Yeager v. Reliance Standard Life Ins. Co.

• Decision Date: 08 July 1996
• Docket Number: No. 95-5872,95-5872
• Citation: 88 F.3d 376
• Parties: Pens. Plan Guide P 23922Q Juanita YEAGER, Plaintiff-Appellee, v. RELIANCE STANDARD LIFE INSURANCE COMPANY, Defendant-Appellant.
• Court: U.S. Court of Appeals — Sixth Circuit

Page 376

88 F.3d 376

Pens. Plan Guide P 23922Q

Juanita YEAGER, Plaintiff-Appellee, v. RELIANCE STANDARD LIFE INSURANCE COMPANY, Defendant-Appellant.

No. 95-5872.

United States Court of Appeals Sixth Circuit.

Argued June 3, 1996.

Decided July 8, 1996.

David A. Friedman (argued and briefed), Taustine, Post, Stosky, Berman, Fineman & Kohn, Louisville, KY, Harris J. Berman, Louisville, KY, for Juanita Yeager.

Christopher M. Hill (argued and briefed), McBrayer, McGinnis, Leslie & Kirkland, Frankfort, KY, for Reliance Standard Life Ins. Co.

Before: MILBURN and SUHRHEINRICH, Circuit Judges; JORDAN, District Judge. ^*

MILBURN, Circuit Judge.

Defendant Reliance Standard Life Insurance Company ("Reliance") appeals the district court's award of disability benefits to plaintiff Juanita Yeager in this action for improper denial of benefits under the Employee Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. § 1001 et seq. On appeal, the issues are (1) whether the district court erred in applying a de novo standard of review to defendant's decision to deny benefits, and (2) whether defendant's decision to deny benefits to plaintiff should be reversed. For the reasons that follow, we reverse.

I.

A.

From 1972 to June 23, 1991, plaintiff Yeager worked for National Tobacco Company in Louisville, Kentucky, as an industrial nurse. Pursuant to her employment, she was covered by a Group Long Term Disability Insurance Policy ("the Plan") provided to National Tobacco Company employees by defendant Reliance and governed by ERISA. The terms of the Plan provide that Reliance will pay a monthly benefit if a claimant:

(1) is Totally Disabled as the result of a Sickness or Injury covered by [the Plan];

(2) is under the regular care of a Physician;

(3) has completed the Elimination Period; and (4) submits satisfactory proof of Total Disability to [Reliance].

J.A. 35. The Plan further states:

"Totally Disabled" and "Total Disability" mean, that as a result of an Injury or Sickness:

(1) during the Elimination Period and for the first 60 months for which a Monthly Benefit is payable, an Insured cannot perform the material duties of his her regular occupation....

(2) after a Monthly Benefit has been paid for 60 months, an insured cannot perform the material duties of any occupation....

J.A. 30. The maximum duration of benefits under the Plan for someone who is less than 61 years old when disabled is age 65.

On November 21, 1991, plaintiff Yeager applied for disability benefits under the Plan. Her initial application listed as her disabling conditions: "fibronyalgia [sic], ¹ lower extremity pain, weakness--fatigue--chronic low back--Arthritis, Herniated Curvical [sic] Disc Bilaterial [sic] Carpal Tunnel or TOS." J.A. 41. She listed several doctors whom she had seen for these conditions. Defendant Reliance investigated the application for disability benefits by writing plaintiff's physicians, Dr. Donna Metz-Dunn, Dr. Nigel Harris, Dr. Ken Kleinsteuber, and Dr. Gary Fox, to determine whether they had treated plaintiff for the stated conditions. Defendant Reliance also had plaintiff independently evaluated through a functional capacity evaluation and forwarded the evaluation reports to plaintiff's physicians for their comments.

Reliance's investigation established the following facts. Plaintiff first consulted Dr. Donna Metz-Dunn for the conditions of which she complained on March 12, 1990. On November 13, 1991, Dr. Metz-Dunn completed a statement of disability, listing her diagnosis as fibromyalgia and stating that plaintiff was disabled from her regular occupation but not from any occupation. J.A. 58. She also indicated a need to "consult with rheumatology" concerning her diagnosis of fibromyalgia. Id. On January 13, 1992, Dr. Metz-Dunn wrote defendant a letter that described plaintiff's diagnosis as "degenerative disc disease with a possible element of fibromyalgia." J.A. 55. This letter stated:

Mrs. Yeager feels she is unable to continue the duties entailed in her current job situation. Mrs. Yeager is unable to perform activities involving lifting, pushing, pulling or significant amounts of physical activity due to her back disease. Further prognostic determinations are dependent on her follow-up evaluation with Dr. Harris[, her rheumatologist,] as is the extent of her disability.

J.A. 56. Finally, Dr. Metz-Dunn sent defendant a letter on March 7, 1992, stating that plaintiff had been diagnosed with fibromyalgia/fibrositis and that she was unable to perform her usual duties due to myalgias and arthralgias. J.A. 54. After examining the results of plaintiff's functional capacity evaluation, Dr. Metz-Dunn stated that disability was not her area of specialty and that she strongly suggested that a disability physician assess the entire situation. J.A. 46.

Dr. Nigel Harris, a rheumatologist, examined plaintiff on three occasions: August 22, 1990, January 8, 1991, and August 22, 1991. At Reliance's request, Dr. Harris summarized his opinion of plaintiff's condition on December 26, 1991. He stated that he did not "have a good handle on Ms. Yeager's problems" and that he was uncertain of the extent to which her degenerative disc disease contributed to her pain. J.A. 67. He further stated that he had considered fibromyalgia as a possible diagnosis but found that plaintiff did not have the number of tender points normally accepted for a diagnosis of fibromyalgia. He concluded:

I believe Ms. Yeager's complaints to be real and (in her view) disabling, but I can offer no definite diagnosis for these symptoms. It would be difficult for me to make a recommendation about disability and would suggest she be assessed by an independent evaluator.

J.A. 67-68. In a subsequent letter, Dr. Harris again wrote that he believed plaintiff Yeager's complaints to be real but had been "unable to document any physical abnormality that might account for her pains...." J.A. 64. In a final letter on May 6, 1992, following his review of the functional capacity evaluation, Dr. Harris wrote:

Performance of CPR and other physical activities required in an emergency would be difficult for her to do because of pain. These are subjective complaints, but as far as this patient is concerned, they are real enough. Certainly, I would not recommend that she be expected to respond and render assistance in serious emergencies. As to her remaining duties, I have stated that she has no musculoskeletal abnormalities that would prevent her doing these, but her complaints of bodily pain seem real enough and in her estimation may detract from her ability to function normally. A complete evaluation by me on more than one occasion would find no anatomic explanation for her body pains and is commonly the case in patients with fibrositis.

J.A. 62.

Dr. Ken Kleinsteuber wrote defendant on January 22, 1993, indicating that plaintiff had been diagnosed with fibromyalgia by Dr. Harris prior to seeing him. He further wrote:

In view of Ms. Yeager's job description, her neck and back pains limit her ability to lift and pull. Her persistent pain and stress can detract from her concentrating on her other duties, and I feel that Ms. Yeager's complaints keep her from carrying out her normal work duties.

J.A. 91. In a second letter on April 12, 1993, Dr. Kleinsteuber stated that after reviewing plaintiff's job description and functional capacity evaluation, he felt that she could perform ninety-five percent of her occupation. The only job duty in which he felt she was limited was running while carrying an oxygen unit to the scene of an accident or illness episode. He further wrote that "[t]here is no definitive test to support a diagnosis of fibromyalgia." J.A. 94.

Finally, Dr. Gary Fox, a neurologist to whom plaintiff was referred by Dr. Metz-Dunn, wrote on September 17, 1991 that he had found "no objective neurologic abnormalities." J.A. 98. Following its investigation, Reliance denied plaintiff's claim for benefits on May 27, 1992, on the ground that there was insufficient evidence that plaintiff was totally disabled within the meaning of the Plan.

B.

On June 30, 1993, plaintiff filed a complaint in the Circuit Court for Jefferson County, Kentucky alleging that defendant had wrongfully deprived her of benefits that she was due under the terms of the Plan in violation of 29 U.S.C. § 1132(a)(1)(B). Defendant removed the action to federal court on July 21, 1993, on the ground that it presented a federal question. Subsequently, defendant moved for summary judgment, arguing in part that the district court should review its denial of benefits to plaintiff under an arbitrary and capricious standard. On May 11, 1994, the district court denied defendant's motion for summary judgment, holding that a de novo standard applied to its review of the case and that under such a standard, defendant was not entitled to summary judgment. J.A. 10.

On February 13, 1995, the district court issued its opinion in the case, finding sufficient evidence to support plaintiff's claim that she was totally disabled from performing the material duties of her regular occupation and holding that plaintiff was entitled to disability benefits for sixty months. In reaching this conclusion, the court considered a June 4, 1993 decision by the Department of Health and Human Services that plaintiff was entitled to social security disability benefits to be significant. However, the district court also held that plaintiff's evidence fell short of demonstrating that she was disabled from all work permanently and therefore entitled to lifetime benefits.

Subsequently, plaintiff requested clarification of the district court's order. The court stated that it "intended to adjudicate and conclude Plaintiff's eligibility for sixty (60) months disability at this time." J.A. 19. It also stated that it had "concluded that Plaintiff had not provided sufficient evidence to entitle her to lifetime benefits at this time," but that...