Mote v. Aetna Life Ins. Co.

• Decision Date: 12 September 2007
• Docket Number: No. 06-4127.,06-4127.
• Citation: 502 F.3d 601
• Parties: Brenda MOTE, Plaintiff-Appellant, v. AETNA LIFE INSURANCE COMPANY and Arthur Andersen LLP Group Long Term Disability Insurance Plan, Defendants-Appellees.
• Court: U.S. Court of Appeals — Seventh Circuit

502 F.3d 601

Brenda MOTE, Plaintiff-Appellant, v. AETNA LIFE INSURANCE COMPANY and Arthur Andersen LLP Group Long Term Disability Insurance Plan, Defendants-Appellees.

No. 06-4127.

United States Court of Appeals, Seventh Circuit.

Argued June 5, 2007.

Decided September 12, 2007.

Mark D. Debofsky (argued), Daley, Debofsky & Bryant, Chicago, IL, for Plaintiff-Appellant.

Elizabeth A. McDuffie, Philip S. Holloway (argued), Gonzalez, Saggio & Harlan, Chicago, IL, for Defendants-Appellees.

Before EASTERBOOK, Chief Judge, and MANION and WOOD, Circuit Judges.

MANION, Circuit Judge.

Brenda Mote sued Aetna Life Insurance Co. ("Aetna") and the Arthur Andersen Long-Term Disability Plan (the "Plan") under the Employment Retirement Income Security Act ("ERISA"), 29 U.S.C. § 1001 et seq., alleging that Aetna and the Plan arbitrarily and capriciously terminated her disability benefit payments and that they should be estopped from terminating her disability benefits because the Social Security Administration found her "disabled" under its regulations. The district court dismissed Mote's claims against Aetna upon finding that Aetna was not a proper party to the action, denied Mote's motion for summary judgment against the Plan, and granted summary judgment to the Plan on all of Mote's claims against it. Mote appeals. We affirm.

I.

Brenda Mote was a human resource generalist with Arthur Andersen LLP until she ceased working on April 10, 1998, due to back pain and physical complications, including fibromyalgia,¹ stemming from an August 1997 accident. On the day that Mote stopped working for Arthur Andersen, she applied for long-term disability benefits under the Plan, which was administered by Aetna. The Plan states that for purposes of ERISA, Aetna shall act as the Plan's fiduciary and be vested with "discretionary authority" both to "determine whether and to what extent employees and beneficiaries are entitled to benefits; and construe any disputed or doubtful terms of this policy." Specifically, Mote applied for long-term disability benefits under the Plan's "own occupation" definition of disability. That provision states that an employee is "totally disabled" if the insured employee is unable "[d]uring the first 5 years of disability to perform the material duties of the employee's own occupation." The Plan approved Mote's application, and on July 10, 1998, she began receiving long-term disability benefits. Following the Plan's approval of her application, Mote continued to receive medical care for her back pain and fibromyalgia, and the Plan periodically reassessed her condition to ensure that she remained eligible for long-term disability benefits.

After Mote had been receiving long-term disability benefits for five years, on December 8, 2003, the Plan notified her that it recently had reevaluated her claim under its stricter, five-year definition of "totally disabled" and determined that she no longer qualified for long-term disability benefits. Under the Plan, while an employee only needs to demonstrate that he is unable to "perform the material duties of [his] own occupation" during the first five years of his disability, after five years the employee must demonstrate that he is unable to "work at any occupation for which [he] is, or may reasonably become, fitted by education, training or experience." In its letter to Mote, the Plan stated that it reached its decision after reviewing the office notes of Mote's treating physicians, various lumbar MRIs, CT scans, and surgical procedures, as well as statements by Mote's physicians regarding her physical limitations and restrictions. The letter also informed Mote that the Plan had hired an independent investigator who, in January 2003, videotaped her engaging in activities that she stated on her April 30, 2003, Claim Questionnaire that she was unable to perform. The Plan's letter further stated that it based its decision on the results of Mote's November 11, 2002, functional capacity examination and her September 15, 2003, independent medical examination, both of which found that Mote was capable of performing sedentary work. The letter also noted that the Plan's consulting physicians reviewed Mote's medical information on two recent occasions and reached the same conclusion.

Mote requested that the Plan review its decision. In support of her request for review, Mote submitted additional medical evidence from her treating physicians, including her primary care physician, Terry West, M.D., and her pain management specialist, James Gruft, M.D. Dr. West opined that Mote was suffering from a "class 5" physical impairment, which rendered her "incapable of minimal (sedentary) activity." He further noted that, in his opinion, "maximum medical improvement has [been] achieved. I don't believe she can ever work again." In a letter dated August 10, 2004, Dr. West stated that Mote suffers from fibromyalgia and chronic back pain, which remain unchanged, and he concluded that Mote "is still unable to work at this time, due to limitations of motion and need for sedating pain medication." Dr. Gruft also opined that Mote was incapable of sedentary activity, and that he believed that Mote's condition had "retrogressed."

Upon its receipt of Mote's additional information, the Plan informed Mote that it referred her file for an independent medical review. The Plan retained William Hall, M.D., to conduct its review. In his September 2, 2004, report, Dr. Hall stated that he reviewed Mote's medical history and opined:

I must conclude that the weight of the medical credibility be given to the opinions of [Mote's] treating physicians and that, absent medical or personal information regarding [Mote] to the contrary, her subjective musculoskeletal symptoms are of such severity to be totally medically limiting.

However, during his initial review of Mote's medical records, Dr. Hall was unaware of the videotaped evidence of Mote's daily activities that the Plan obtained from its independent investigator. The independent investigator recorded the videotapes between January 29, 2003, and February 4, 2003. Dr. Hall subsequently viewed selected portions of the videotapes, which showed Mote running errands, driving an elderly relative to doctors' appointments, and loading groceries into her car. Upon reviewing the videotape evidence of Mote's functional abilities, Dr. Hall changed his opinion regarding Mote's level of disability, stating:

After viewing surveillance videos of [Mote's] activities for the dates and durations noted, I do not agree with assessments of severity or with medically limiting conclusions by [Mote's] treating physicians. I am not able to identify an objective or absolute impediment to [Mote] pursuing sustained and otherwise unrestricted activities at a light level of exertion.

In a letter dated September 28, 2004, the Plan notified Mote that, after a "full and fair review of the decision to terminate [her] claim," it was upholding its decision to terminate her long-term disability benefits.² The Plan's letter cited a long list of materials that it reviewed in reaching its decision, and stated that "the weight of the medical information does not support a condition of total disability."³ Mote then filed suit against both the Plan and Aetna, claiming that they improperly terminated her long-term disability benefits. The district court dismissed Aetna as an improper party, denied Mote's cross-motion for summary judgment, and granted the Plan's cross-motion for summary judgment. Mote appeals.

II.

We review a district court's decision on summary judgment de novo. Davis v. Unum Life Ins. Co. of Am., 444 F.3d 569, 574 (7th Cir.2006) (citations omitted). "Summary judgment is proper when the `pleadings, depositions, answers to interrogatories, and admissions on file, together with the affidavits, if any, show that there is no genuine issue as to any material fact and that the moving party is entitled to a judgment as a matter of law.'" Tegtmeier v. Midwest Operating Eng'rs Pension Trust Fund, 390 F.3d 1040, 1045 (7th Cir. 2004) (quoting Fed.R.Civ.P. 56(c)). "With cross-motions, our review of the record requires that we construe all inferences in favor of the party against whom the motion under consideration is made." Id. (quotations and citations omitted).

On appeal, Mote first argues that the Plan's decision to stop paying her benefits after finding that she did not meet the stricter five-year definition of "total disability" was arbitrary and capricious. In Firestone Tire & Rubber v. Bruch, 489 U.S. 101, 109 S.Ct. 948, 103 L.Ed.2d 80 (1989), the Supreme Court held that "`a denial of benefits challenged under § 1132(a)(1)(B) is to be reviewed under a de novo standard unless the benefit plan gives the administrator or fiduciary discretionary authority to determine eligibility for benefits or to construe the terms of the plan.'" Diaz v. Prudential Ins. Co. of Am., 424 F.3d 635, 636-37 (7th Cir.2005) (quoting Firestone, 489 U.S. at 115, 109 S.Ct. 948). "When, as here, the terms of an employee benefit plan afford the plan administrator broad discretion to interpret the plan and determine benefit eligibility, judicial review of the administrator's decision to deny benefits is limited to the arbitrary-and-capricious standard." Davis, 444 F.3d at 575 (citing Sisto v. Ameritech Sickness & Accident Disability Benefit Plan, 429 F.3d 698, 700 (7th Cir. 2005)).

Under the arbitrary and capricious standard, "we will overturn a plan administrator's decision `only ... if it is downright unreasonable.'" Herman v. Cent. States, Se. & Sw. Areas Pension Fund, 423 F.3d 684, 692 (7th Cir.2005) (quoting Carr v. Gates Health Care Plan, 195 F.3d 292, 294 (7th Cir.1999) (internal quotation omitted)). "That is, this court will not substitute the conclusion it would have reached for the decision of the administrator, as long as the administrator makes an informed judgment and articulates an...