Lead Opinion
On this appeal, we review a summary judgment entered on behalf of Gary A. Levinson (“Levinson”) on his claim against Reliance Standard Life Insurance Company (“Reliance”) for long-term disability
I. BACKGROUND
Levinson, an attorney, filed a claim for benefits with Reliance under his law firm’s group long-term disability policy (“the policy” or “the plan”) governed by the Employee Retirement Income Security Act (“ERISA”).
Under the Reliance policy, an insured is entitled to monthly benefits if he “(1) is Totally Disabled as the result of a Sickness or Injury covered by this Policy; (2) is under the regular care of a Physician; (3) has completed the Elimination Period; and (4) submits satisfactory proof of Total Disability to [Reliance].”
Reliance separately obtained Levinson’s medical records and denied Levinson benefits, citing a lack of physical symptoms and “objective medical findings.” Reliance stated that Levinson’s condition did not preclude him from performing the material duties of his occupation, so he did not meet the definition of “Totally Disabled.” In making its decision, Reliance relied on the report of a nurse in its medical records department and the opinion of a claims person. Levinson requested formal review of the decision, and submitted a supporting letter from Dr. Azar. After Reliance denied his appeal, Levinson filed this lawsuit in state court pursuant to 29 U.S.C. § 1132(a)(1)(B) to recover benefits due to him under a group policy governed by ERISA. Reliance removed to the district court.
Levinson moved for summary judgment, asking the district court to review
II. DISCUSSION
We review a district court’s grant of summary judgment de novo, applying the same legal standards that controlled the district court’s decision. See Shannon v. Jack Eckerd Corp.,
A. Whether the Claim Decisions Were Arbitrary and Capricious
The district court concluded, after an independent review of the record and a de novo determination of the issues, that the plan administrator’s decision was arbitrary and capricious and that Reliance had no basis upon which it could deny Levinson’s claim. The district court found that the plan administrator’s decision did not survive even the most deferential standard of review.
Because the policy gives the administrator discretion to determine eligibility for benefits, we must determine whether the administrator’s decision was arbitrary and capricious. See Firestone Tire & Rubber Co. v. Bruch,
To support his initial claim, Levinson submitted an APS from Dr. Azar stating that he was totally disabled. Levinson was under the care of a physician, and there is no dispute that he completed the elimination period. Reliance also had access to Levinson’s medical records that detailed his heart condition. At the time Reliance made the decision on Levinson’s claim, it appears that the only facts known to it were based on Dr. Azar’s APS, Levinson’s medical records, and Levinson’s status as a full time employee at the law firm. Reliance’s decision on Levinson’s appeal involved a review of the same facts as its first decision, as well as: (1) Dr. Azar’s letter of January 1996 which stated Levinson could not perform the material duties of his occupation on a full-time basis; and, (2) office attendance records showing that between Levinson’s initial appointment with Dr. Azar and the date of his termination Levinson had taken two sick days, left early for a doctor’s appointment one day, and had taken ll/£ vacation days.
We find that Reliance’s decisions on Levinson’s claims were wrong from a perspective of de novo review, and its self-interest in this case requires that we determine whether the claims decisions were arbitrary and capricious. It does not appear that there was a reasonable basis for Reliance’s decisions, based on the evidence known to Reliance at the time it made the decisions. Aside from the report from his law firm indicating that Levinson was a full-time employee, there did not appear to be any evidence before Reliance that contradicted Levinson’s evidence from his physician that he was totally disabled under the terms of the plan. Therefore, the district court was correct in holding the claim decision was arbitrary and capricious.
B. The District Court’s Refusal to Remand to Reliance
1. Liability
Reliance argues that remand is required where it cannot be said that it would have been unreasonable for Reliance to deny Levinson’s claim on any ground. Reliance also argues that remand is required where the administrative record could support liability only through the date of the most recent medical evidence and contained insufficient evidence upon which to determine the amount of benefits through that date.
The district court held that remand was not necessary in this case because the administrator had considered all of the record evidence and had reached a conclusion under the heightened arbitrary and capricious standard that was unsupported by the evidence in the record. The district court reasoned that in cases like this one, where the administrator considered all of the record evidence and reached a conclusion, remand is not appropriate.
Reliance cited Miller v. United Welfare Fund,
Reliance also argues that the independent medical opinion obtained for its summary judgment motion is evidence it could consider on remand. In support of this proposition, Reliance cites a Seventh Circuit opinion that held “[a]s a general matter a court should not resolve the eligibility question on the basis of evidence never presented to a pension fund’s trustees but should remand to the trustees for a new determination.” Wardle v. Central States, Southeast & Southwest Areas Pension
In Shannon, after affirming the district court’s decision that a claim decision was arbitrary and capricious, we also affirmed the district court’s decision to remand to the plan administrator. See Shannon,
We find persuasive the Eighth Circuit’s reasoning in Davidson v. Prudential Ins. Co. of America,
2. Benefits
Reliance argues that even if the district court correctly determined that remand was not necessary to determine Levinson’s initial eligibility for benefits under the plan, remand was required to determine the amount of benefits Levinson should receive. Reliance contends that the administrative record does not contain any information as to whether Levinson worked part-time or full-time since October, 1995, which would be relevant to determining the amount to offset from Levinson’s benefits. Rebanee also contends that the administrative record’s last medical evidence is from January, 1996, so Reliance’s liabibty should run to that date only.
Reliance argues that this Court should require the district court to vacate its award of damages to Levinson and remand to Reliance to decide the amount of benefits to which Levinson is entitled. Then, if Levinson is not satisfied with that amount, he can bring another action under § 1132(a)(1)(B), and the district court can review Reliance’s determination under the arbitrary and capricious standard to assess its reasonableness.
The text of § 1182(a)(1)(B), under which Levinson brought this action, allows a beneficiary to bring a civil action “to recover benefits due to him under the terms of his plan....” 29 U.S.C. § 1132(a)(1)(B). Under the text of the statute, it does not appear that the court was required to remand to Reliance to determine the amount of benefits to which he was entitled. We stated in Jett that “ ‘[a]s a general matter a court should not resolve the eligibility question on the basis of evidence never presented to [an ERISA plan’s administrator] but should remand to the [administrator] for a new determination.’” Jett,
The district court noted that Levinson continued to provide proof of his continuing total disability throughout the litigation, and because of that, Reliance could not argue that Levinson failed to perform his duties under the part of the insurance contract requiring the insured to furnish proof of disability. The court also found that there was sufficient evidence to find that Levinson was still “Totally Disabled” under the policy, and that Reliance had not shown Levinson’s condition had improved. In making the latter determination, the court discounted the opinion of Dr. Myer-burg who reviewed Levinson’s documents. The court stated that the problem with Myerburg’s testimony was that he argued Levinson was never disabled, not that his condition improved to the point where he was no longer disabled (Myerburg agreed with Levinson’s doctors that Levinson’s condition was not likely to improve; the disagreement was that Myerburg did not believe that emotional stress from work would worsen Levinson’s condition as Lev-inson’s doctors did).
The district court also gave less weight to Myerburg’s testimony, as he was a reviewing physician, and not a treating physician or examining physician. The court cited Donaho v. FMC Corp.,
Under the language of the plan, once Levinson became eligible for monthly benefits, those benefits would not terminate until “the date [he] ceases to be permanently disabled,” or “the date [he] fails to furnish the required proof of Total Disability.” During discovery in this ease, Levin-son continued to provide proof that he was “Totally Disabled” under the terms of the plan. Under the Eighth Circuit’s holding in Donaho, reversing the district court with instructions to remand to the plan administrator would appear to be the proper action for us to take. We find, however, that remand to Reliance to determine whether Levinson was still disabled would have hindered the goal of judicial economy. In this case, where all of the evidence before the district court showed that Levinson’s condition had not improved and tended to show that he was still disabled under the terms of the plan, remand was neither a necessary nor an appropriate remedy. See, e.g., Quesinberry v. Life Ins. Co. of N. Am.,
The dissent argues that Reliance never had the opportunity to determine “whether Levinson was still totally disabled at the time of trial in late 1999” and that the district court should have remanded the claim to Reliance so that it could determine whether Levinson remained disabled under the terms of the plan. We agree that, as a general rule, remand to the plan fiduciary is the appropriate remedy when the plan administrator has not had an opportunity to consider evidence on an issue. See Jett,
C. The District Court’s Award of Damages to Levinson
Reliance argues that the district court erred in two other ways: by requiring Reliance to prove Levinson ceased to be disabled when it never determined Levin-
Reliance asserts that it could not meet the burden of proving that Levinson was no longer disabled because it had always taken the position that he was never disabled. Reliance contends that when the court found that Levinson was disabled, it wrongly switched the burden to Reliance to prove Levinson was no longer disabled in order to end benefits. Reliance points out that in Miller, the Second Circuit found a decision by an ERISA fiduciary to be arbitrary and capricious, but noted that the burden of proof on remand remained with the insured. See Miller,
Reliance introduced billing records from September 1995 to January 1998 that purportedly demonstrated Levinson worked in excess of the four to five hours a day he said he was capable of working. At trial, Levinson testified that he did not actually work all of the hours that he billed, but that he “value billed” his clients, so a job that may have taken him one hour was billed for eight hours. Reliance argues that the testimony is not credible, because Levinson either lied or violated the Florida Bar’s ethical rules on billing elients.
Levinson also testified that “for the most part” he worked less than five hours a day. Levinson further testified that on some days, he would not go into the office at all, or would only go into the office for short periods of time, or would not spend the entire time he was at the office working. Levinson also stated that on some days, he did work more than five hours. Based on this evidence, the district court made a factual determination that Levin-son did not work full time and therefore, did not cease to be disabled. We review this factual finding for clear error. See Fed.R.Civ.P. 52(a). Our review of the record does not leave us “with the definite and firm conviction that a mistake has been committed.” United States v. United States Gypsum Co.,
III. CONCLUSION
The district court correctly found Reliance’s claim decisions were arbitrary and capricious, and correctly refused to remand to Reliance for decisions on Levin-son’s eligibility or the amount of benefits to which he was entitled. For the foregoing reasons, we affirm the decision of the district court.
AFFIRMED.
Notes
. The Employee Retirement Income Security Act of 1974 and as amended, 29 U.S.C. §§ 1001 et seq.
. The Elimination Period is defined in the policy as 90 consecutive days of total disability for which no benefit is payable.
. The policy defines partially disabled as: "capable of performing the material duties of his/her regular occupation on a part-time basis or some of the material duties on a full-time basis.”
.Levinson filed his claim on August 24, 1995, and the law firm through which he was covered terminated his employment on August 15.
. Reliance sought to appeal this decision under the ministerial exception to the finality doctrine, as all that remained for the district court to do was the ministerial act of remanding the case to Reliance to calculate damages. We dismissed the appeal for lack of jurisdiction (No. 98-5539).
. Reliance asserts that Levinson's attendance and billing records and status as a full-time employee constitute record evidence that it should not consider Levinson to be disabled. In Marecek v. BellSouth Telecomms., Inc.,
. Reliance did not obtain an independent medical opinion until Levinson moved for summary judgment, when it had a University
. The policy states that the monthly benefit will stop on "the earliest of: (1) the date the Insured ceases to be Totally Disabled .... "or "(4) the date the Insured fails to furnish the required proof of Total Disability.”
. At the trial to determine the amount of benefits Levinson was to receive, the parties agreed that the amount of Levinson’s monthly benefit would be calculated according to the formula in the policy (60% of covered monthly earnings on the date prior to disability or $3,500 per month), and the prejudgment interest. amount to be added to Levinson’s benefits. The only issues the district court tried were the time period over which benefits were payable, and the amount of "Other Income Benefits” to offset from the monthly benefit amount.
. Levinson’s billing records indicate that he billed "in excess of twelve hours in a day on two occasions, ten or more hours on two occasions, in excess of nine hours on one occasion, and eight or more hours on four occasions during the period between February 1996 and November 1997.” These nine days in a period of nearly two years do not indicate that Levinson was capable of performing all of the material duties of his occupation on a full-time basis.
. We certainly do not condone such a practice, but its propriety is not before us today.
Concurrence Opinion
concurring in part and dissenting in part:
I do not join the court’s opinion, but concur in the holding that Reliance’s denial of Levinson’s 1995 claim was arbitrary and capricious given the limited administrative record before Reliance at the time it rejected the claim. The district court erred, however, by proceeding to conduct an inquiry into whether Levinson had remained disabled until the time of trial.
The role of the courts when plan participants file suit alleging the improper denial of benefits is to review the decisions made by plan administrators. See, e.g. Jett v. Blue Cross and Blue Shield of Alabama,
ERISA provides district courts with jurisdiction over actions for recovery of benefits allegedly improperly denied a plan participant. See 29 U.S.C. § 1132(a)(1)(B). It does not, however, empower courts to hear claims for benefits which were not first presented to and decided by the plan fiduciary. Here, Reliance made its last decision on Levinson’s eligibility for benefits on March 3, 1996. Accordingly, the proper course in this case would have been to remand the claim to Reliance with instructions to find that Levinson was totally disabled as of March 3,1996.
The district court, under the guise of trying the question of damages, proceeded to try the question of whether Levinson remained disabled through the time of trial — over three years after his initial claim was denied by Reliance on appeal.
The record in this case contains substantial evidence that Levinson, a real estate lawyer, has continued to practice law full-time since making his initial claim. Levin-son testified that he has continued to work steadily since 1995. (R.8 at 59). Although Levinson contended that he has worked at most five hours a day, he conceded on cross examination that his billing records for the period from September 1995 through January 1998 reflected that he worked six and seven hour days on numerous occasions and had also recorded days that he billed his clients for eight, ten and
Although the district court apparently found that Levinson’s billing records significantly exaggerated the amount of time he worked, I suggest that Reliance — not the district court — was entitled to evaluate this evidence and make its own determination about whether Levinson was working full-time.
. The court had previously precluded Reliance from obtaining an independent medical examination of Levinson and from taking depositions on the ground that "the issue in this case is not the disability of [Levinson], but rather the decision of [Reliance].” (R.1-37, R.1-38.).
. The billing records evidence may not conclusively demonstrate that Levinson was working full-time in the period after his filed his claim. However, its existence does belie the assertion that all the evidence before the district court suggested that Levinson was still disabled under the terms of the plan. Because the record did contain evidence which tended to show that Levinson was no longer disabled, J believe that the goal of judicial economy does not support the district court's refusal to remand.
. The district court made no specific findings as to whether Levinson’s billing records accurately reflected the time he spent working, instead noting that Levinson had worked "part-time” since filing his disability claim.
