Gilewski v. Provident Life & Accident Insurance Co.
683 F. App'x 399
| 6th Cir. | 2017Background
- Plaintiff Les Gilewski, former owner/president of an auto-supply company, applied for long-term disability (LTD) benefits from Provident for major depressive disorder beginning June 2009; Provident paid under a short-term policy and initially under the LTD policy through July 2013.
- Provident terminated LTD benefits July 12, 2013 after an independent psychiatric exam (Dr. Dudley) found Major Depressive Disorder stabilized with a GAF of 80 and no work restrictions; Provident’s in-house reviewer (Dr. Szlyk) and an appeal file reviewer (Dr. Brown) agreed.
- Gilewski’s treating psychiatrist (Dr. Shiener) consistently opined Gilewski remained unable to work but submitted largely boilerplate attending statements and resisted disclosing full treatment records; earlier treating clinicians (Drs. Guyer and Roberts) had noted improvement by 2010–2011.
- On administrative appeal Provident affirmed denial; Gilewski sued under ERISA § 1132(a)(1)(B). The district court reviewed the administrative record de novo and upheld Provident; the Sixth Circuit affirmed.
- Central factual questions: (1) whether the medical record supports that Gilewski remained unable to perform the material duties of his occupation as company owner/president as of July 2013, and (2) whether Provident improperly discounted the treating psychiatrist or was biased by its dual role as payor/administrator.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether substantial evidence supported Provident’s termination of LTD benefits | Gilewski argued the record, especially his treating psychiatrist’s opinions and vocational evidence, shows ongoing disability preventing return to his prior occupation | Provident argued independent exam and file reviews show stabilized depression, significant functional improvement, and no occupationally preclusive restrictions | Affirmed: substantial evidence supported termination; medical record showed stabilization and activities inconsistent with disabling impairment |
| Weight accorded to treating psychiatrist (Dr. Shiener) | Treating physician’s opinion should be given controlling or greater weight and was improperly discounted | Provident argued Dr. Shiener’s statements were conclusory, repetitive, lacked objective support and treatment detail, justifying reliance on independent exam and reviewers | Held: Provident permissibly credited independent examiner and reviewers where treating doctor’s reports were sparse, unsupported, and inconsistent with other evidence |
| Need for vocational expert/job analysis to determine ability to return to prior occupation | Gilewski contended Provident should have obtained a vocational analysis about the demands of his prior job | Provident argued medical evidence alone can determine ability to perform prior occupation; vocational testimony not required in LTD context | Held: No vocational expert required; medical assessment of functional capacity against known job duties was sufficient |
| Significance of conflict of interest (plan as payor and decisionmaker) | Gilewski asserted Provident’s dual role created a structural conflict that tainted the decision, especially because independent examiner may have relied on in-house summaries | Provident maintained no improper influence: independent examiner personally examined claimant and prepared a comprehensive report; agreement with in-house summaries did not show bias | Held: Conflict-of-interest factor did not alter outcome; no evidence that bias affected the decision or Dr. Dudley’s independence |
Key Cases Cited
- Wilkins v. Baptist Healthcare Sys., 150 F.3d 609 (6th Cir.) (standard: de novo review where administrator has no discretionary authority)
- Elliott v. Metropolitan Life Ins. Co., 473 F.3d 613 (6th Cir.) (administrator must explain reasons when rejecting treating physician, but need not afford it special deference)
- Black & Decker Disability Plan v. Nord, 538 U.S. 822 (Sup. Ct.) (treating-physician opinions not automatically controlling in ERISA benefit determinations)
- Calvert v. Firstar Finance, Inc., 409 F.3d 286 (6th Cir.) (file reviews by qualified physicians are permissible in benefits determinations)
- Judge v. Metropolitan Life Ins. Co., 710 F.3d 651 (6th Cir.) (discussing conflict-of-interest factor post-Glenn)
- Metropolitan Life Ins. Co. v. Glenn, 554 U.S. 105 (Sup. Ct.) (plan administrator’s dual role is a relevant factor in abuse-of-discretion review)