Raymond Shaw v. AT&T Umbrella Benefit Plan
795 F.3d 538
| 6th Cir. | 2015Background
- Raymond Shaw, covered by AT&T Umbrella Benefit Plan, stopped working due to chronic neck pain and received short-term disability (STD) benefits through Aug. 7, 2010.
- Shaw applied for long-term disability (LTD) benefits; Plan (administered by Sedgwick) required "objective Medical Documentation" and reserved discretion to evaluate claims and order examinations.
- Treating providers (family physician, orthopedists, pain clinic, physical therapist) documented MRI-proven C6-7 herniation, limited neck range of motion, functional limits (e.g., sitting/standing ~30 minutes), EMG findings, and treating physicians endorsed surgery or conservative treatment.
- Sedgwick denied LTD initially, and on appeal relied on independent file-review physicians who concluded Shaw could perform sedentary work; Sedgwick also relied on a transferable-skills analysis identifying sedentary jobs.
- Social Security Administration (SSA) awarded Shaw benefits, finding him disabled from July 31, 2009; Sedgwick nonetheless upheld its denial after consultant reviews and limited attempts to contact treating physicians.
- District court granted summary judgment for the Plan; the Sixth Circuit reversed, concluding the Plan’s denial was arbitrary and capricious and directing award of LTD benefits.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Standard of review | Shaw argued no discretionary authority was properly delegated so de novo review should apply | Plan argued the program granted Sedgwick discretionary authority, so arbitrary-and-capricious review applies | Court: plan unambiguously delegated discretion to Sedgwick; arbitrary-and-capricious standard applies |
| Adequacy of medical review / evidence weighing | Shaw argued Plan ignored and selectively discounted objective treating-provider evidence (range-of-motion, RFC, EMG, MRI, functional-capacity evaluation); did not conduct its own exam and gave treating doctors no meaningful chance to respond | Plan relied on independent physician file reviews and transferable-skills analysis concluding sedentary work possible; consultants found insufficient objective evidence of total disability | Court: Plan acted arbitrarily and capriciously — ignored favorable treating evidence, selectively reviewed records, failed to perform physical exam despite authority to do so, over-relied on non‑examining consultants |
| Effect of SSA disability finding | Shaw argued SSA’s favorable finding supports credibility and weight of medical record | Plan did not give dispositive weight to SSA decision; relied on its own review | Court criticized Plan for failing adequately to consider SSA decision among record factors; SSA decision supports finding of disability |
| Remedy | Shaw requested benefits or remand | Plan would prefer remand for reevaluation | Court: remand unnecessary — record contains objective medical evidence showing Shaw clearly entitled to LTD benefits; directed district court to enter judgment awarding benefits |
Key Cases Cited
- Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101 (standard of review for ERISA benefit denials)
- Black & Decker Disability Plan v. Nord, 538 U.S. 822 (plan need not defer to treating physicians but cannot arbitrarily refuse reliable treating evidence)
- Glenn v. MetLife, 461 F.3d 660 (6th Cir.) (arbitrary-and-capricious standard requires deliberate, principled reasoning)
- DeLisle v. Sun Life Assur. Co. of Canada, 558 F.3d 440 (6th Cir.) (substantial-evidence support and reasoned explanation required)
- Helfman v. GE Grp. Life Assurance Co., 573 F.3d 383 (6th Cir.) (failure to conduct physical exam when authorized raises questions about thoroughness)
- Elliott v. Metro. Life Ins. Co., 473 F.3d 613 (6th Cir.) (plan must give reasons when rejecting treating physician opinions)
- Cooper v. Life Ins. Co. of N. Am., 486 F.3d 157 (6th Cir.) (awarding benefits where objective medical evidence clearly shows disability)