TJOFLAT, Circuit Judge:
Diane Melech is the beneficiary of an employee welfare benefit plan provided by her employer Hertz. The plan includes a disability insurance policy (the "Policy") issued and administered by the Life Insurance Company of North America ("LINA"). LINA's administration of the Policy is governed by the Employee Retirement Income Security Act of 1974 ("ERISA"), 88 Stat. 829, 29 U.S.C. §§ 1001-1461. Melech stopped working at Hertz in May 2007, when her treating orthopedist took her off work on account of his diagnoses of degenerative disc disease in her cervical spine and tendonitis in her right shoulder.
LINA denied Melech's claim in November 2007, while her SSDI application was still pending before the Social Security Administration ("SSA"). Melech appealed the denial of her claim through LINA's administrative process. Meanwhile, in December 2007, the SSA asked Melech to visit two new physicians for an independent assessment of her condition. The SSA granted Melech's application for disability benefits in February 2008, and Melech so informed LINA. LINA then went on to deny two consecutive administrative appeals without considering or even asking Melech for the SSA's decision, the two
Melech brought this ERISA action in October 2010, claiming that LINA violated the Policy's terms and ERISA's requirements—in part because LINA ignored the SSA process and the information it generated. The District Court granted summary judgment in favor of LINA because it concluded that LINA's ultimate decision to deny benefits under the Policy was correct based on the administrative record in LINA's possession at the time it made its decision—a record that did not contain any information related to Melech's SSDI application. Melech now appeals to this court.
Today, we do not judge the propriety of LINA's ultimate decision to deny Melech's claim for benefits under the Policy because we hold that LINA had an obligation to consider the evidence presented to the SSA. Thus, because LINA did not have this evidence when it denied her last appeal—and in fact could not have had that evidence when it initially denied her claim—we vacate the District Court's judgment and remand the case with instructions to remand Melech's claim to LINA for its consideration of the evidence presented to the SSA.
The crux of our holding lies in the relationship between LINA's claim-evaluation process and the parallel SSA process. LINA's Policy effectively requires claimants who apply for benefits under the Policy to also apply for disability benefits from the SSA. LINA is then allowed to reduce the benefits it pays, if any, to account for a claimant's receipt of these SSA benefits. At the outset, we presume that LINA's interactions with all claimants are the same: LINA shepherds them into the SSA process in anticipation of the possibility that it might have to pay benefits. But a divergence arises in LINA's interest in its claimants' SSA applications in cases where LINA finishes its evaluation of the claim before the SSA reaches a decision on the SSDI application. The SSA deduction only remains relevant to LINA if LINA decides that the claimant is eligible for benefits under the Policy. In these situations, LINA exercises its rights under the Policy to insert itself into the SSA process in an attempt to influence the outcome to protect LINA's SSDI deduction. Conversely, in Melech's case, LINA initially sent her to the SSA but then decided that she was not eligible for benefits under the Policy. Because it no longer needed to protect its SSDI deduction, LINA ignored the status of Melech's SSDI application and the SSA's eventual decision to award benefits.
Importantly, the SSA process produces more than just a final sum of money—it also may produce additional evidence that is relevant to the claimant's physical condition and vocational capacity. The question we address in part C below is whether LINA is free to selectively use the results of the SSA process only to the extent that it serves LINA's interest to do so. We begin by first explaining in detail the Policy terms that relate to LINA's rights to monitor and participate in the SSA process when it has a financial stake in the outcome. Then, we turn to LINA's disregard for the SSA process when it does not have any skin in the game, which we illustrate by explaining LINA's evaluation of Melech's claim.
To receive long-term disability benefits under the Policy, a claimant has the burden
These benefits paid out under the Policy are subject to a deduction for the amount of "Other Income Benefits" that the claimant receives because of her disability. Other Income Benefits includes Social Security Disability Income ("SSDI") that the claimant actually receives, or is "assumed to receive." By default, if the claimant is not actually receiving other benefits, LINA will nonetheless "assume the [claimant]... [is] receiving benefits for which they are eligible" and will "reduce the [claimant's] Disability Benefits by the amount of Other Income Benefits it estimates are payable to the [claimant]." Record, no. 112-2, at 126. According to LINA's claims manual, it uses a spreadsheet tool to determine claimants' eligibility for SSDI and to estimate the amount that the SSA would award. The spreadsheet itself is not part of the record before us, but we note that the eligibility determination and estimate of "assumed" benefits requires LINA to step into the SSA's shoes to determine what medical and vocational evidence would be available to the SSA and then evaluate that evidence using the SSA's separate rules for granting disability benefits.
The need to deduct "assumed" SSDI only comes into play in those cases where LINA decides to pay benefits under the Policy, but the claimant has not yet been awarded SSDI—either because the SSA has not reached a final determination or because the claimant did not apply in the first place. If the claimant did not apply, LINA may immediately deduct assumed SSDI from its payments to the claimant. If the SSA is still considering the claimant's application, LINA will delay the assumed-benefits deduction until the SSA process has run its course, so long as the claimant promises to reimburse LINA for any "overpaid" benefits in the event that the she later receives retroactive SSDI that overlaps with LINA's payments under the Policy. While LINA waits for the SSA to reach a decision, LINA's claim managers are expected to monitor the status of the claimant's application by periodically asking the claimant for information on her SSDI application. If the SSA eventually grants the application, then LINA will deduct the actual amount of the award from any future benefits paid under the Policy and the claimant will reimburse LINA for any past benefits that LINA overpaid. If the SSA denies the application, LINA may require the claimant to take an appeal "if it believes a reversal ... is possible."
The Policy also authorizes LINA to assist claimants in navigating the SSA process, and LINA has a Social Security Assistance Program ("SSAP"), which is administered by a handful of third-party vendors, to help its claimants obtain SSDI. LINA refers most claimants to one of its SSAP vendors shortly after they file their claim with LINA—though a claimant can opt to pursue SSDI on her own. LINA's disclosure authorization form, which authorizes it to obtain information directly from the claimant's physicians, employer, etc., also authorizes LINA to share the claimant's information with these vendors. LINA's claim managers are instructed to transfer a claimant's medical information to a vendor upon referring the claimant to that vendor, ostensibly so the vendor can then use that information to help the claimant obtain SSDI. If a claimant refuses to cooperate with the vendor, or if she pursues SSDI on her own and does not provide LINA with the documentation it asks for in relation to her application, LINA may deduct assumed SSDI.
To summarize, the Policy effectively requires all claimants to apply for SSDI at the outset; if a claimant fails to do so, LINA can reduce her benefits under the Policy, if any, by the amount of SSDI LINA says she could have gotten. In the event that LINA decides to pay a claim, the Policy allows LINA to hold the claim open, at least with respect to the total amount LINA must pay, until the SSA reaches a final decision. LINA may assist the claimant in obtaining SSDI, even going so far as to transfer the medical evidence that LINA gathered to LINA's vendor, who then presumably transfers it to the SSA. And if the SSA denies the claimant's application, LINA can force the claimant to exhaust her administrative appeals. All this effort makes perfect sense from LINA's perspective because—having decided to pay the claim—every dollar the claimant gets from the SSA is one less dollar LINA has to pay.
Next, we turn to the alternative scenario, present in Melech's case, where LINA has initially determined not to pay benefits under the Policy and therefore does not have a financial interest in the claimant's SSDI award.
When Melech filed her claim for disability benefits in October 2007, LINA sent her a letter describing the claim-evaluation process and what LINA needed from her. LINA explained the Policy terms (described above) that allow it to deduct SSDI from any benefits she might receive under the Policy. LINA also provided an information
As any rational policyholder would do in her situation, Melech applied for SSDI in October 2007 and informed LINA shortly thereafter. In mid-November, LINA referred Melech's case to Advantage 2000 Consultants—one of LINA's SSAP vendors—so that Advantage could contact Melech and assist her in navigating the SSDI application process.
Meanwhile, in December 2007, the SSA asked Melech to visit two physicians—J.M. Jackson, PsyD, and Eugene Bass, MD—for an independent assessment of her condition. Based on Drs. Jackson's and Bass's reports, along with the information the SSA gathered from Melech's treating physicians, the SSA approved Melech's application on February 16, 2008.
Melech did not accept LINA's invitation to submit more evidence and filed this ERISA action in October 2010, alleging that LINA violated the terms of the policy and ERISA's requirements when it denied her claim. See 29 U.S.C. § 1132(a)(1)(B). After discovery, LINA filed a motion for summary judgment, claiming that Melech had not produced evidence to show that its decision to deny her disability claim—based on the record in LINA's possession at the time it made that decision—was incorrect.
Record, no. 151, at 4. The District Court agreed that its review of LINA's decision was limited to the administrative record before LINA at the time it made its final decision to deny Melech's claim, and so the District Court did not consider the SSA file in reaching its conclusion that LINA's decision was correct.
On Melech's appeal to this court, LINA maintains that it only had an obligation to evaluate information related to the SSA's determination if Melech submitted that evidence during the pendency of her claim. And so, "[s]ince Plaintiff failed to present available evidence to LINA during the claim's adjudication process, she cannot now fault LINA, or the District Court, for failing to consider such evidence." LINA Brief, at 35.
Based on these actions and representations, it appears that Melech's SSDI application became irrelevant to LINA—or at least no more relevant than any other evidence in Melech's possession—once it initially decided to deny her claim for benefits under the Policy in November 2007. When LINA initially denied Melech's claim, it knew that her SSDI application was still pending. The clear inference from the timing of this initial denial is that LINA's decision would have been the same, regardless of what the SSA decided or what information came out of the SSA investigation.
The question we address, then, is whether LINA was free to ignore the results of the SSA process once it initially determined that Melech had not provided enough evidence to support her claim for benefits under the Policy. We conclude that LINA should have considered the evidence generated by the SSA process, but before explaining that conclusion in detail, we first explain where our evaluation today fits into our standard of review under ERISA.
Courts of appeal review a district court's grant of summary judgment in an ERISA case de novo, applying the same judicial standard to the administrator's decision that the district court used to guide its review. Blankenship, 644 F.3d at 1354. While ERISA and the Secretary of Labor's regulations provide certain minimum procedural requirements, the statute and regulations do not provide a judicial standard of review for courts reviewing administrators' benefit-eligibility decisions. See 29 U.S.C. § 1133; 29 C.F.R. § 2560.503-1. Drawing on traditional principles of trust law, the Supreme Court articulated a framework for judicial review, which this circuit has distilled into a six-part test.
The District Court here concluded, under Williams's first step, that LINA's decision was correct based on LINA's administrative record at the time it denied Melech's claim; as explained above, the administrative record did not contain the SSA file that Melech produced at trial. The District Court did not address the separate, normative, question of whether LINA should have considered the information contained in the SSA file. As a matter of common sense, we cannot evaluate LINA's ultimate decision to deny Melech's claim without first considering whether the record LINA had before it was complete. See Jett v. Blue Cross & Blue Shield of Ala., Inc., 890 F.2d 1137, 1140 (11th Cir.1989) (explaining that courts should not make benefit-eligibility determinations under ERISA plans based on evidence that the administrator did not consider). This inquiry is not as much a Williams "step zero" as it is a predicate to our ability to review the substantive decision we have been asked to review. Cf. Pres. Endangered Areas of Cobb's History, Inc. v. U.S. Army Corps of Eng'rs, 87 F.3d 1242, 1246 (11th Cir.1996) (explaining that when reviewing executive agencies' decisions, "if the agency has not considered all relevant factors, or if the reviewing court simply cannot evaluate the challenged agency action on the basis of the record before it, the proper course, except in rare circumstances, is to remand to the agency for additional investigation or explanation") (quoting Fla. Power & Light Co. v. Lorion, 470 U.S. 729, 744, 105 S.Ct. 1598, 1607, 84 L.Ed.2d 643 (1985)). Thus, before deciding whether LINA was correct when it denied Melech's claim for benefits under the Policy, we must first determine whether LINA should have considered the information contained in her SSA file.
To answer this question, we begin with the foundational observation that Melech had the burden of proving her entitlement to disability benefits under the Policy.
First, we note that LINA's role in its claimants' SSDI applications is not one of a mere passive observer. LINA does not simply plug whatever number the SSA spits out into its own calculations. Instead, it tries to actively influence the outcome and even reserves the right to second guess the SSA and step into the agency's shoes to determine what it might have done. To estimate the amount of "assumed" SSDI that a claimant could have received, LINA must necessarily determine what evidence the SSA would have considered when making that determination and how it would weigh that evidence in reaching an outcome. Alternatively, if a claimant engages the SSA process, LINA may attempt to maximize its own deduction by arranging for a third party to help the claimant prove her disability to the SSA and by making the claimant's medical information available for use in the SSA proceedings. Even then, LINA can second guess an adverse SSA decision and require the claimant to take an appeal. To evaluate whether the SSA was wrong when it denied an application and whether an appeal would result in a reversal of that decision, LINA would have to know what evidence the SSA had before it when it denied the application. Because LINA's disclosure authorization form allows it to obtain information directly from the SSA, and because LINA's policies allow it to deduct "assumed" SSDI if a claimant does not cooperate with LINA's requests for information, any documentation LINA needs regarding its claimants' SSDI applications is available upon request.
Yet, once LINA decided at first blush that Melech had not provided enough medical evidence to support her claim, it treated the SSA process and the evidence generated by it as irrelevant and unavailable. This treatment is internally inconsistent with LINA's mode of evaluating claims. If LINA had been inclined to pay Melech's claim, it would have withheld its own determination regarding the amount of benefits due until the SSA reached a decision on her SSDI application—in the process, potentially requiring Melech to pursue administrative appeals. As explained above, this process would have allowed LINA to consider the evidence in the SSA's possession. But because LINA was initially inclined to deny her claim based on the evidence available to it at the time, LINA did not wait for the conclusion of the SSA
As LINA explained in its appellate brief and its motion to strike in the District Court, because of the SSA's distinct evidentiary rules and administrative process, the SSA investigation was likely to generate different evidence than LINA's own evaluation—and in fact it did, because the SSA sent Melech to Drs. Jackson and Bass. This medical evidence is certainly relevant to LINA's determination regarding Melech's ability to perform her Hertz job or some other job, even if the SSA's ultimate conclusion is distinguishable on account of the distinct SSA rules for granting SSDI.
In Melech's case, LINA refused to wait for the SSA evidence, even though it could have relied on that same evidence to protect its SSDI deduction had it decided to pay Melech's claim. LINA is not free to selectively use evidence in this manner. If LINA had sent Melech to another doctor for an independent evaluation, it could not have ignored the doctor's opinion simply because it did not serve LINA's interests. Similarly, having sent Melech to the SSA to seek alternative compensation, LINA was not free to ignore the evidence generated by the SSA process as soon as it no longer had a financial stake in the amount of money the SSA decided to award.
Other circuits have grappled with the question of what to do with the specter of procedural unreasonableness that arises from facts like these. Most courts have confronted some variation of the question when reviewing the merits of an administrator's denial under an abuse of discretion standard.
We are similarly struck by the procedural unfairness created by LINA's approach. We conclude that LINA's treatment of Melech's SSA application is inconsistent with the fundamental requirement that an administrator's decision to deny benefits must be based on a complete administrative record that is the product of a fair claim-evaluation process. Because LINA's decision to deny benefits here was based on an administrative record that did not contain the information from Melech's SSA file, the proper course of action is to remand Melech's claim to LINA rather than to evaluate the merits of Melech's claim for benefits under the Policy using evidence that LINA did not consider. See Levinson v. Reliance Standard Life Ins. Co., 245 F.3d 1321, 1330 (11th Cir.2001) ("[A]s 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.") (citing Jett, 890 F.2d at 1140).
Therefore, we vacate the District Court's grant of summary judgment in favor of LINA and remand to the District Court with instructions to remand the matter to LINA. In doing so, we do not prejudge the ultimate outcome. LINA may be able to draw a principled distinction between its own standards for granting disability benefits under the Policy and the SSA's standards for awarding SSDI. All we require of LINA is to decide Melech's claim with the full benefit of the
VACATED AND REMANDED.
EVANS, Judge, dissenting:
I respectfully dissent. I agree with the majority that an ERISA plan administrator's decision to deny disability benefits without reviewing medical reports in the possession of the Social Security Administration could lead to incongruous or arguably inequitable results. However, on the facts of this case, I would hold simply that the district court's decision was de novo correct and that the arguments Melech makes regarding procedural unfairness are without merit.
LINA did comply with all ERISA regulations, including notifying Melech of "any additional material or information necessary for [Melech] to perfect [her] claim and [provide] an explanation of why such material or information is necessary." 29 C.F.R. § 2560.503-1(g)(1)(iii). Specifically, LINA informed Melech in writing that she should submit medical documentation to support her appeal, which "includes, but is not limited to: copies of office notes, test results, physical examination reports, mental status reports, consultation reports, or any other pertinent medical information." Record, no. 112-2, at 74. This admonition was repeated in LINA's response to Melech's letter of October 10, 2008, which stated she had been granted Social Security disability benefits and that this decision had been based in part on seeing Drs. Jackson and Bass. LINA's response granted Melech an additional 45 days within which to file new medical documentation and file a second appeal request. LINA could not have independently obtained the Jackson and Bass opinions from the Social Security Administration.
The district court correctly ruled that it would not consider any materials which were not before the plan administrator at the time it made its decision to deny benefits. The district court's decision meticulously considered all the evidence which had been before the plan administrator and affirmed the plan administrator's decision. While the majority's opinion explicitly says "neither ERISA nor the Policy required LINA to ferret out evidence in Melech's or the SSA's possession," I think that will be the perceived message of the majority opinion. I am concerned that the majority opinion promotes uncertainty in the already confusing law which surrounds ERISA disability cases.
Blankenship, 644 F.3d at 1355 (citation omitted). The phrase "arbitrary and capricious" and "abuse of discretion" are used interchangeably. Id. at 1355 n. 5.
DeLisle v. Sun Life Assur. Co. of Can., 558 F.3d 440, 445-46 (6th Cir.2009) (alteration in original) (citations omitted) (internal quotation marks omitted).
As an alternative conceptual approach towards the same end, Judge Posner has invoked the doctrine of judicial estoppel to enforce a "modicum of consistency" on an administrator's position regarding its claimants' disability status. Ladd v. ITT Corp., 148 F.3d 753, 756 (7th Cir.1998). While recognizing that the doctrine is not technically applicable where the administrator did not participate in the parallel SSA proceedings, Judge Posner would nonetheless view an administrator's conclusion that a claimant is not disabled more skeptically if the administrator had previously urged the same claimant to make the opposite argument to the SSA. Id.
We cite these decisions to support our conclusion that LINA's denial of benefits under the Policy without considering the evidence from the SSA process raises questions of procedural fairness. We do not imply that the SSA's ultimate conclusion that Melech was "disabled" under the SSA standard creates a presumption that she is eligible for benefits under the Policy.