Brigham v. Sun Life of Canada

• Decision Date: 28 January 2003
• Docket Number: No. 02-1237.,02-1237.
• Citation: 317 F.3d 72
• Parties: Bradley B. BRIGHAM, Plaintiff, Appellant, v. SUN LIFE OF CANADA, Defendant, Appellee.
• Court: U.S. Court of Appeals — First Circuit

317 F.3d 72

Bradley B. BRIGHAM, Plaintiff, Appellant, v. SUN LIFE OF CANADA, Defendant, Appellee.

No. 02-1237.

United States Court of Appeals, First Circuit.

Heard November 7, 2002.

Decided January 28, 2003.

COPYRIGHT MATERIAL OMITTED

Cristobal Bonifaz with whom John C. Bonifaz and Law Offices of Cristobal Bonifaz were on brief for appellant.

Jay P. Symonds with whom Joseph M. Hamilton and Mirick, O'Connell, DeMallie & Lougee were on brief for appellee.

Mary Ellen Signorille and Melvin R. Radowitz on brief for amicus curiae AARP.

Before LIPEZ, Circuit Judge, COFFIN and STAHL, Senior Circuit Judges.

COFFIN, Senior Circuit Judge.

Appellant Bradley Brigham claims that appellee Sun Life of Canada violated the Employee Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. §§ 1001-1461, when it terminated his long-term disability benefits. Brigham had been receiving benefits for five years based on his inability to perform his regular occupation. After that time period, benefits were available under his plan only if he was disabled from performing any occupation for which he was or could become qualified. Sun Life concluded that he was capable of sedentary work, and the district court found that the insurer's determination indisputably was supported by substantial evidence in the record. Appellant argues on appeal that the court used the wrong standard and, even under the standard it used, reached the wrong result. Although our judgment might have differed from Sun Life's were we deciding on a clean slate, on the record before us we are constrained to affirm the summary judgment.

I. Background¹

Appellant Brigham, a 47-year-old man who has been a paraplegic since a motorcycle accident when he was 16, was hired in the spring of 1990 as an employment coordinator for a social services organization. He served as an advisor on the employment of handicapped individuals, visiting multiple employers every day. The travel required frequent transfers from his car to his wheelchair and back, and after two years on the job the repeated twisting and lifting of his chair led to significant left side and back pain that his family doctor diagnosed as muscle strain.

The employee benefit plan issued by Sun Life to Brigham's employer provides for both short-term and two stages of long-term disability benefits. Long-term benefits are available for the first sixty months of a totally disabling illness if it prevents the employee from performing "all of the material duties of his regular occupation" (emphasis added). After that initial five-year period, an employee is eligible for benefits only if the disabling condition prevents him from engaging in "any occupation for which he is or becomes reasonably qualified by education, training or experience" (emphasis added).

In June 1993, Brigham developed a respiratory tract infection that triggered severe coughing spells, exacerbating his left side pain and forcing him to stop work. He received short-term disability benefits for six months and then in December 1993 applied for long-term benefits based on his severe back and side strain. In an Attending Physician's Statement of Disability ("APS") dated December 21,² Dr. Christopher French opined that Brigham was unable to perform his own job because "the stress of frequent transfer from [his] car [is an] intolerable physical symptom." He characterized Brigham's physical impairment as "Class 4" out of five levels of progressively more limited physical capacity, signifying a "[m]oderate limitation of functional capacity; capable of clerical/administrative (sedentary) activity." Although Dr. French stated that Brigham was totally disabled, he also observed that he was a "good candidate for more sedentary work but to do this he must get retraining." Brigham graduated from both Williams and Amherst colleges and holds a master's degree. In February 1994, Sun Life approved the payment of the first stage of long-term disability benefits under the "own occupation" provision. He received those benefits until December 1998, when the sixty months of coverage ran out, although Sun Life temporarily cancelled benefits in January 1995 based on its belief that Brigham could at that point return to his regular job. Brigham appealed, and after further investigation, Sun Life reinstated the "own occupation" benefits in March 1995.

During the five years in which Brigham received long-term disability payments, Dr. French submitted at least six additional APS reports after the one filed in support of the original application for benefits. Because this case turns on the sufficiency of the evidence of Brigham's ability to work, we have closely reviewed the medical information contained in the record. We summarize below Dr. French's reports during the relevant five-year period and review other details surrounding Brigham's receipt of benefits.

— March 1994. In response to a request from Sun Life for updated information, Dr. French sent a letter dated March 31 that stated:

[Brigham] is a paraplegic who had developed left side and hip pain secondary to [the] frequent car to chair transfer his work requires. These symptoms have improved following several months of leave from work. I believe, therefore, that he should avoid situations that require frequent car to chair transfers.

— July 1994. Sun Life conducted an extensive personal interview of Brigham, and the notes in the insurer's file state that he "indicated that he would have resumed another position with his company if it did not involve being out on the road, but they had no work for him." The notes also state that Brigham reported applying to law school and indicated an interest in earning a law degree so that, among other endeavors, he could represent individuals with disabilities. He further stated that, if law school proved too demanding, he would consider earning a teaching certificate, noting that he previously had worked as a teacher in a private school.

— October 1994. The third APS from Dr. French,³ dated October 12, reported that Brigham's condition remained unchanged, but the physician increased the level of his physical impairment to Class 5, a "[s]evere limitation of functional capacity; incapable of minimal (sedentary) activity." In the section labeled "Rehabilitation," however, Dr. French indicated that Brigham could work despite his impairment if the job did not involve getting into and out of a car, and he recommended retraining.

— November 1994-March 1995. In a letter dated November 9, Dr. French stated that Brigham's back pain had subsided since he had stopped working, and expressed concern that a return to his previous position — with its frequent travel — would bring it back. He again recommended that Brigham "be placed in a situation that does not require getting in and out of the car all day." In a December conversation with a Sun Life representative, Dr. French reported that Brigham's condition had improved and his muscle strain had resolved. A week later, Brigham told another caller from Sun Life that he hadn't pursued either schooling or alternative work. According to Sun Life's notes, Brigham explained that "he has difficulty mobilizing himself and [his] wheelchair for extended periods during the day." On December 22, Sun Life's medical consultant, Maureen Speed, a nurse, spoke with Dr. French to clarify the assessment in the doctor's Nov. 9 letter. Based on Dr. French's information, including a statement that Brigham's return to his previous job "might" trigger a recurrence of pain, Sun Life concluded that he no longer was disabled from performing his own occupation because "the possibility of a problem recurring in and of itself does not constitute a disabling condition." In so informing Dr. French, Sun Life's claims manager also wrote that "[i]f any condition continues to exist, objective medical information to support the continued disability is necessary."

As noted above, the company reversed its position and reinstated Brigham's benefits after it received clarifying letters from Drs. French and Perri stating that Brigham's pain would "no doubt" return with repeated transfers into and out of his car. The insurer previously had confirmed with his employer that Brigham would have to transfer five to ten times a day if he resumed his previous job.

— June 1995. Brigham responded to an inquiry from Sun Life about the impact of his disability on his daily life by stating that he is "severely limit[ed] ... in fundamental ways." He wrote:

For example, it is very painful for me to transfer from my wheelchair onto the toilet, into the bathtub, into bed, and into my car. As a result, I require assistance to perform all or part of these transfers.

— October 1995. Dr. French submitted a fourth APS that reported Brigham's condition as unchanged, but he designated Brigham's physical impairment as both Classes 4 and 5. The doctor again described Brigham as totally disabled, but noted in the "Remarks" section that he could re-enter the workforce "with appropriate part-time job and available transportation."

— January-February 1996. Brigham reported that his daily activities remained "limited" because of muscle pain and that he was no longer able to independently transfer into or out of his current vehicle. Noting that he needed a lift-equipped van "in order to attempt to either re-enter the work force or acquire appropriate professional re-training," he proposed that Sun Life buy out his disability coverage so that he could purchase a van as soon as possible. Brigham ultimately rejected as inadequate Sun Life's approximately $52,000 settlement offer.

— November 1996. Dr. French's fifth APS again reported Brigham's progress as "unchanged," but this time he classified his physical impairment as Class 4. The doctor stated that a job modification would enable Brigham to work "[t]o some extent," and in the "Remarks" section he wrote: "patient has use of upper body —...