Harris v. Savannah River Remediation Disability Short and Long Term Disability Plan, 1:18-cv-00152

Background:

Harris received short-term disability for abdominal symptoms in 2016, underwent cholecystectomy (Oct 2016) and hysterectomy (Dec 2016), and was approved for long-term disability starting Jan 1, 2017; benefits were terminated effective Feb 15, 2017.
Sedgwick (claims administrator) and the Plan Administrator reviewed medical records from treating gastroenterologist Dr. Glen Portwood and others; Portwood described chronic nausea, abdominal pain, SIBO, GERD and opined flares could preclude work but also submitted forms indicating limited, intermittent restrictions (e.g., may miss 1–2 days/month; ambulatory; can lift 10–25 lbs).
Independent reviewers (two gastroenterologists and an endocrinologist) concluded Harris had no functional disability and could return to her Associate Process Improvement Analyst duties without restrictions as of Feb 15, 2017.
Sedgwick and then the Plan Administrator denied long-term disability at initial and appellate levels, citing insufficient objective evidence that Harris could not perform her own occupation; the Plan grants the administrator discretionary authority.
Harris sued under ERISA § 502(a)(1)(B) challenging the denial; the district court reviewed the administrative record and applied the deferential (arbitrary-and-capricious) standard because the Plan conferred discretion.
The court affirmed the denial, finding reasonable grounds in the record (treating notes did not show continuous inability to perform essential job functions; independent reviews supported denial), and that any structural conflict of interest did not render the decision arbitrary and capricious.

Issues:

Issue	Plaintiff's Argument	Defendant's Argument	Held
Standard of review / discretion	Harris argued denial was wrong; court should review de novo	Plan gave discretionary authority; deferential review applies	Court applied arbitrary-and-capricious review and found denial reasonable
Weight given to treating physician (Dr. Portwood)	Portwood’s opinions showing inability to work were improperly discounted	Administrator relied on entire record and independent reviewers; no special deference owed to treating physician	Court held administrator reasonably weighed conflicting evidence and could credit independent reviewers over treating physician
Incorrect disability definition in early denial letters	Early Sedgwick letters cited a more stringent "any reasonable occupation" standard, rendering denials arbitrary	Final Plan Administrator decision applied correct "own occupation" standard; review limited to final decision	Court found final denial used proper standard in substance and review is limited to the final decision, so no reversible error
Conflict of interest (self-funded plan)	Plan’s dual role tainted decision; heightened scrutiny required	Although conflict exists, independent reviews and a full appeals process show a fair, reasonable decision	Court acknowledged conflict as a factor but concluded it did not make the denial arbitrary and capricious

Key Cases Cited

Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101 (1989) (denial reviewed de novo unless plan grants administrator discretionary authority)
Metropolitan Life Ins. Co. v. Glenn, 554 U.S. 105 (2008) (structural conflict of interest is a factor in abuse-of-discretion review)
Blankenship v. Metro. Life Ins. Co., 644 F.3d 1350 (11th Cir. 2011) (framework for reviewing ERISA benefit denials and limiting review to administrative record)
Capone v. Aetna Life Ins. Co., 592 F.3d 1189 (11th Cir. 2010) (burden on plaintiff to show administrator's decision was arbitrary; conflict is a factor)
Black & Decker Disability Plan v. Nord, 538 U.S. 822 (2003) (administrators need not give special deference to treating physicians)
Slomcenski v. Citibank, N.A., 432 F.3d 1271 (11th Cir. 2005) (denial upheld if supported by reasonable factual basis despite contrary evidence)
Townsend v. Delta Family-Care Disability & Survivorship Plan, [citation="295 F. App'x 971"] (11th Cir. 2008) (administrative record limits court's review)