Myra Ray v. Sun Life & Health Insurance Company
443 F. App'x 529
11th Cir.2011Background
- ERISA plan granted the claims fiduciary discretion to decide all claim and eligibility decisions, with deference to the fiduciary absent arbitrary and capricious action.
- Ray claimed total disability in 2005 due to a heart condition; initial approval was followed by a requirement for periodic medical updates.
- Sun Life relied on medical records, surveillance, and independent reviews (Dr. Eaton, Dr. Rosenberg) to terminate benefits effective May 31, 2008.
- Dr. Bourge’s records and statements were inconsistent with his own notes and with other medical reviews; two non-examining experts found Ray capable of returning to work.
- SSA awarded Ray benefits; Sun Life advised SSA decision was not controlling and considered a plan-specific eligibility standard.
- District court applied the multi-step ERISA framework (Firestone/Glenn) and affirmed the termination.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether Sun Life’s decision was de novo wrong | Ray | Sun Life relied on medical reviews and records | Not de novo wrong |
| Whether Sun Life abused its discretion given the record | Ray contends treating physician’s view should control | Non-examining opinions supported termination | No abuse of discretion; decision reasonable |
| Whether the conflict of interest affected the decision | Conflict tainted Sun Life’s decision | Conflict weighed as factor, but not outcome-determinative | Conflict did not render decision arbitrary and capricious |
| Role of treating physician and SSA in ERISA review | SSA benefits imply disability under ERISA | SSA adjudication not controlling for ERISA plan | SSA not controlling; plan terms govern |
Key Cases Cited
- Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101 (S. Ct. 1989) (established de novo to deferential review framework for ERISA benefits)
- Metropolitan Life Ins. Co. v. Glenn, 554 U.S. 105 (U.S. 2008) (directs multi-step framework for discretionary review)
- Black & Decker Disability Plan v. Nord, 538 U.S. 822 (U.S. 2003) (treating physician’s opinion not given special weight)
- Blankenship v. Metropolitan Life Ins. Co., 644 F.3d 1350 (11th Cir. 2011) (district court properly applied ERISA framework)
- Whatley v. CNA Ins. Cos., 189 F.3d 1310 (11th Cir. 1999) (SSA benefits not conclusive for ERISA plan)