Burell v. Prudential Ins. Co. of Am.

• Decision Date: 11 April 2016
• Docket Number: No. 15–50035.,15–50035.
• Citation: 820 F.3d 132
• Parties: Patrick BURELL; Aracelli Burell, Plaintiffs–Appellants, v. PRUDENTIAL INSURANCE COMPANY OF AMERICA, Defendant–Appellee.
• Court: U.S. Court of Appeals — Fifth Circuit

820 F.3d 132

Patrick BURELL; Aracelli Burell, Plaintiffs–Appellants

v.PRUDENTIAL INSURANCE COMPANY OF AMERICA, Defendant–Appellee.

No. 15–50035.

United States Court of Appeals, Fifth Circuit.

April 11, 2016.

Dax O. Faubus, Esq. (argued), Faubus Keller & Burford, L.L.P., Houston, TX, for Plaintiffs–Appellants.

Ian Hugh Morrison, I, Esq. (argued), Seyfarth Shaw, L.L.P., Chicago, IL, Esteban Shardonofsky, Esq., Seyfarth Shaw, L.L.P., Houston, TX, for Defendant–Appellee.

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

Before STEWART, Chief Judge, and BARKSDALE and PRADO, Circuit Judges.

EDWARD C. PRADO

, Circuit Judge:

Plaintiff–Appellant Patrick Burell filed a claim for long-term disability benefits with Defendant–Appellee Prudential Insurance Company of America (“Prudential”). Prudential denied Burell's initial claim and two subsequent appeals. Burell then filed suit against Prudential under the Employee Retirement Income Security Act (“ERISA”), 29 U.S.C. § 1001 et seq.,

alleging that its denial of his long-term disability-benefits claim was in error. The district court granted summary judgment in favor of Prudential, and we affirm.

I. FACTUAL AND PROCEDURAL BACKGROUND

In 1985, Burell began working as an entry-level technician for Methodist Healthcare Systems (“MHS”). After 26 years, he ended his career as Director of Biomedical Services for all San Antonio MHS facilities. As an employee of MHS, Burell participated in the company's insurance plan (“the Plan”), which is provided through HCA Management Services, L.P. Prudential acts as both administrator and insurer of the Plan. In order to qualify for long-term disability benefits, a claimant must meet the following definition of “disabled”: the claimant must (1) be “unable to perform the material and substantial duties of [his or her] regular occupation due to [his or her] sickness or injury ”; (2) be “under the regular care of a doctor ”; and (3) suffer “a 20% or more loss in [his or her] monthly earnings due to that sickness or injury.”

Burell was diagnosed with multiple sclerosis

(“MS”) in 2008. Citing worsening symptoms of MS, in September 2011, Burell went on medical leave and filed for long-term disability benefits with Prudential, claiming that he qualified for benefits under the Plan due to MS, headaches, depression, and anxiety. In January 2012, he stopped working altogether, ending his employment with MHS. In support of his claim, Burell submitted medical records from his treating physicians and a psychiatrist. Prudential hired Heidi Garcia, a registered nurse, and Dr. Alan Neuren, who is board certified in neurology, to review Burell's claim. Dr. Neuren found that Burell's diagnosis of MS was unsupported by his medical records. He also found it unlikely that Burell suffered any cognitive impairments, opining that job stress is “likely the source of his complaints as opposed to a neurological disorder.” Garcia focused her review on Burell's claim of depression and anxiety, ultimately finding that any cognitive symptoms he was experiencing were not sufficient to prevent him from working. Based on their reports and the medical records submitted, Prudential denied Burell's claim for long-term disability benefits.

Burell then appealed the decision through Prudential's internal review process. On appeal, his claim was reviewed by Dr. Stuart Isaacson, who is board certified in psychiatry and neurology, and Dr. James Boone, who is a clinical neuropsychologist. Dr. Isaacson found that Burell did not meet the diagnostic criteria for MS and did not have “any medically necessary restrictions and/or limitations from any one condition or combination of conditions.”

Dr. Boone found that Burell's “file records do not validly support psychological and/or cognitive symptoms” and that he has no “medically necessary restrictions and/or limitations.” Based on the opinions of these physicians and Burell's medical records, which included additional documentation submitted during the appeal process, Prudential again denied Burell's claim.

Burell next sent Prudential a letter demanding the benefits he believed he was owed under the Plan. Prudential treated this demand letter as a second appeal and had the claim further reviewed by Dr. Omuwunmi Osinubi, who is board certified in anesthesiology and occupational medicine, and Dr. Melvyn Attfield. Dr. Osinubi found that although Burell's medical records did in fact support a diagnosis of MS, he did not have any physical limitations due to the disease. Dr. Osinubi was unable to make a finding on Burell's alleged cognitive impairments and suggested an additional neuropsychological review be performed. Upon Dr. Osinubi's recommendation, Dr. Michael Chafetz, who is board certified in clinical neuropsychology, performed an independent neuropsychological evaluation, finding that Burell did not suffer any cognitive impairments. On the basis of these opinions and Burell's medical records, which included additional documentation submitted during the second appeal process, Prudential denied Burell's claim for a third time.

In April 2013, Burell filed suit against Prudential under 29 U.S.C. § 1132(a)(1)(B)

and (a)(3), alleging that Prudential wrongfully denied his claim for long-term disability benefits. In December 2014, the district court granted summary judgment in favor of Prudential, and Burell timely appealed.

II. DISCUSSION

The district court had jurisdiction over this suit under 29 U.S.C. § 1132(e)

. This Court has jurisdiction pursuant to 28 U.S.C. § 1291.

In ERISA actions, “[s]tandard summary judgment rules control.” Cooper v. Hewlett–Packard Co., 592 F.3d 645, 651 (5th Cir.2009)

(quoting Vercher v. Alexander & Alexander Inc., 379 F.3d 222, 225 (5th Cir.2004) ). This Court reviews a district court's grant of summary judgment de novo, viewing “all facts and evidence in the light most favorable to the non-moving party.” Amerisure Mut. Ins. Co. v. Arch Specialty Ins. Co., 784 F.3d 270, 273 (5th Cir.2015). Summary judgment is appropriate “if the movant shows that there is no genuine dispute as to any material fact and the movant is entitled to judgment as a matter of law.” Fed.R.Civ.P. 56(a). A genuine dispute of material fact exists when “the evidence is such that a reasonable jury could return a verdict for the nonmoving party.” Savant v. APM Terminals, 776 F.3d 285, 288 (5th Cir.2014) (quoting Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 248, 106 S.Ct. 2505, 91 L.Ed.2d 202 (1986) ).

A. Underlying Standard of Review

As a preliminary matter, Burell challenges the standard of review the district court used in analyzing Prudential's denial of his claim. The district court reviewed the denial for an abuse of discretion, while Burell argues that the court should have reviewed the denial de novo. “ ‘Whether the district court employed the appropriate standard in reviewing an eligibility determination made by an ERISA plan administrator is a question of law’ that we review de novo.” Green v. Life Ins. Co. of N. Am., 754 F.3d 324, 329 (5th Cir.2014)

(quoting Ellis v. Liberty Life

Assurance Co. of Bos.,

394 F.3d 262, 269 (5th Cir.2004) ).

Generally, in suits brought under 29 U.S.C. § 1132(a)(1)(B)

, district courts review the denial of a long-term disability-benefits claim de novo. Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115, 109 S.Ct. 948, 103 L.Ed.2d 80 (1989). But, if the benefits plan the suit is brought under “gives the administrator or fiduciary discretionary authority to determine eligibility for benefits or to construe the terms of the plan,” id., the denial of benefits is reviewed for an abuse of discretion, Holland v. Int'l Paper Co. Ret. Plan, 576 F.3d 240, 246 (5th Cir.2009). Therefore, in order to determine whether the district court applied the correct standard of review, we must consider whether the terms of the Plan grant Prudential the authority to interpret the Plan and make benefits decisions.

As the district court correctly explained, the terms of the Plan expressly give Prudential discretionary authority. Specifically, the Plan defines “Claim Fiduciary” as follows:

Claims Fiduciary means an individual or entity, designated in the Plan (including the Summary Plan Description, Insurance Contracts or appendices, which are part of the Plan) or otherwise appointed by the Plan Administration Committee, to have final discretionary authority to interpret the terms of the Plan and decide questions of fact, as necessary to make a determination as to whether the Claims presented to the Claims Fiduciary are payable, in whole or in part, in accordance with the terms of the Plan.

The Summary Plan Description (“SPD”) designates Prudential as the Claims Fiduciary: “All claims and appeals are handled by Prudential. Prudential has absolute discretion in deciding claims and appeals.” As the Plan expressly gives Prudential discretionary authority,¹ the district court did not err in reviewing the denial of Burell's long-term disability-benefits claim under an abuse of discretion standard.

Burell argues that the district court improperly relied on language in the SPD. We find this argument unavailing. Typically, the terms of a SPD are not controlling unless the SPD is incorporated into the plan. See Engleson v. Unum Life Ins. Co. of Am., 723 F.3d 611, 620 (6th Cir.2013)

; Eugene S. v. Horizon Blue Cross Blue Shield of N.J., 663 F.3d 1124, 1131–32 (10th Cir.2011). In his brief, Burell concedes that “[o]nly the plan may subsume an [sic] SPD by integrating it in the plan's express terms.” In this case, the Plan expressly integrates the SPD in several places. For example, the Plan states that “[t]he Plan document is comprised of this Plan document and, with respect to each benefit program included within the Plan, the summary plan description(s) applicable to that benefit program.” The definition of “Claims Fiduciary” above also expressly incorporates the SPD: “Claims Fiduciary means an individual or entity,...