J. LEON HOLMES, District Judge.
This is an ERISA action in which Bobby Gene Hankins seeks to recover benefits under the long-term disability plan offered by his former employer, Stephens Inc., through Standard Insurance Company. The parties have submitted an administrative record and briefed the issues, so the case is ripe for decision. For the following reasons, Standard's decision to deny Hankins' claim for long-term disability benefits is affirmed.
In April 2002, Bobby Gene Hankins began working as the director of commercial security at Stephens, Inc. (Adm. R. 351, 381). In that position, Hankins managed a staff of 30 security personnel while reporting to the Stephens vice president and chief security officer. (Id.). Stephens summarized Hankins' position as requiring him:
(Adm. R. 381). Hankins' job description also contained a lengthy list of "Essential Duties and Responsibilities" that include potentially physical requirements such as "responding to all emergency and crisis situations as necessary, ... transporting and assisting incapacitated persons, interceding in physical disturbances, subduing violent individuals, ... assisting victims of offenses," participating in investigations, making arrests, and providing "`back-up' support to law enforcement agencies as necessary." (Adm. R. 381-82).
Through his employment with Stephens, Hankins was covered by the "Group Long Term Disability Insurance Policy" provided by Standard. (Adm. R. 9). The Policy states that a person is entitled to disability benefits during the "Own Occupation Period" if he meets the "Own Occupation Definition of Disability." (Adm. R. 13, 18). A person meets this definition, in part, by being "unable to perform with reasonable continuity the Material Duties of [his] Own Occupation." (Adm. R. 18).
On October 15, 2009, Hankins was running at work in the fitness program for Stephens' security personnel when he heard a pop and felt a severe pain in his right buttock. (Adm. R. 114, 208, 230). After undergoing an MRI the next day, Hankins was examined on October 20 by W. Scott Bowen, M.D., an orthopedic surgeon in Little Rock. (Adm. R. 114-15, 122-23).
At some point before the end of January 2010, Stephens terminated Hankins, apparently because he was unable to run the required 300-meter sprint in the allotted time. (Adm. R. 208, 328, 351). On February 10, 2010, Bowen advised Standard in writing of Hankins' permanent restrictions and his light duty recommendation. (Adm. R. 274). Soon thereafter, on March 9, Standard Vocational Case Manager Karol Paquette filed an "Own Occupation Review" concerning Hankins in order to "clarify the material duties and physical demands of [Hankins'] job to determine the Own Occupation." (Adm. R. 358).
Standard also hired John Hart, D.O., an osteopathic physician and independent contractor, to review Hankins' medical records and respond to various questions from Standard. (Adm. R. 208-17). Hart submitted his report on March 19, 2010. (Adm. R. 208). In the report, Hart labeled Hankins' position as security director as sedentary, although he noted that Stephens required Hankins to run 300 meters in under 66 seconds. (Id.). Hart also set out Hankins' medical history from the time of the injury until the report, noting that while Bowen had stated in November and December 2009 that he believed Hankins would be able to run 300 meters within three months, Bowen had revised this opinion in January 2010, declaring that such an action was permanently unlikely. (Adm. R. 208-09). In response to questions, Hart stated that an individual in Hankins' situation should not have been precluded from working in any capacity, and that such a person should have been able to return to sedentary work within one week of the injury and to light work within two weeks of the injury. (Adm. R. 209-10). Finally, when asked when he would anticipate a material change in Hankins' condition, Hart responded that he agreed with Bowen's earlier assessment that 300 meters would be possible within three months, although the report is ambiguous as to whether Hart was referring to Hankins or to a hypothetical individual in Hankins' earlier situation. (Adm. R. 210). In answering this question, Hart did not mention Bowen's later reassessment of Hankins' situation, where Bowen declared that 300 meters was likely a permanent impossibility. (Id.).
On April 8, 2010, Standard advised Hankins in a letter that it had denied his claim for long-term disability benefits because he was not disabled under the Policy's "Own Occupation" definition. (Adm. R. 317-21). In the letter, Standard stated that as part of its review it had analyzed the Policy, Hankins' medical records, Hart's report, and Paquette's report. (Id.). Standard summarized the information from those sources, and in the end it embraced Paquette's conclusion that Hankins' "Own Occupation" was best described by the DOT Security Manager position. (Adm. R. 317-19). Standard concluded by stating that, while it acknowledged that Hankins could not maintain his own position because of the physical demands, it did not find sufficient evidence or documentation that his injury would prevent him from performing his "Own Occupation" for other employers. (Adm. R. 320).
As of May 24, 2010, Hankins was still experiencing muscle spasms related to the hamstring injury, and Bowen advised him to continue physical therapy and medication. (Adm. R. 109). On July 28, Hankins was discharged from physical therapy after meeting all of his goals and reporting no pain other than discomfort from sitting and driving on a recent vacation. (Adm. R. 132). The next day, Bowen released Hankins from his care without recommending any further treatment, in part because an MRI had revealed that there
On October 7, 2010, Hankins requested, through his attorney, that Standard provide him the entire file regarding his claim. (Adm. R. 304). The parties dispute whether Standard has complied.
On December 8, 2010, Robert White, a vocational specialist, interviewed Hankins at Hankins' request in order to prepare a vocational assessment.
On December 14, 2010, Hankins sent White's assessment and curriculum vitae to Standard, along with updated medical reports indicating Hankins' permanent restrictions, requesting that Standard overturn its previous denial of Hankins' claim. (Adm. R. 298-99). Soon thereafter, Standard hired Joseph Mandiberg, M.D., a physician and independent consultant, to review Hankins' records. (Adm. R. 96, 102-03).
On March 11, 2011, at the behest of Standard, Paquette authored another memorandum analyzing White's vocational assessment. (Adm. R. 343-47). In the report, Paquette determined that White's findings were irrelevant and did not
On March 15, 2011, Standard notified Hankins by letter that it had completed an independent review of Hankins' original claim determination and subsequently provided information, and it was affirming its denial. (Adm. R. 282). In the letter, Standard explicitly embraced Paquette's second memorandum and her critique of White's assessment, criticisms, and recommendations, finding Paquette's assessment to be "well reasoned and supported by information in the claim file." (Adm. R. 284-87). Standard again acknowledged that Hankins' specific job had very high physical requirements, but it noted that "when determining Mr. Hankins' Own Occupation, we are looking at the way the occupation is generally performed in the national economy." (Adm. R. 286). Since Stephens' physical requirements were "not characteristic of how [Hankins'] occupation is performed in the general economy," and since Hankins' job summary focused on managerial and not physical duties, Standard asserted that comparing it to Security Manager was appropriate since Hankins' position summary was "remarkably similar to the job description for Security Manager." (Id.). In the end, Standard affirmed its denial and insisted that its "review was conducted fairly and objectively, taking into consideration all information in Mr. Hankins' claim file and all policy provisions applicable to his claim." (Adm. R. 288).
ERISA § 502(a)(1)(B) provides that "a participant or beneficiary" may bring a civil action "to recover benefits due to him under the terms of his plan, to enforce his rights under the terms of the plan, or to clarify his rights to future benefits under the terms of the plan." 29 U.S.C. § 1132(a)(1)(B) (2009).
Although ERISA contains no standard of review, the Supreme Court has held that a reviewing court should make a de novo review unless the plan gives the "administrator or fiduciary discretionary authority to determine eligibility for benefits or to construe the terms of the plan." Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 109, 115, 109 S.Ct. 948, 953, 956-57, 103 L.Ed.2d 80 (1989). If the plan grants the administrator or fiduciary discretionary authority to determine eligibility for benefits or to construe the terms of the plan, the court reviews for an abuse of discretion. Farfalla v. Mutual of Omaha Ins. Co., 324 F.3d 971, 973 (8th Cir.2003)
(Adm. R. 34-35). Hankins argues that the Court should engage in de novo review because the Policy does not use the term "discretion" or contain any "language specifying that the fiduciary has discretionary authority to interpret the plan provisions." In support, he points primarily to Baxter ex rel. Baxter v. Lynn, where the Eighth Circuit held that de novo review was appropriate even though the plan in question gave the administrator "final authority to determine all matters of eligibility for the payment of claims." 886 F.2d 182, 188 (8th Cir.1989).
First, contrary to Hankins' assertion, the Policy grants Standard "full and exclusive authority" to interpret the Policy. (Adm. R. 34). This fact alone takes Baxter out of the equation, as the Eighth Circuit in Baxter stated that it came to its conclusion because the plan under consideration did "not grant to the trustees the authority to construe ambiguous terms." Baxter, 886 F.2d at 188 (noting additionally that the Eighth Circuit "could find no other provision in the plan specifically giving the trustees the discretionary power to interpret the meaning of its subrogation clause.").
Second, while Hankins is correct that the word "discretion" does not appear in the Policy, the Policy nonetheless grants discretion to Standard. The Eighth Circuit has held that plan language granting an administrator sole responsibility for the administration and interpretation of a plan did indeed give the administrator discretionary authority. Kennedy v. Georgia-Pacific Corp., 31 F.3d 606, 609 (8th Cir. 1994). Like Kennedy, the Policy language here clearly grants sole administrative and interpretive authority to Standard, thus it is discretionary. See also McKeehan v. Cigna Life Ins. Co., 344 F.3d 789, 792 (8th Cir.2003) (abuse-of-discretion standard applied when plan language granted the administrator full and exclusive authority to control, manage, administer, interpret, and resolve issues concerning the plan); Whitmore v. Standard Ins. Co., No. 4:06CV1486, 2007 WL 1557371, at *1-2 (E.D.Mo. May 25, 2007) (finding that virtually identical plan language conferred administrative and interpretive discretion on Standard).
Even if the plan or policy grants discretion, the Eighth Circuit has held that
Hankins argues that roughly five Standard actions are procedural irregularities. First, he asserts that Standard relied on a faulty vocational assessment by Paquette — faulty because it failed to consider any of his essential duties at Stephens that involved physical demands. Second, he argues that Standard relied upon the fact that Hankins did not have legal authority to make arrests rather than on the fact that Stephens required Hankins to have the physical ability to make arrests. Third, he argues that Standard chose to give its own physicians and vocational case manager more weight than his treating physician and White's vocational assessment. Fourth, Hankins argues that Standard has failed to produce certain information relevant to its decision to deny benefits. Fifth, Hankins argues that Standard chose to focus solely upon the DOT, rather than looking at Hankins' actual job, in making its "Own Occupation" determination.
Standard counters by arguing that all of these contentions have been misconstrued as procedural arguments when they are, in reality, substantive arguments that go to the merits of Standard's decision to deny benefits. With the exception of Hankins' failure-to-provide-information argument, Standard is correct. In Weidner v. Federal Express Corp., the Eighth Circuit emphasized that "procedural irregularity" refers "to the sorts of external factors that are sufficient under the common law of trusts to call for application of a less deferential standard of review." 492 F.3d 925, 928 (8th Cir.2007) (quotation omitted). In
Based on the above reasoning, however, Hankins final argument — that Standard has failed to provide certain information, either in the administrative record or to Hankins — is an argument for a procedural irregularity. Hankins makes this argument concerning two separate pieces of information. The Court will address each of these in turn.
Hankins first argues that Standard has failed to provide the notes and full substance of a phone conversation between Paquette and Smith, a Stephens representative. Standard counters by observing, correctly, that the administrative record already includes two paragraphs of Paquette's notes describing the substance and details of her conversation with Smith. See Adm. R. 379. Hankins provides nothing to show that these notes do not detail the conversation in full, or that a more complete record exists (e.g. an audio copy), so the assertion is without merit.
Hankins next argues that Standard has refused to provide a list of all previous cases in which Standard retained the consultants that it used in Hankins' case. Standard admits that it has not provided the information, but observes, correctly, that Hankins has pointed to nothing in the Policy, the ERISA statutes, or the applicable regulations, that imposes upon Standard the duty to provide such information. Without a duty, there cannot be a procedural irregularity. Hankins cites no authority for the proposition that a plan administrator or insurer must provide a list
Even if the failure to provide a list of all cases reviewed by the outside professionals who reviewed Hankins' claim was a procedural irregularity, that would not end the inquiry. Hankins would also have to show that the procedural irregularity "caused a serious breach of the plan administrator's fiduciary duty...." Woo, 144 F.3d at 1160. This second requirement presents a "considerable hurdle" for Hankins, which he has not overcome. See Chronister v. Baptist Health, 442 F.3d 648, 655 (8th Cir.2006) (noting that, in order to strip a plan administrator of deference, a procedural irregularity must be so egregious as to trigger a total lack of faith in the integrity of the decision-making process).
Because Hankins has not demonstrated the existence of a procedural irregularity that caused a serious breach of Standard's fiduciary duty, the Court reviews to see whether Standard abused its discretion. Under the traditional abuse-of-discretion analysis, the proper inquiry is whether the plan administrator's decision was reasonable, or supported by substantial evidence. Ortlieb v. United HealthCare Choice Plans, 387 F.3d 778, 781 (8th Cir.2004) (citation omitted). "Substantial evidence is `more than a scintilla but less than a preponderance.'" Smith v. UNUM Life Ins. Co. of Am., 305 F.3d 789, 794 (8th Cir.2002) (quoting Schatz v. Mutual of Omaha Ins. Co., 220 F.3d 944, 949 (8th Cir.2000)). Stated differently, substantial evidence "means such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Fletcher-Merrit v. NorAm Energy Corp., 250 F.3d 1174, 1179 (8th Cir.2001) (quotation omitted). Relevant evidence includes "all comments, documents, records, and other information submitted by the claimant relating to the claim." 29 C.F.R. § 2560.503-1(h)(2)(iv). An administrator's decision is reasonable if a reasonable person could have reached a similar decision given the evidence in the record, not whether a reasonable person necessarily would have reached that decision. Ferrari v. Teachers Ins. & Annuity Ass'n, 278 F.3d 801, 807 (8th Cir.2002). While abuse of discretion review is deferential in the ERISA context, it "is not tantamount to rubber-stamping the result." Torres, 405 F.3d at 680.
Under an abuse-of-discretion analysis, the Court must defer to an administrator's reasonable plan interpretation "even if the court would interpret the language differently as an original matter." Darvell v. Life Ins. Co. of N. Am., 597 F.3d 929, 935 (8th Cir.2010). To determine reasonableness, the Court looks at whether the administrative interpretation: (1) is contrary to the plan's clear language; (2) conflicts with ERISA's substantive or procedural requirements; (3) renders plan language "meaningless or internally inconsistent;" (4) is consistent with plan goals; and (5) has been followed consistently by the administrator. Id. (citing Finley v. Special Agents Mut. Benefit Ass'n, 957 F.2d 617, 621 (8th Cir.1992)).
Hankins' primary argument is that Standard abused its discretion by making an unreasonable interpretation of the Policy. More specifically, Hankins argues that the Policy required Standard to look at Hankins' actual job duties first, and
The Policy defines "Own Occupation" as:
(Adm. R. 19).
According to the DOT, the occupation of Security Manager is sedentary. It is undisputed that Hankins has the ability to engage in sedentary work. See, e.g., Adm. R. 110 (opining by Bowen that Hankins could reasonably work a desk or participate in light duty). Hence, he was not and is not disabled from engaging in his "Own Occupation," even though he was and is unable to meet the physical requirements for employment at Stephens.
Hankins argues that a conflict of interest exists because Standard has the authority to determine his eligibility for long-term disability benefits while also serving as the insurance company that would pay off the claim. Standard responds by arguing that Hankins has not demonstrated that the conflict actually impacted the outcome of his case. Standard also argues that its determination was obviously appropriate, thus the conflict can be ignored because it would not serve as a tie-breaking factor.
A conflict exists when the "plan administrator both evaluates claims for benefits and pays benefit claims." Khoury v. Group Health Plan, Inc., 615 F.3d 946, 953 (8th Cir.2010) (quoting Glenn, 554 U.S. at 112, 114, 128 S.Ct. at 2348-49). A conflict of interest is "one factor among many that a reviewing judge must take into account" in analyzing a claimant's argument that a plan administrator abused its discretion. Glenn, 554 U.S. at 116, 128 S.Ct. at 2351. A conflict should be given more weight "where circumstances suggest a higher likelihood that it affected the benefits decision, including, but not limited to, cases where an insurance company administrator has a history of biased claims administration." Id. at 117, 128 S.Ct. 2343. Less weight, or no weight at all, should be given to a conflict of interest "where the administrator has taken active steps to reduce potential bias and to promote accuracy, for example, by walling off claims administrators from those interested in firm finances, or by imposing management checks that penalize inaccurate decisionmaking irrespective of whom the inaccuracy benefits." Id. Here, taking into account Standard's conflict of interest as the party that both evaluates and pays claims, the Court does not find that Standard abused its discretion.
Hankins argues that Standard, in evaluating his claim, failed to take into account that Hankins should be considered of "advanced age." As Standard correctly notes, however, it was not obligated by the Policy, ERISA, or case law to apply Social Security Administration standards concerning age in determining Hankins' "Own Occupation" or disability. More importantly, the issue is not whether Hankins is
Hankins' final argument is that Standard gave too much weight to its independent medical consultants and too little weight to the opinion of Bowen, Hankins' treating physician. This argument is without merit, as Standard was not required to give any special deference to the opinion of Hankins' treating physician over the conflicting opinion of a reviewing physician. McGee v. Reliance Standard Life Ins. Co., 360 F.3d 921, 925 (8th Cir.2004). Regardless, even if Bowen's opinions were accepted as conclusive, the outcome could not be changed as Bowen himself opined that Hankins could perform light duty, and the Court has determined that it was reasonable for Standard to view Hankins' "Own Occupation" as sedentary.
For the reasons stated, Standard's determination that Hankins is not eligible to receive long-term disability benefits is affirmed.