Sweatman v. Commercial Union Ins. Co.

• Decision Date: 09 December 1994
• Docket Number: No. 94-40474,94-40474
• Citation: 39 F.3d 594
• Parties: 18 Employee Benefits Cas. 2600 Cynthia SWEATMAN, Plaintiff-Appellant, v. COMMERCIAL UNION INSURANCE CO., et al., Defendants-Appellees. Summary Calendar.
• Court: U.S. Court of Appeals — Fifth Circuit

Page 594

39 F.3d 594

18 Employee Benefits Cas. 2600

Cynthia SWEATMAN, Plaintiff-Appellant, v. COMMERCIAL UNION INSURANCE CO., et al., Defendants-Appellees.

No. 94-40474

Summary Calendar.

United States Court of Appeals, Fifth Circuit.

Dec. 9, 1994.

Byron A. Richie, Richie & Richie, Shreveport, LA, for appellant.

Alvin Pasternak, Cornelia E. Dude, Michelle C. Schecker, Metropolitan Life Ins. Co., Law Dept., New York City, for Met. Life.

Appeal from the United States District Court for the Western District of Louisiana.

Before SMITH, EMILIO M. GARZA and PARKER, Circuit Judges.

EMILIO M. GARZA, Circuit Judge:

After Metropolitan Life Insurance Company ("MetLife") denied Cynthia Sweatman's claim for disability benefits, Sweatman brought an action under ERISA, 29 U.S.C. Sec. 1132(a)(1)(B) (1988), seeking district court review of MetLife's determination. The court upheld MetLife's decision, and Sweatman appeals. We AFFIRM.

I

Cynthia Sweatman worked for Commercial Union Insurance Co. ("Commercial Union") for nineteen years as a claims adjuster, a job that required her to climb ladders, inspect roofs, and crawl under houses. When Sweatman stopped working for Commercial Union, she timely submitted a statement of claim for benefits under Commercial Union's Long Term Disability Plan ("the Plan"). Sweatman claimed that her medical condition (listed as rheumatoid arthritis and/or fibrositis) rendered her unable to perform any of her job duties. ¹

Under the terms of the Plan, Sweatman was eligible for long-term disability benefits if she was totally disabled. The Plan defines "total disability" as follows:

"Total Disability" means that during the first 24 months of disability you are unable because of sickness or accident to perform the duties of your own occupation for any employer. Thereafter, "total disability" means the inability to perform any occupation for which you are fitted by training, education, or experience.

Record on Appeal, vol. 1, at 48. As claims administrator for the Plan, ² MetLife sought to determine whether Sweatman was in fact "totally disabled." Shirley Darvasi, a claim reviewer employed by MetLife, attempted to gather Sweatman's medical records from her various physicians. At first, this task proved difficult. Dr. Burda, the physician who completed the Attending Physician Statement accompanying Sweatman's disability claim, did not promptly produce Sweatman's complete medical records.

To expedite its review of Sweatman's claim, MetLife sent the records it had received to Underwriting Medical Actuarial Consultants, Inc. ("UMAC"). Dr. Peter Blendonhy, a board certified physiatrist retained by UMAC, reviewed Sweatman's medical records and concluded that they did "not support limitations on work or physical activity." After UMAC's peer review board, the "Physician's Roundtable," reviewed and concurred with Dr. Blendonhy's opinion, UMAC sent MetLife a report summarizing its findings. The report pointed to numerous deficiencies in Sweatman's medical records and noted that the diagnosis of rheumatoid arthritis had not been established according to the American Rheumatism Association's criteria.

Even after receiving UMAC's report, MetLife continued its efforts to obtain Sweatman's complete medical records. After repeatedly contacting the physicians listed on Sweatman's disability claim, MetLife was able to gather additional records. Because these records had not been considered by UMAC in its first review, MetLife forwarded the additional records to UMAC for a second review. Dr. Dwyer, an orthopedic surgeon, reviewed the complete records and concluded that they did not support the physical limitations that Sweatman claimed. After its Physician's Roundtable reviewed and concurred with Dr. Dwyer's opinion, UMAC issued a second report summarizing its findings. Specifically, UMAC found that Sweatman's lab work refuted a diagnosis of rheumatoid arthritis. UMAC also concluded that "the diagnosis of fibromyositis or fibromyalgia, if accepted, is certainly not substantiated to the degree that would disable Sweatman."

MetLife also hired Equifax Services ("Equifax") to investigate Sweatman's claim. An investigator working for Equifax interviewed Sweatman's neighbors and a local merchant who operated a business across the street from that of Sweatman's husband. None of these sources knew of Sweatman's disability. The neighbors reported that Sweatman was taking care of her husband, who was confined to a wheelchair after suffering a stroke, on a full-time basis. The investigator also interviewed Sweatman and reported that she "moved about with no apparent restrictions or obvious signs of impairments."

Based on Sweatman's medical records, the two UMAC reports, the Equifax claim investigation, and its own employment-related information, Darvasi recommended in writing to her supervisor Allen Carson, a MetLife unit claims manager, that Sweatman's disability claim be denied. Carson reviewed the claim file and agreed that Sweatman was not totally disabled within the meaning of the Plan. MetLife then informed Sweatman by letter of the denial and explained its reasons for denying her claim. MetLife also explained that Sweatman could request reconsideration of her claim.

When Sweatman requested review of the denial, MetLife forwarded her file to Laura Sullivan, a "procedure analyst" at MetLife who had not been involved in the prior decision to deny Sweatman's claim. Sullivan reviewed the file and upheld the original determination. Consequently, MetLife informed Sweatman by letter of its decision to uphold the earlier denial.

Sweatman filed suit under ERISA, 29 U.S.C. Sec. 1132(a)(1)(B) seeking district court review of MetLife's disability determination. ³ After a bench trial submitted on pleadings, depositions, and the administrative record, the court held that MetLife did not abuse its discretion when it denied Sweatman's claim, and the court entered judgment against Sweatman. Sweatman now appeals, alleging: (1) that the district court erroneously applied an abuse of discretion standard of review to MetLife's determination, and (2) that even if "abuse of discretion" was the proper standard, MetLife abused its discretion in determining that Sweatman was not "totally disabled."

II

A

Sweatman argues that the district court erroneously applied an abuse of discretion standard of review to MetLife's denial of her claim. In the Fifth Circuit, the proper standard for district court review of a plan administrator's benefit determination is governed by the Supreme Court's decision in Firestone Tire and Rubber Co. v. Bruch, 489 U.S. 101, 109 S.Ct. 948, 103 L.Ed.2d 80 (1989), and our decision in Pierre v. Connecticut General Life Insurance Co., 932 F.2d 1552 (5th Cir.), cert. denied, --- U.S. ----, 112 S.Ct. 453, 116 L.Ed.2d 470 (1991). In Bruch, the Court held that "a denial of benefits challenged under Sec. 1132(a)(1)(B) is to be reviewed under a de novo standard unless the benefit plan gives the plan administrator or fiduciary discretionary authority to determine eligibility for benefits or to construe the terms of the plan." 489 U.S. at 115, 109 S.Ct. at 956-57. In Pierre, we held "that for factual determinations under ERISA plans the abuse of discretion standard of review is the appropriate standard." 932 F.2d at 1562. ⁴ Consequently, district courts in the Fifth Circuit review under an abuse of discretion standard a plan administrator's factual determinations and determinations made pursuant to a plan that gives the administrator discretionary authority to determine eligibility or interpret the terms of the plan.

Sweatman concedes that MetLife's determination that she was not disabled was "more factual in nature than interpretive in nature," and therefore is ordinarily subject to abuse of discretion review by the district court under Pierre. However, she argues that two special circumstances in her case warrant heightened scrutiny of MetLife's decision.

First, Sweatman argues that because she was deprived of the "full and fair review" of her claim required by ERISA, 29 U.S.C. Sec. 1133(2) (1988), the district court should have reviewed MetLife's decision de novo. We do not reach this issue ⁵ because in this case MetLife conducted a "full and fair review" of Sweatman's claim.

Section 1133(2) provides that "every employee benefit plan shall ... afford a reasonable opportunity to any participant whose claim for benefits has been denied for a full and fair review by the appropriate named fiduciary of the decision denying the claim." ⁶ Other circuits have explained that "full and fair review means 'knowing what evidence the decision-maker relied upon, having an opportunity to address the accuracy and reliability of the evidence, and having the decision-maker consider the evidence presented by both parties prior to reaching and rendering his decision.' " Sage v. Automation, Inc. Pension Plan & Trust, 845 F.2d 885, 893-94 (10th Cir.1988) (quoting Grossmuller v. International Union Local 813, 715 F.2d 853, 858 n. 5 (3d Cir.1983)).

Sweatman contends that MetLife's review of her claim was inadequate because "the word 'review' contemplates an examination and evaluation of the file by someone other than the various people who initially denied the claim." This argument is both legally and factually inaccurate. The word "review" does not connote examination by a second party. Instead, "review" means "to view, look at, or look over again." The Random House College Dictionary 1130 (Rev. ed. 1980); see also Black's Law Dictionary 1320 (6th ed. 1990) ("Review. To re-examine judicially or administratively. A reconsideration; second view or examination; revision; consideration for purposes of correction."). We have found no case law supporting Sweatman's interpretation of "review" as it appears in Sec. 1133(2). To the contrary, courts have held that a plan administrator's reconsideration of its prior decision satisfies Sec....