Lead Opinion
Brenda Mote sued Aetna Life Insurance Co. (“Aetna”) and the Arthur Andersen Long-Term Disability Plan (the “Plan”) under the Employment Retirement Income Security Act (“ERISA”), 29 U.S.C. § 1001 et seq., alleging that Aetna and the Plan arbitrarily and capriciously terminated her disability benefit payments and that they should be estopped from terminating her disability benefits because the Social Security Administration found her “disabled” under its regulations. The district court dismissed Mote’s claims against Aet-na upon finding that Aetna was not a proper party to the action, denied Mote’s motion for summary judgment against the Plan, and granted summary judgment to the Plan on all of Mote’s claims against it. Mote appeals. We affirm.
I.
Brenda Mote was a human resource generalist with Arthur Andersen LLP until she ceased working on April 10, 1998, due to back pain and physical complications, including fibromyalgia,
After Mote had been receiving long-term disability benefits for five years, on December 8, 2003, the Plan notified her that it recently had reevaluated her claim under its stricter, five-year definition of “totally disabled” and determined that she no longer qualified for long-term disability benefits. Under the Plan, while an employee only needs to demonstrate that he is unable to “perform the material duties of [his] own occupation” during the first five years of his disability, after five years the employee must demonstrate that he is unable to “work at any occupation for which [he] is, or may reasonably become, fitted by education, training or experience.” In its letter to Mote, the Plan stated that it reached its decision after reviewing the office notes of Mote’s treating physicians, various lumbar MRIs, CT scans, and surgical procedures, as well as statements by Mote’s physicians regarding her physical limitations and restrictions. The letter also informed Mote that the Plan had hired an independent investigator who, in January 2003, videotaped her engaging in activities that she stated on her April 30, 2003, Claim Questionnaire that she was unable to perform. The Plan’s letter further stated that it based its decision on the results of Mote’s November 11, 2002, functional capacity examination and her September 15, 2003, independent medical examination, both of which found that Mote was capable of performing sedentary work. The letter also noted that the Plan’s consulting physicians reviewed Mote’s medical information on two recent occasions and reached the same conclusion.
Mote requested that the Plan review its decision. In support of her request for review, Mote submitted additional medical evidence from her treating physicians, including her primary care physician, Terry West, M.D., and her pain management specialist, James Gruft, M.D. Dr. West opined that Mote was suffering from a “class 5” physical impairment, which rendered her “incapable of minimal (sedentary) activity.” He further noted that, in his opinion, “maximum medical improvement has [been] achieved. I don’t believe she can ever work again.” In a letter dated August 10, 2004, Dr. West stated that Mote suffers from fibromyalgia and chronic back pain, which remain unchanged, and he concluded that Mote “is still unable to work at this time, due to limitations of motion and need for sedating pain medication.” Dr. Gruft also opined that Mote was incapable of sedentary activity, and that he believed that Mote’s condition had “retrogressed.”
Upon its receipt of Mote’s additional information, the Plan informed Mote that it referred her file for an independent medical review. The Plan retained William Hall, M.D., to conduct its review. In his September 2, 2004, report, Dr. Hall stated that he reviewed Mote’s medical history and opined:
I must conclude that the weight of the medical credibility be given to the opinions of [Mote’s] treating physicians and that, absent medical or personal information regarding [Mote] to the contrary, her subjective musculoskeletal symptoms are of such severity to be totally medically limiting.
However, during his initial review of Mote’s medical records, Dr. Hall was un
After viewing surveillance videos of [Mote’s] activities for the dates and durations noted, I do not agree with assessments of severity or with medically limiting conclusions by [Mote’s] treating physicians. I am not able to identify an objective or absolute impediment to [Mote] pursuing sustained and otherwise unrestricted activities at a light level of exertion.
In a letter dated September 28, 2004, the Plan notified Mote that, after a “full and fair review of the decision to terminate [her] claim,” it was upholding its decision to terminate her long-term disability benefits.
II.
We review a district court’s decision on summary judgment de novo. Davis v. Unum Life Ins. Co. of Am.,
On appeal, Mote first argues that the Plan’s decision, to stop paying her benefits after finding that she did not meet the stricter five-year definition of “total disability” was arbitrary and capricious. In Firestone Tire & Rubber v. Bruch,
Under the arbitrary and capricious standard, “we will overturn a plan administrator’s decision ‘only ... if it is downright unreasonable.’ ” Herman v. Cent. States, Se. & Sw. Areas Pension Fund,
In this case, Mote first argues that the Plan’s decision was arbitrary and capricious because there was no evidence in the record that her condition improved. Mote contends that a finding of improvement is necessary because the Plan actually terminated her benefits under the “own occupation” definition of “totally disabled,” rather than the five-year, “any occupation” definition. Thus, she reasons that if the Plan found that she could not perform her position as a human resource generalist in 1998, and there is no evidence that her chronic back pain or fibromyalgia had improved, then the Plan had no basis for terminating her benefits. As discussed above, the totality of the evidence indicates that the Plan terminated Mote’s benefits based on the five-year, “any occupation” definition. See supra, at n. 1. Because that definition differs significantly from the more lenient “own occupation” definition, we find that even if Mote’s condition did not improve over the five-year period she was receiving disability benefits, that is not determinative of whether she was “totally disabled” under the five-year definition. Accordingly, we evaluate whether the Plan arbitrarily and capriciously evaluated the evidence before it in making its determination that Mote was capable of performing some occupation, rather than merely her previous occupation.
Mote next asserts that the Plan did not properly weigh her treating physicians’ opinions in reaching its termination decision. Mote’s argument is unavailing, however, because “ERISA does not require plan administrators to accord special deference to the opinions of treating physicians.” Kobs v. United Wis. Ins. Co.,
Mote further argues that the Plan’s reviewing doctors’ opinions regarding her condition were unreliable and rendered the Plan’s decision arbitrary and capricious. Specifically, Mote takes issue with the fact that none of the Plan’s physicians consulted a rheumatologist with specialized expertise in fibromyalgia, nor did the Plan contact her treating physicians to discuss her fibromyalgia. As a threshold matter, an ERISA plan is not required to hire specialists for every claimed malady in cases in which the plan hired an independent expert to conduct a physical examination of the claimant. In this case, the Plan hired an independent expert, orthopedic surgeon Richard Tuttle, M.D., to examine Mote. The record indicates Dr. Tuttle conducted an “18 tender points” examination of Mote to assess her fibro-myalgia, which was the same test that
Next, Mote argues that Dr. Hall’s and Dr. Radford’s opinions are suspect simply because the Plan hired them. Mote’s assertion that the Plan’s employees or its consultants had an incentive to deny her claim is without support in the record. As we recognized in Leipzig v. AIG Life Insurance Co., “most insurers are well diversified, so that the decision in any one case has no perceptible effect on the bottom line,” and thus “[tjhere is correspondingly slight reason to suspect that they will bend the rales,” absent suspect circumstances such as “an insurer or plan administrator pay[ing] its staff more for denying claims than for granting them.”
Mote also asserts that the Plan’s reliance on the results of her November 11, 2002, functional capacity examination (“FCE”) was unreasonable. In his report, the FCE evaluator concluded that Mote “is currently capable of working at the sedentary physical demand level within the material handling and positional tolerances set forth in the report, of an eight hour day.” Despite that conclusion, Mote asserts that the FCE evaluator’s opinion was
Mote then contends that Dr. Hall’s opinion is suspect because he changed his conclusion after viewing the videotape snippets of her daily activities and that the Plan’s consideration of the videotapes during its deliberative process was improper. These argument also are without merit. In Shyman v. Unum Life Insurance Co.,
Mote further argues that the Plan was estopped from asserting that she was not totally disabled because the Social Security Administration (“SSA”) later found Mote to be disabled under its standards. Mote, however, ignores the fact that the Plan’s five-year definition of “totally disabled,” and the standard used in other ERISA plans, is not the same as the standard used for evaluating disability under the Social Security Act, 42 U.S.C. § 423(d)(1)(A). See Nord,
Finally, Mote contends that the district court erred by dismissing her claims against Aetna upon its finding that Aetna was not a proper party to the action. She asserts that she should be able to sue both her employer’s ERISA plan (i.e., the Plan) and the Plan’s administrator, Aetna. Generally, in a suit for ERISA benefits, the plaintiff is “limited to a suit against the Plan.” Blickenstaff v. R.R. Donnelley & Sons Co. Short Term Disability Plan,
III.
The district court properly entered summary judgment for the Plan and denied Mote’s motion for summary judgment because the Plan’s decision to terminate Mote’s long-term disability benefits was neither arbitrary nor capricious, and because the Plan was not estopped from terminating Mote’s benefits based upon the Social Security Administration’s subsequent finding that Mote was disabled under its regulations. The district court also properly dismissed Mote’s claims against Aetna because Aetna was not a proper party to the action. Accordingly, the district court’s judgment is Affirmed.
Notes
. Fibromyalgia is “pain and stiffness in the muscles and joints that is either diffuse or has multiple trigger points.” Dorland's Illustrated Medical Dictionary 673 (29th ed.2000).
. The Plan’s letter of December 8, 2003, indicates that it based its decision to terminate Mote's benefits on the Plan's stricter, five-year definition of "totally disabled." Specifically, that letter states: "Our review of the information in our file indicates you have the functional capacity to perform the material duties of any occupation and you no longer meet the plan requirements for total disability.” The Plan’s letter of September 28, 2004, indicates that the Plan is "upholding [its] termination on December 8, 2003,” and it cites both the initial and five-year definitions of "totally disabled.” However, the Plan’s second letter then states that Mote's long-term benefits "ceased on December 8, 2003, after it was assessed you are capable of performing your own sedentary occupation.” The Plan argues that the reference to Mote’s own occupation in the second letter was a scrivener’s error, and that Mote was apprised adequately of and able to respond to the stricter five-year definition set forth in the first termination letter. We agree that the Plan’s letter of December 8, 2003, adequately notified Mote that the Plan’s termination of her benefits—which occurred exactly five years after it originally approved her claim—was based on the five-year definition, and provided Mote with an opportunity to submit additional evidence challenging the Plan’s decision under that definition of "totally disabled.” The fact that the Plan erroneously cited the wrong definition of “total disability” in its final denial letter was inconsequential because that letter merely informed Mote that the Plan had affirmed its decision to deny her claim following its review of its earlier decision, which the parties do not dispute was based on the five-year definition. Accordingly, the Plan’s scrivener’s error in the second letter does not warrant remand to the plan administrator. See Schleibaum v. Kmart Corp.,
. The dissent asserts that the Plan's letter to Mote of September 28, 2004, adds entirely new language to the Plan. The “entire new language” that it quotes is a sentence lifted from a three-page letter explaining, after an "independent, full and fair review,” why the Plan is upholding its decision to terminate Mote's claim for long-term disability benefits. The language that the dissent quotes is not an addition of entirely new language to the Plan, and when taken out of context, it misconstrues the text of the Plan’s letter. Also, the dissent does not mention that the sentence that it quotes is surrounded by a full analysis detailing the Plan’s rationale for its prior decision and the medical evidence Mote presented for reconsideration. Following the quoted statement, the Plan's letter goes on to express its rationale for denying the request for reconsideration. When read in context, it is clear that the quoted statement does not indicate that the Plan began its analysis with the premise that reported pain can never be enough.
. On appeal, Mote also raises for the first time the following arguments: (1) that Dr. Radford was not qualified to render an opinion because he is an occupational medicine specialist; (2) that Dr. Tuttle did not have the entire record to review before his independent medial examination; and (3) that Drs. Tuttle, Radford, and Hall were opining outside their respective scopes of expertise when they determined that Mote could work at a sedentary occupation. Because Mote failed to raise those arguments in the district court, she has waived her opportunity to raise them at this stage. Taubenfeld v. AON Corp.,
. The dissent takes issue with the Plan’s use of portions of the surveillance videotapes, and attempts to draw conclusions regarding Mote's activities depicted on the videotapes. As the parties indicated during oral argument, neither the snippets of the videotapes viewed by Dr. Hall, nor the raw footage, are in the record. We are thus unable to review either set of videotapes to determine whether the parties’ representations regarding the substance of those videotapes are accurate. What is in the record, however, are Dr. Hall’s statements regarding their content after he reviewed them, as well as the records from the investigators who conducted the surveillance. Based on those memorialized accounts in the record, there is ample evidence that the activities in which Mote engaged con-dieted with her representations regarding her functional abilities. Even if this is a close call, there is insufficient contrary evidence to conclude that the evidence presented on the videotapes rendered the Plan’s decision arbitrary and capricious.
Moreover, if Mote believed that the portions of the surveillance videotapes relied upon by the Plan were not representative of her functional abilities, or if she believed the videotapes had been edited to omit evidence that supported her claim, she was free to submit that evidence to the court. Mote elected not to submit any portion of the surveillance videotapes, and thus it is not a proper function of this court to speculate on what the videotapes may or may not have shown.
Concurrence Opinion
concurring in part and dissenting in part.
In fact-specific cases like this one, the court of appeals is usually defacto the last stop on the road for the litigants. It is thus critical that we get the facts right, even if we agree on the governing legal standards. Here, although I agree with the majority’s assessment of the claims against Aetna, the administrator of the plan at issue, I must part ways with its evaluation of Brenda Mote’s claims against the long-term disability plan (“the Plan”). According to Mote’s treating physicians and other specialists, since at least 1998 she has suffered from fibromyalgia, migraines, a sleep disorder, depression, and pain throughout her body. From 1998 to 2003, she received benefits from the long-term disability plan sponsored by her former employer, Arthur Andersen. In 2003, Mote’s disability benefits were terminated because the length of Mote’s disability triggered a shift in the applicable standard for disability, from the earlier one in which she needed to show that she could not perform her own job, to the more stringent one in which she needed to show that she could not perform any work at all. Mote appealed the decision, but the Plan affirmed itself. Mote then filed this suit in federal court, alleging that the Plan’s decision to terminate her benefits was arbitrary and capricious.
Although arbitrary and capricious review ties our hands considerably, it is “not a rubber stamp.” Hackett v. Xerox Corp. Long-Term Disability Income Plan,
I see two significant problems in the Plan’s consideration of Mote’s appeal, either one of which would require reversal even under arbitrary and capricious review. First, in denying Mote’s appeal on September 28, 2004, the Plan made the following statement: “Reported pain also cannot be relied upon as [a] sufficient indicator of functional impairment since perception of pain may be affected by individual tolerance, motivation or psychological factors.” Perhaps if this plan had language in it to that effect, that conclusion might be acceptable. But most plans do not, and this one is no exception. To the contrary, section VII, which includes the governing definitions for the Plan, says only that “total disability/totally disabled” means
that solely because of an illness, pregnancy or accidental bodily injury, an insured employee is unable: (1) [djuring the first 5 years of disability to perform the material duties of the employee’s own occupation; and (2) [fjrom then on, to work at any occupation for which such employee is, or may reasonably become, fitted by education, training or experience. The availability of employment will not be considered in the assessment of the employee’s disability.
Plan, sec. VII, ¶ 29. In other words, the Plan takes a functional approach to disability. It does not forbid an employee from showing functional incapacity through self-reported symptoms. The ability to “interpret” cannot mean the ability to add entirely new language to plans. In my view, Mote’s case is indistinguishable from another ERISA case involving fibromyalgia, in which we held that subjective reports of pain can suffice to show one’s complete disability. Hawkins v. First Union Corp. Long-Term Disability Plan,
Second, although surveillance evidence can be used to undermine the credibility of a doctor’s medical opinions where the diagnosis is based substantially on patient reports, whether it was used properly here depends on how it was used and for what purpose. The record indicates that the Plan’s medical reviewer, Dr. Hall, did not receive all of the surveillance information about Mote, which was gathered over days and days of observation. Instead, as the majority concedes, he received only a compilation of two hours of pre-selected footage. After reviewing this material and looking at no other new evidence, Dr. Hall withdrew his earlier conclusion that Mote was totally disabled from working in any occupation. The fact that the tapes themselves are not in the record does not somehow make Dr. Hall’s conclusion reliable. No one disputes that he never saw the vast majority of the evidence that was collected. One might just as well view a two-hour snippet of Mote sitting on a sofa, and conclude that this was all she ever did. Dr. Hall’s opinion was based on inherently unreliable evidence and thus should not have been entitled to any weight.
Properly used, surveillance evidence can provide a basis for choosing between contradictory medical evidence by rendering some of that evidence less credible. This court has noted that “[w]e can imagine an argument that even if the activity disclosed ... does not indicate a capacity to engage in full-time work, the fact that it is discrepant with the level of activity described by [the treating physician], presumably on the basis of representations made to him by [the plaintiff], fatally undermines [the plaintiffs] credibility.” Hawkins,
Mote may well have concluded that there was no need to supplement the record before this court by furnishing all of the surveillance tapes, because even the evidence that Dr. Hall viewed was generally consistent with the records from Mote’s treating physicians. One problem with the way in which the Plan used the surveillance evidence is the fact that it made assumptions that find no support in the
Most troubling to me is that when the activities observed by surveillance are put in context, their utility in assessing Mote’s level of disability appears flimsy at best. Mote’s medical records state that Mote “overdoes it. Others aware of her overdoing it and depend on it. Patient aware of need for changes.” We have recognized in the past that some disabled people manage to keep going only through superhuman efforts; in those circumstances their activities do not negate the fact that they are disabled. See Perlman v. Swiss Bank Corp. Comprehensive Disability Protection Plan,
Other courts have concluded that segments of surveillance showing light physical activities by a plaintiff do not amount to a showing that she is able to manage full-time employment. See Osbun v. Auburn Foundry, Inc.,
Viewed in any light, the surveillance evidence in Mote’s case is nothing like what this court faced in Shyman v. Unum Life Ins. Co.,
Before concluding, I note with some concern that the actual plan underlying this claim is shrouded in mystery. Bizarrely, at oral argument, defense counsel acknowledged that although he represents both Aetna and the Plan, his only direction in this case came from Aetna. Aetna, however, was dismissed from the case at the district court level, and all three judges on this panel agree that this was correct. It is odd, at best, that Aetna therefore seems to be handling the litigation on appeal and that the Plan is nowhere to be found. The evidence of the Plan was also handled carelessly. Mote attached a copy of the long-term disability insurance contract between Arthur Andersen and Aetna to her complaint, entitled “Long-Term Disability Policy,” rather than another document, entitled “Arthur Andersen LLP Group Long Term Disability Insurance Plan,” which appears later in the record. Both Mote and the defendants refer to the first document as the plan at issue in this case. In the insurance contract, obligations are imposed on “Aetna” and the “policyholder” throughout, with Arthur Andersen (Mote’s former employer) identified as the policyholder. In the latter document, which seems to be the actual plan at issue, obligations are imposed upon the “Administrator,” “Fiduciary,” and “Appeals Fiduciary,” as one would expect. Arthur Andersen, which is defunct at this point, is named as the Plan Administrator, while both Fiduciary roles are filled by Aetna.
Given these two documents, it is unclear how an employee would know which plan document she should rely upon, who was in charge of the Arthur Andersen long-term disability plan, or if the Plan was its own entity separate from Aetna. The employee would need to consult both plans, which notably have similar but not identical definitions of disability. Mote has not pressed this issue in support of any of her arguments, and so we do not need to consider its implications on the case at hand. It does help to explain, however, some of the problems in this case.
Because, in my view, Mote has raised genuine issues of fact on the question whether Aetna’s determination (or, more accurately, the Plan’s) that she could not show inability to perform any job in the economy was arbitrary and capricious, I would reverse the district court’s grant of summary judgment in favor of the Plan and remand for further proceedings. I therefore respectfully dissent.
. My colleagues believe that the Plan's letter of September 28, 2004, taken as a whole, does not rest on the premise that reported pain can never be enough, but I see nothing in the letter that qualifies the statement quoted above. Page 1 of the letter summarizes the Plan's conclusion that Mote is not entitled to relief and sets forth the definition of disability from the Plan. From the bottom of page 1 through the middle of page 2, the letter reviews Mole's medical history. It then states that
[a]vailable medical records do not include references to clinical, laboratory or radio-graphic findings of progressive or worsening organic illness, or to severe or intractable medication side effects. They also do not furnish descriptors of severity of your musculoskeletal symptoms or other subjective symptoms. Although your subjective musculoskeletal symptoms are credible, they are not accounted for by identifiable neurological or musculoskeletal pathology.
In my view, the only way to read this letter is that Mote’s reported pain is insufficient to justify relief.
The only other items to which the letter refers are the surveillance evidence, which for the reasons I outline later is insufficient to support the Plan's conclusions, and an Independent Medical Examination ("IME”) conducted by a Dr. Tuttle on September 15, 2003. Dr. Tuttle was commissioned by the defense to examine Mote, but his examination could only have been as good as the data he had. As Mote pointed out in her brief, both his background and the file he consulted were deficient. Dr. Tuttle was given only a partial record to review and “lacked the appropriate medical specialization to evaluate a fibro-myalgia claim.” Based on his one-time examination of Mote, his review of an incomplete record of her medical history, and his viewing of the selective excerpts from the surveillance tapes, Dr. Tuttle stated that he could not "see any reason why [Mote] cannot
