Filed: Nov. 13, 2017
Latest Update: Mar. 03, 2020
Summary: NOT PRECEDENTIAL UNITED STATES COURT OF APPEALS FOR THE THIRD CIRCUIT _ No. 17-1782 _ KRISTEN ANN DAVIES, Appellant v. FIRST RELIANCE STANDARD LIFE INSURANCE COMPANY _ On Appeal from the United States District Court for the Middle District of Pennsylvania (D.C. No. 1-15-cv-02348) District Judge: Honorable John E. Jones, III _ Submitted Under Third Circuit L.A.R. 34.1(a) November 6, 2017 Before: JORDAN, HARDIMAN, and SCIRICA, Circuit Judges. (Opinion Filed: November 13, 2017) _ OPINION* _ * This
Summary: NOT PRECEDENTIAL UNITED STATES COURT OF APPEALS FOR THE THIRD CIRCUIT _ No. 17-1782 _ KRISTEN ANN DAVIES, Appellant v. FIRST RELIANCE STANDARD LIFE INSURANCE COMPANY _ On Appeal from the United States District Court for the Middle District of Pennsylvania (D.C. No. 1-15-cv-02348) District Judge: Honorable John E. Jones, III _ Submitted Under Third Circuit L.A.R. 34.1(a) November 6, 2017 Before: JORDAN, HARDIMAN, and SCIRICA, Circuit Judges. (Opinion Filed: November 13, 2017) _ OPINION* _ * This d..
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NOT PRECEDENTIAL
UNITED STATES COURT OF APPEALS
FOR THE THIRD CIRCUIT
____________
No. 17-1782
____________
KRISTEN ANN DAVIES,
Appellant
v.
FIRST RELIANCE STANDARD LIFE INSURANCE COMPANY
____________
On Appeal from the United States District Court
for the Middle District of Pennsylvania
(D.C. No. 1-15-cv-02348)
District Judge: Honorable John E. Jones, III
____________
Submitted Under Third Circuit L.A.R. 34.1(a)
November 6, 2017
Before: JORDAN, HARDIMAN, and SCIRICA, Circuit Judges.
(Opinion Filed: November 13, 2017)
____________
OPINION*
____________
*
This disposition is not an opinion of the full Court and pursuant to I.O.P. 5.7 does
not constitute binding precedent.
HARDIMAN, Circuit Judge.
Kristen Ann Davies appeals a summary judgment denying her claim for long-term
disability benefits under the Employee Retirement Income Security Act (ERISA), 29
U.S.C. §§ 1001–461. We will affirm, essentially for the reasons stated by the District
Court in its thorough and cogent opinion.
I1
A pharmaceutical sales representative, Davies stopped working in August 2011
and requested disability benefits from her employer’s insurer, First Reliance Standard
Life Insurance Company. First Reliance approved the claim, and Davies’s disability
payments began to accrue in January 2012. Like many policies, the one issued by First
Reliance entitled Davies to receive disability payments for 24 months if she was unable
to perform her regular occupation, but she would receive payments beyond that time only
if she was unable to perform any occupation.
As the 24-month period was winding down, First Reliance asked Davies to submit
to an independent medical examination. After reviewing Davies’s medical records and
interviewing her, the examining physiatrist (who was chosen by First Reliance) observed
that “[t]he majority of her current complaints seem to be of a psychological nature . . . .”
1
The District Court had jurisdiction under 28 U.S.C. § 1331. See 29 U.S.C.
§ 1132(a)(1)(B). We have jurisdiction under 28 U.S.C. § 1291.
2
Ohio App. 821. He also concluded that Davies was “capable of sedentary activities, including
work,” despite her fibromyalgia, chronic fatigue, and “[d]epression/anxiety.”
Id.
Relying heavily on the physiatrist’s opinion, First Reliance informed Davies that
her disability benefits would be terminated at the end of the “regular occupation” period.
Its decision was based on two factors: (1) Davies could still perform “a sedentary
occupation”; and (2) even if she had been totally disabled from performing any
occupation, the policy’s limitation on benefits for disabilities “caused by or contributed to
by mental or nervous disorders” barred her from receiving additional benefits because,
according to Davies’s own treating physicians, “depression and anxiety are amongst [her]
primary diagnoses . . . .” App. 383–84. Davies, through her mother, appealed First
Reliance’s decision and submitted records from her treating physicians, along with
information from a pharmacy listing possible side effects of her medications and
descriptions of her mother’s “own, regular first-hand interaction with her daughter.”
Davies Br. 10. The appeal submission included a fall 2013 note in which Davies’s
psychiatrist stated: “Though patient does have ADHD and anxiety, they are being
aggravated by her pain and medical situation . . . .” App. 890.
In consideration of Davies’s appeal, First Reliance located a rheumatologist to
perform another independent medical examination. After summarizing Davies’s medical
history and records the rheumatologist concluded after an examination that “no organic
musculoskeletal disease such as fibromyalgia . . . corroborate[d] all of her multiple
3
subjective complaints.” App. 964. Accordingly, First Reliance upheld its prior decision
and sent Davies a denial letter that included summaries of records from both her treating
physicians and the independent medical examiners.
Davies sued First Reliance under ERISA, claiming it had improperly stopped
paying disability benefits. Davies and First Reliance filed cross-motions for summary
judgment. Finding that First Reliance’s benefits determination was not arbitrary and
capricious, the District Court entered summary judgment in favor of the insurer and
denied Davies’s motion. Davies filed this appeal.
II2
Davies argues that First Reliance’s claim determination (A) is not entitled to any
deference; and (B) was improper because she established a total disability from any
occupation, and the policy’s “mental or nervous disorders” limitation does not apply. We
address each argument in turn.
A
The District Court was right to reject Davies’s argument that the Court should
apply something more than the “arbitrary and capricious” standard that usually applies to
a denial of benefits where, as here, the administrator has “fiduciary discretionary
2
We review summary judgments de novo, applying the same standard as the
District Court. Viera v. Life Ins. Co. of N. Am., 642 F.3d 407, 413 (3d Cir. 2011). We also
review de novo the “district court’s determination of the proper standard to apply in its
review of an ERISA plan administrator’s decision . . . .”
Id.
4
authority to determine eligibility . . . .” Firestone Tire & Rubber Co. v. Bruch,
489 U.S.
101, 115 (1989). In Estate of Schwing v. Lilly Health Plan,
562 F.3d 522 (3d Cir. 2009),
we squarely rejected the argument that a structural conflict of interest—which arises
when the same entity administers benefits and pays claims—necessarily demands
increased scrutiny.
Id. at 525–26. We concluded that Metropolitan Life Insurance Co. v.
Glenn,
554 U.S. 105 (2008), abrogated this “sliding scale” approach, so courts should
instead “apply a deferential abuse of discretion standard of review across the board and
consider any conflict of interest as one of several factors . . . .”
Schwing, 562 F.3d at 525.
The District Court correctly applied this binding precedent.
B
Not only is the abuse of discretion standard “deferential” and “difficult to
overcome,” App. 20, the policy itself sets a high bar after 24 months. Under its terms,
Davies had to be totally disabled from any occupation. And even if she were totally
disabled, the cause of her disability had to be independent of her depression, anxiety, and
other non-physical issues. Because that limitation precludes further benefits for
disabilities “caused by or contributed to by mental or nervous disorders,” App. 46
(emphasis added), the District Court correctly recognized that Davies “must establish that
it was arbitrary and capricious for First Reliance to determine that her physical conditions
alone did not render her totally disabled from performing any occupation,” App. 19
(emphasis added).
5
The problem for Davies is that the medical evidence she needs to support her
claim that she is totally disabled from any occupation also confirms that her depression
and anxiety contribute to her disability. Davies concedes that the record is replete with
references, several of which the District Court listed and which we need not reiterate
here, linking her physical and psychiatric conditions. Davies Br. 27. In fact, the evidence
Davies cites is more than sufficient to establish that First Reliance’s termination decision
was not arbitrary and capricious. See, e.g., Davies Br. 6 (according to Davies’s treating
psychiatrist, hers is a “complicated case and it is very hard to separate how much [of her]
symptoms are coming from depression”).3
And as the District Court correctly observed, what little evidence Davies presents
that does not link her physical and psychiatric conditions—her mother’s observations and
subjective beliefs, criticisms of the independent rheumatologist’s report, and potential
side effects of her medications—does not satisfy her burden to show that she is physically
incapable of performing any occupation. The independent medical examiners’ opinions
3
Davies points out that First Reliance explained in a letter that the limitation
applied if the claimant’s “main disability occur[ed] as a result of a mental or nervous
disorder.” App. 330 (emphasis added). But it was within First Reliance’s “fiduciary
discretionary authority to determine eligibility for benefits [and] to construe the terms of
the plan” when it terminated her benefits two years later. See Firestone, 489 U.S. at 115.
In any event, Davies’s own psychiatrist classified her mental diagnoses as “primary” and
her physical conditions “secondary.” App. 422–23.
6
that Davies was not totally disabled merely reinforce the conclusion that a “multitude of
evidence” already supports. App. 17.
Our assessment of the structural and procedural factors underlying First Reliance’s
decision does not alter this conclusion. “Since Glenn, we have only been willing to
disturb an administrator’s decision based on a conflict of interest if evidence either
suggests the conflict actually infected the decisionmaking or if the conflict is one last
straw that calls a benefits determination into question.” Dowling v. Pension Plan for
Salaried Emps. of Union Pac. Corp. & Affiliates, 871 F.3d 239, 251 (3d Cir. 2017). We
agree with the District Court that many of Davies’s asserted “procedural shortcomings”
are conclusory and unsupported. Others, such as an allegation that a First Reliance claim
reviewer’s notes “assuming” Davies “seem[ed]” to have the capacity for sedentary work
were improper, App. 299–300, are either inconclusive or unpersuasive in the face of
ample support for the termination decision found in the records of Davies’s own treating
physicians.
For these reasons, we find no error in the District Court’s conclusion that, taking
into account “the structural conflict of interest at play, the procedural inadequacies
argued by [Davies], and all of the medical evidence available to First Reliance in making
its benefits determination,” First Reliance’s decision to terminate Davies’s benefits was
not arbitrary and capricious. App. 20. Accordingly, we will affirm the judgment of the
District Court.
7
