Frazier v. Life Ins. Co. of N. Am.

• Citation: 725 F.3d 560
• Decision Date: 05 August 2013
• Docket Number: No. 12–6216.,12–6216.
• Parties: Kimberly A. FRAZIER, Plaintiff–Appellant, v. LIFE INSURANCE COMPANY OF NORTH AMERICA, Defendant–Appellee.
• Court: U.S. Court of Appeals — Sixth Circuit

725 F.3d 560

Kimberly A. FRAZIER, Plaintiff–Appellant,

v.LIFE INSURANCE COMPANY OF NORTH AMERICA, Defendant–Appellee.

No. 12–6216.

United States Court of Appeals,

Sixth Circuit.

Argued: June 12, 2013.

Decided and Filed: Aug. 5, 2013.

ARGUED:Michael D. Grabhorn, Grabhorn Law Office, PLLC, Louisville, Kentucky, for Appellant. Cameron S. Hill, Calwell & Berkowitz, P.C., Chattanooga, Tennessee, for Appellee. ON BRIEF:Michael D. Grabhorn, Grabhorn Law Office, PLLC, Louisville, Kentucky, for Appellant. Cameron S. Hill, Marcie K. Bradley, Calwell & Berkowitz, P.C., Chattanooga, Tennessee, for Appellee.

Before: COLE and McKEAGUE, Circuit Judges; ZOUHARY, District Judge. ^*

OPINION

ZOUHARY, District Judge.

Kimberly Frazier filed this lawsuit against Life Insurance Company of North America (“LINA”) under the Employee Retirement Income Security Act (“ERISA”), 29 U.S.C. § 1001 et seq., seeking to obtain long term disability (“LTD”) and other benefits allegedly owed her under an employer-sponsored insurance policy (“Policy”) issued by LINA. The district court granted judgment for LINA, reasoning that LINA had the discretionary authority to deny Frazier's claim, and that the denial of benefits was neither arbitrary nor capricious. We affirm.

BACKGROUND

Frazier's Medical History

Frazier worked as a “sorter” for Publishers Printing Company, LLC (“Publishers”). In this position, she was covered by Publishers' employee benefit plan (“Plan”), which provided disability insurance as set forth in the Policy. In July 2009, she left her job at the age of 42 due to pain in her back that radiated down both legs, a condition she thought was caused by arthritis and a “bulging disc,” though she could not identify or remember any particular trauma, fall, or injury that initiated the pain.

Frazier underwent an MRI of her lumbar spine in early July 2009, which revealed mild disc dislocation at the L4–5 level. Later that month, she visited her family physician, Dr. Brian Eklund, complaining of pain in her right foot with accompanying numbness and tingling. He diagnosed her with lower back pain and radiculopathy. Frazier visited Dr. Eklund several times between July and December 2009, and his final opinion, which he expressed to LINA in 2010, was that Frazier was unable to return to work at regular capacity.

After visiting Dr. Eklund in July 2009, Frazier began a course of physical therapy aimed at decreasing pain. The administrative record reflects Frazier participating in only a limited stretch of physical therapy, ending in August 2009, but her discharge summary indicates she had met all treatment goals.

Following completion of physical therapy, Frazier began seeing another physician, Dr. Kyaw Htin, for an evaluation of her chronic pain. During her first visit, Dr. Htin prescribed a treatment plan consisting of lumbar epidural injections. Frazier received several such injections from August 2009 to February 2010, and Dr. Htin's notes indicate that although Frazier's pain level varied each visit, the injections were effective in achieving a decrease in pain for some period of time. The last discharge instruction from Dr. Htin permitted her to return to work the following day.

Policy Provisions

Publishers is the administrator of the Plan under which Frazier claims benefits. See29 U.S.C. § 1002(16). It “has appointed [LINA] as the named fiduciary for deciding claims for benefits under the Plan, and for deciding any appeals of denied claims.”

Under the Policy, Frazier is considered disabled if she is “unable to perform the material duties of [ ] her Regular Occupation,” and “unable to earn 80% or more of [ ] her indexed earnings from working in [ ] her regular occupation.” The term “Regular Occupation” is defined as:

The occupation the Employee routinely performs at the time the Disability begins. In evaluating the Disability, the Insurance Company will consider the duties of the occupation as it is normally performed in the general labor market in the national economy. It is not work tasks that are performed for a specific employer or at a specific location.

To be eligible for LTD benefits under the Policy, Frazier must provide “satisfactory proof of disability,” and show that she has been “continuously disabled” for a period of 180 days, known as the “elimination period,” before benefits will be paid.

The Policy also provides that LINA may assist Frazier in applying for Social Security Disability Income (“SSDI”) benefits, and if she chose not to cooperate with LINA, LINA would reduce its benefit payments by the amount it estimates she would have received in SSDI benefits. This provision is contained in a section of the Policy entitled “Other Income Benefits,” which notes that LINA “may reduce” LTD benefit payments by the amount received from other listed income sources, including SSDI.

Frazier's Claim for LTD Benefits

In January 2010, Frazier submitted a claim to LINA for LTD benefits due to lower back pain and radiation of pain down both legs. She indicated her job title with Publishers was “sorter,” and that her primary duties included sorting and bagging mail, boxing, lifting, bending, and twisting. Publishers identified her job title as “mail sorter,” and noted her duties included separating magazines by zip codes (in bunches of about fifteen pounds) at “production speeds,” and listed the job requirements as “continuous standing and twisting motion; lifting approximately 15 lb. lifts; arm and wrist movement.” This definition accords with the U.S. Department of Labor's job description of “mail sorter,” which indicates it is a “light” strength occupation that includes “lifting, carrying, pushing, pulling 20 lbs. occasionally, frequently up to 10 lbs. or negligible amount constantly.”

LINA denied the claim in February 2010 after reviewing available medical evidence and the job descriptions from Publishers and the U.S. Department of Labor. Among the medical evidence reviewed by LINA and a nurse case manager were: the July 2009 MRI of Frazier's spine, office visit notes from Drs. Eklund and Htin, physical therapy evaluations, and Dr. Eklund's attending physician statement. LINA explained that the primary shortcoming in Frazier's application was a lack of sufficient medical evidence of continuous disability:

The [doctor] notes consistently indicate no sensory deficits and normal strength bilaterally. No lower extremity atrophy, current range of motion scales, consistently positive straight leg raises, documented nerve root impingement or cord compression, documented instability on flexion or extension were noted. Overall, the medical information available for review is insufficient to support a significant physical deficit throughout the Elimination Period.

In its letter to Frazier denying her claim, LINA also explained her appeal rights:

You have the right to submit written comments as well as any new documentation you wish us to consider.... Additional information includes, but is not limited to: physician's office notes, hospital records, consultations, test result reports, therapy notes, physical and/or mental limitations, etc. You may also wish to have your physician(s) provide some or all of the following: Clinical examination findings, such as sensory, motor and gait, and objective test results upon which the above limitations and restrictions are based.

Frazier appealed LINA's initial decision in March 2010, and submitted as additional documentation a Functional Capacity Evaluation (“FCE”) performed that same month. The FCE indicates Frazier “is currently functionally capable of meeting the lower demands for the Medium Physical Demand level on a 8 hour per day basis according to the U.S. Department of Labor Standards.”

LINA affirmed its decision in April 2010, noting in another letter to Frazier that a review of all available information indicates Frazier's “current functional ability would allow [her] to perform the material duties of [her] regular occupation.” LINA again informed Frazier of her ability to appeal the denial, but this time instructed her that she would be required to submit new documentation.

Frazier filed this lawsuit under 29 U.S.C. § 1132(a)(1)(B) in February 2011. Both parties moved for judgment on the administrative record. Frazier argued that LINA wrongly denied her claim, and that the district court should review the denial de novo because LINA had not been given discretionary authority under the Plan to review disability claims. LINA countered that the district court should apply the arbitrary and capricious standard, and that, in any event, its denial of Frazier's claim was reasoned and correct.

In September 2012, the district court determined that LINA had discretionary authority to review LTD claims, and thus applied the arbitrary and capricious standard. It then found the denial to be neither arbitrary nor capricious given LINA's review of the full record, which included the various medical records and job descriptions, and granted LINA's motion. Frazier timely filed a notice of appeal, which is properly before this Court under 28 U.S.C. § 1291.

DISCUSSION

This Court reviews de novo questions of law, including the “district court's determination regarding the proper standard to apply in its review of a plan administrator's decision.” Haus v. Bechtel Jacobs Co., 491 F.3d 557, 561–62 (6th Cir.2007) (internal quotation marks omitted). A district court's factual findings “inherent in deciding an ERISA claim are reviewed for clear error.” Williams v. Int'l Paper Co., 227 F.3d 706, 714 (6th Cir.2000). “[F]actual findings are clearly erroneous if, based on the entire record, we are left with the definite and firm conviction that a mistake has been committed.” Shelby Cnty. Health Care Corp. v. Majestic Star Casino, 581 F.3d 355, 364–65 (6th Cir.2009).

1. The Arbitrary and Capricious Standard of Review

Under ERISA, a denial of benefits “is to be reviewed under a de novo standard unless the benefit plan...