720 F.3d 472
2d Cir.2013Background
- Ralph Miles, a Venable LLP partner, stopped working on April 17, 2009, citing bilateral tinnitus, ear pain, hearing loss, headaches, vertigo, and resulting concentration problems; he applied for long-term disability (LTD) benefits under an ERISA plan insured/administrated by Principal Life.
- Treating physicians (ENT and neurologist) documented tinnitus, hearing loss, vertigo, and cognitive complaints; some testing (VNG, audiology, MRI) showed objective findings for hearing loss and vestibular abnormalities, but tinnitus has no definitive objective test.
- Principal denied benefits after file reviews by independent physicians who emphasized a lack of objective findings supporting functional restrictions; Principal repeatedly noted the subjective nature of many complaints and requested objective corroboration and specific treating-physician restrictions.
- On appeal to Principal, Miles submitted additional medical documentation (treating letters, VNG results, SSA decision). The Social Security Administration found Miles disabled since April 2009 and credited his symptoms.
- Principal issued a final denial reiterating its view that the record lacked objective evidence tying Miles’s symptoms to inability to perform his own-occupation duties; Miles sued under 29 U.S.C. § 1132(a)(1)(B). The district court upheld Principal; the Second Circuit reversed and remanded.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether Principal properly discounted subjective complaints (tinnitus, headaches, concentration) | Miles: Principal arbitrarily rejected subjective complaints without assigning weight or adequate reasons; many symptoms undisputed and corroborated by treating physicians and SSA decision | Principal: May accord less weight to subjective complaints absent objective corroboration; requested objective evidence and treating-physician restrictions | Court: Principal acted arbitrarily and capriciously by disregarding subjective complaints without reason or assigning weight; must consider them and explain any discounting |
| Whether Principal reasonably required objective proof of tinnitus | Miles: Tinnitus often lacks objective tests; plan does not require proof of cause, only sickness and functional inability | Principal: Reasonable to demand objective evidence of impairment beyond diagnosis to prove inability to work | Court: Unreasonable to require objective proof where none exists or where Principal failed to identify an available objective test; reliance on lack of objective evidence was arbitrary |
| Whether Principal selectively/mischaracterized the record in denying benefits | Miles: Principal misstated communications, omitted treating physicians’ statements (e.g., "unable to work"), and selectively quoted reviewers | Principal: Relied on independent reviewers and gaps in record | Court: Principal made selective readings and inaccurate characterizations (e.g., regarding Dr. Etra and attempts to obtain releases); this undermined reasoned decisionmaking |
| Appropriate remedy after finding arbitrary and capricious denial | Miles: Award benefits | Principal: Remand or denial justified | Court: Reverse and remand for reconsideration consistent with legal standards; do not award benefits now because remand could produce a reasonable denial |
Key Cases Cited
- Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101 (1978) (standard of review for ERISA benefit decisions; defer to administrator when plan grants discretion)
- Connors v. Connecticut General Life Insurance Co., 272 F.3d 127 (2d Cir. 2001) (plan administrators may not dismiss subjective pain complaints simply because they are subjective)
- Hobson v. Metropolitan Life Insurance Co., 574 F.3d 75 (2d Cir. 2009) (administrator may require objective corroboration when claimant was notified and objective tests exist)
- Glenn v. Metropolitan Life Insurance Co., 554 U.S. 105 (2008) (conflict of interest in administrator/insurer affects degree of deference)
- McCauley v. First Unum Life Insurance Co., 551 F.3d 126 (2d Cir. 2008) (administrator acts arbitrarily when imposing standards not in plan)
- Miller v. United Welfare Fund, 72 F.3d 1066 (2d Cir. 1995) (court ordinarily remands for reconsideration rather than awarding benefits absent impossibility of a reasonable denial)
- Pagan v. NYNEX Pension Plan, 52 F.3d 438 (2d Cir. 1995) (definition of arbitrary and capricious review)