was capable of full-time sedentary work.
- Foster appealed administratively (mandatory and voluntary), submitted treating physician reports, IME/INE reports, and affidavits; Principal repeatedly upheld its denial relying on independent reviewers (including Drs. Harrop, Miller, Chafetz).
- Foster sued under 29 U.S.C. § 1132(a)(1)(B); the district court granted judgment for Principal; the Fifth Circuit reviewed de novo whether the administrator abused its discretion and affirmed.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether Principal abused its discretion by relying on reviewers who assessed ability to do "full-time sedentary work" rather than Foster’s specific attorney duties under the Own-Occupation clause | Foster: reviewers were not asked to evaluate her specific job duties; generic "sedentary" findings cannot show ability to perform material duties of a healthcare attorney | Principal: reviewers were provided Foster’s job description and considered cognitive/non-exertional demands; at least one reviewer (Chafetz) assessed attorney-specific duties | Held: No abuse of discretion; substantial evidence (including physician reviews considering non-exertional skills) supported denial |
| Whether Principal improperly required objective medical evidence for migraines when migraines are often verified subjectively | Foster: migraines lack objective markers; Principal demanded impossible objective proof and thus erred | Principal: while existence of migraines may be subjective, objective evidence of functional inability to work is reasonable to require; experts assessed functional impairment, not mere existence of pain | Held: No abuse of discretion; administrator reasonably relied on absence of objective clinical evidence of functional work impairment and independent expert opinions |
| Whether Principal improperly favored its own experts over treating physicians | Foster: treating physicians support disability and should carry weight | Principal: obligated to base decision on substantial evidence; not required to accept treating physicians where independent experts contradict them | Held: No abuse of discretion; administrator may credit independent reviewers over treating physicians where supported by substantial evidence |
| Effect of structural conflict (insurer = administrator) on review | Foster: structural conflict should weigh against Principal’s credibility | Principal: conducted extensive investigation; conflict has limited weight here | Held: Conflict considered but given little weight; did not render decision abusive |
Key Cases Cited
- Pilot Life Ins. Co. v. Dedeaux, 481 U.S. 41 (ERISA preemption and claims under ERISA)
- Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101 (abuse-of-discretion review when plan grants discretion to administrator)
- Anderson v. Cytec Indus., Inc., 619 F.3d 505 (5th Cir. 2010) (administrators may require objective evidence of functional limitations; experts need not accept treating physicians)
- Corry v. Liberty Life Assurance Co. of Bos., 499 F.3d 389 (5th Cir. 2007) (substantial-evidence standard governs administrator decisions)
- Ellis v. Liberty Life Assurance Co. of Bos., 394 F.3d 262 (5th Cir. 2004) (even substantial evidence offered by claimant does not trump administrator’s decision if administrator’s decision is supported by substantial evidence)
- Metro. Life Ins. Co. v. Glenn, 554 U.S. 105 (structural conflict is a factor in abuse-of-discretion review)
- Robinson v. Aetna Life Ins. Co., 443 F.3d 389 (5th Cir. 2006) (insurer’s denial reversed when finding about essential job duties lacked evidentiary support)