Dutkewych v. Standard Insurance Company , 781 F.3d 623 ( 2015 )

United States Court of Appeals
For the First Circuit
No. 14-1450
MARK DUTKEWYCH,
Plaintiff, Appellant,
v.
STANDARD INSURANCE COMPANY,
Defendant, Appellee,
and
MINTZ LEVIN COHN FERRIS GLOVSKY & POPEO P.C. GROUP
LONG TERM DISABILITY PLAN,
Defendant.
APPEAL FROM THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF MASSACHUSETTS
[Hon. Denise J. Casper, U.S. District Judge]
Before
Lynch, Chief Judge,
Souter,* Associate Justice,
and Stahl, Circuit Judge.
Mala M. Rafik, with whom S. Stephen Rosenfeld was on brief,
for appellant.
Brooks R. Magratten, with whom Ronald M. LaRocca and Pierce
Atwood LLP were on brief, for appellee.
*
Hon. David H. Souter, Associate Justice (Ret.) of the
Supreme Court of the United States, sitting by designation.
March 30, 2015
-2-
LYNCH, Chief Judge. Plaintiff Mark Dutkewych is a
participant in a disability plan (the "Plan"), insured and
administered by Defendant Standard Insurance Company under the
Employee Retirement Income Security Act ("ERISA"), 29 U.S.C. § 1001et seq. The Plan limits long-term disability ("LTD") benefits to
24 months for "a Disability caused or contributed to by . . . :
(1) Mental Disorders; (2) Substance Abuse; or (3) Other Limited
Conditions." Applying this Limited Conditions Provision, Standard
terminated Dutkewych's benefits after 24 months, on June 1, 2011.
After Dutkewych's administrative appeal failed, he brought this
lawsuit against Standard for unpaid benefits. The district court
entered summary judgment against Dutkewych's claims. Dutkewych v.
Standard Ins. Co., No. 12-cv-11073, 2014 WL 1334169 (D. Mass. Mar.
29, 2014). Dutkewych appealed.
Dutkewych contests Standard's decision to limit his LTD
benefits to 24 months, saying he has been diagnosed with chronic
Lyme disease, "a physical illness that is not limited under the
terms of the Plan." Despite the hot dispute between the parties on
this issue, this case does not turn on the insurer's doubts about
the validity of Dutkewych's diagnosis with chronic Lyme disease.
Instead, this case turns on the insurer's application of a
different provision of the Plan, the subset of the Limited
Conditions Provision related to mental disorders ("Mental Disorder
Limitation"). Standard maintains that, even if Dutkewych was
-3-
disabled as a result of chronic Lyme disease in June 2011, the
Mental Disorder Limitation nonetheless applies because his mental
disorders, regardless of their cause, contributed to his disability
as of June 2011.
Standard's interpretation of the Mental Disorder
Limitation is reasonable and its application to Dutkewych's case is
supported by substantial evidence. We affirm the entry of summary
judgment to Standard.
I. Factual Background
A. Standard's LTD Plan
The Plan provides that a participant qualifies as
"Disabled from your Own Occupation if, as a result of Physical
Disease, Injury, Pregnancy, or Mental Disorder:"
1. You are unable to perform with reasonable
continuity the Material Duties of your Own
Occupation; and
2. You suffer a loss of at least 20% in your
Indexed Predisability Earnings when working in
your Own Occupation.
The "Maximum Benefit Period" allowed Dutkewych to receive benefits
to age 65.
Certain disabilities, however, are subject to a limited
benefits period ("Limited Conditions Provision"). Specifically,
"[p]ayment of LTD Benefits is limited to 24 months during your
entire lifetime for a Disability caused or contributed to by any
one or more of the following . . . : (1) Mental Disorders; (2)
-4-
Substance Abuse; or (3) Other Limited Conditions." "Mental
Disorders" is defined to include "any mental, emotional,
behavioral, psychological, personality, cognitive, mood or stress-
related abnormality, disorder, disturbance, dysfunction or
syndrome, regardless of cause . . . or the presence of physical
symptoms." "Other Limited Conditions" is defined to include
chronic fatigue conditions and chronic pain conditions, such as
fibromyalgia.
The Plan provides two "Rules for Disabilities Subject to
Limited Pay Periods":
1. If you are Disabled as a result of a
Mental Disorder or any Physical Disease or
Injury for which payment of LTD Benefits is
subject to a limited pay period, and at the
same time are Disabled as a result of a
Physical Disease, Injury, or Pregnancy that is
not subject to such limitation, LTD Benefits
will be payable first for conditions that are
subject to the limitation.
2. No LTD Benefits will be payable after the
end of the limited pay period, unless on that
date you continue to be Disabled as a result
of a Physical Disease, Injury, or Pregnancy
for which payment of LTD Benefits is not
limited.
Standard specified in the Plan that it "ha[s] full and
exclusive authority to control and manage the Group Policy, to
administer claims, and to interpret the Group Policy and resolve
all questions arising in the administration, interpretation, and
application of the Group Policy."
-5-
B. Dutkewych's Disability
In early 2008, Dutkewych suffered from mental illness,
substance abuse, and a dizzying array of physical symptoms that
have since received competing diagnoses. Dutkewych left his work
as an associate attorney at a Boston law firm on October 3, 2008,
and sought LTD benefits from Standard. We summarize here the
relevant chronology of Dutkewych's medical history and Standard's
decisions concerning his benefits.
1. Dutkewych's Early Diagnoses
In March 2008, Dutkewych began to experience symptoms
including "severe fatigue, intense back pain and stomach
irritation." His symptoms worsened over the summer as Dutkewych
developed a painful rash, began bruising and bleeding, suffered
severe joint pain, and experienced cognitive issues, including
trouble with reading comprehension, concentration, short term
memory, directions, organization, and sense of time. His primary
care physician, Dr. Eric Serrano, did not identify a cause.
In August 2008, Dr. Serrano referred Dutkewych to a
hematologist-oncologist, Dr. Brenda Haynes, who considered the
possibility of Lyme disease. At that time, Dutkewych reported "no
recent viral exposure or tick exposure that he [was] aware of." A
blood test returned negative results for Lyme disease, but the test
results warned that false negatives are possible in the early
-6-
stages of the disease before the patient produces detectable levels
of antibodies.
Dr. Serrano then referred Dutkewych to a rheumatologist,
Dr. Don Goldenberg, who examined Dutkewych in September 2008. Dr.
Goldenberg concluded that Dutkewych's "musculoskeletal symptoms are
consistent with what is termed fibromyalgia, which overlaps
significantly with mood and sleep disturbances." Dr. Goldenberg
noted that Dutkewych had a history of obsessive compulsive
disorder, which made it "likely that unexplained physical symptoms
with multiple physician evaluations would heighten the intensity of
the symptoms." He recommended Dutkewych's treatment "be primarily
regulated by [his] psychiatrist."
One week later, Dutkewych visited the psychiatric
emergency department at the Cambridge Hospital. He reported his
mental health history and his more recent somatic symptoms. He
noted his recent diagnosis by Dr. Goldenberg, and attributed his
worsening depression to the idea that his doctors did not want to
pursue his physical symptoms. At that time, his wife reported that
he was "self-medicating" with prescription drugs. Dutkewych was
admitted to the Cambridge Hospital's Partial Hospitalization
Program, an outpatient program, for the following two weeks. At
discharge, he was diagnosed with major depressive disorder,
obsessive compulsive disorder, and generalized anxiety disorder.
-7-
In November 2008, Dutkewych visited a family
practitioner, Dr. Jeanne Hubbuch, who ordered additional tests for
Lyme disease. This time, Dutkewych reported experiencing no tick
bites, but noted that ticks had been seen in his house. Western
blot test returned positive results for Lyme disease under the
IGeneX IGG criteria, but negative results under CDC/NYS and Babesia
FISH criteria.
On December 9, 2008, Dutkewych was admitted to the McLean
Hospital for substance abuse treatment. At the hospital, he
reported that he had been abusing Vicodin, and explained that he
had used a stolen credit card to buy things that he then sold to
pay for drugs. His intake form noted his recent diagnosis of Lyme
Disease and his ongoing depression.
He was discharged from the hospital on December 15, 2008,
and immediately entered McLean's residential treatment program. In
an Ambulatory Services Initial Assessment, Dutkewych reported a
"[l]ongstanding" history of obsessive compulsive disorder and
episodic depression. Although his OCD was "in reasonably good
control," his depressive symptoms were still significant and
included suicidal ideation. He admitted to persistent and daily
substance abuse over the last year. Dr. Joshua Katz, who evaluated
Dutkewych during this time, reported that "[m]any if not all of
[Dutkewych's] physical and cognitive symptoms can be explained by
-8-
chronic narcotic use and intermittent withdrawal symptoms."
Dutkewych was discharged on January 21, 2009.
2. Standard's Approval of Limited LTD Benefits
On April 16, 2009, Standard approved Dutkewych's claim
for LTD benefits. At that time, "a significant portion of the
medical records in Mr. Dutkewych's claim file relate[d] to his
psychiatric condition." The physician consultant who reviewed his
records noted that "Mr. Dutkewych has had a combination of chemical
dependency and psychiatric disorder of life threatening
proportions." Standard concluded that his claim "supports that as
of October 4, 2008, [Dutkewych] has been unable to perform with
reasonable continuity the Material Duties of his Own Occupation due
to symptoms and treatment related to substance abuse and major
depression."
Standard specifically warned Dutkewych that his policy
"limits payment of LTD benefits to 24 months during your entire
lifetime for a Disability caused or contributed to by Mental
Disorders, Substance Abuse or Other Limited Conditions." "As major
depression is considered to be a Mental Disorder, Standard will be
applying the Mental Disorder limitation and thus limiting payment
of LTD benefits to a maximum of 24 months."
3. Dutkewych's Treatment for Chronic Lyme Disease
Between June 2009 and December 2009, Dutkewych entered a
second residential substance abuse treatment program and
-9-
participated in two halfway house programs. From around June 5 to
June 22, 2009, Dutkewych was admitted to the McLean Adult Partial
Hospital and Residential Program. From June 22 to September 29,
2009, he resided at Phoenix House Springfield Center, a residential
facility for substance abuse treatment in Springfield,
Massachusetts. From September 29 to December 21, 2009, he
continued his treatment at the "North Cottage" Program, a
residential facility for substance abuse treatment in Norton,
Massachusetts.
During this time, Dutkewych began seeing Dr. Karen
Isselbacher, Dr. Luz J. Ruiz, and Dr. Bernard Raxlen. Each agreed
with the diagnosis of Lyme disease. Dr. Isselbacher, a primary
care physician, conducted a spinal tap in July 2009, and found
elevated levels of proteins which she interpreted as evidence of
Lyme disease. Dr. Raxlen, a psychiatrist, diagnosed Dutkewych with
Lyme disease in December 2009 following a SPECT scan and a clinical
evaluation. Dr. Ruiz, a neurologist, sought an additional Western
blot test in December 2010 which returned identical results to the
test in November 2008 -- positive for Lyme disease under IGeneX
criteria, but negative for Lyme disease under CDC/NYS criteria.
Under their care, Dutkewych has intermittently received
intravenous ("IV") antibiotic treatment for Lyme disease. After
consulting with three physicians, respectively at Columbia, John's
Hopkins, and Beth Israel, Dr. Isselbacher began to treat Dutkewych
-10-
with IV antibiotics in July 2009. While on IV antibiotics from
July 2009 to March 2010, Dutkewych reported improved symptoms. He
suffered a relapse after ending treatment, and restarted IV
antibiotics in April 2010. He stopped again in June 2010, when his
port became infected, and restarted in February 2011, when a new
port was installed.
During this time frame, Dutkewych also applied for and
received a premium waiver on his life insurance policy from
Standard and total disability benefits from the Social Security
Administration ("SSA"). On April 28, 2009, Standard approved
Dutkewych for a premium waiver on his life insurance policy based
on a disability. On June 10, 2010, the SSA approved Dutkewych for
total disability benefits due to "Lyme Disease, fibromyalgia,
muscle/joint pain, depression and substance abuse." The SSA found
that Dutkwewych's "Lyme Disease with associated joint pain and
fatigue as well as his depression preclude him from performing work
at any exertional level of the occupational base on a 'regular and
continuing basis.'"
4. Standard's Termination of LTD Benefits
On April 27, 2011, Standard informed Dutkewych that his
benefits would be terminated as of June 1, 2011,1 "due to the end
of the 24-month Limitation Period." Standard explained that,
1
The 24-month period was extended by 60 days under the terms
of the Plan.
-11-
"[b]ecause the Group Policy limits payments for Disability caused
or contributed to by a Mental Disorder, in order to continue to
receive LTD Benefits, Mr. Dutkewych must be Disabled by a Physical
Disease or Injury." Specifically, "[t]he Physical Disease(s) or
Injury(ies) must be so severe as to cause Disability in the absence
of Substance Abuse, a Mental Disorder or Other Limited Condition."
Standard relied on a physician consultant, Dr. Leonard
Sigal, described as "board-certified in internal medicine and
rheumatology" and "a leading figure in both the treatment and
research of chronic Lyme disease for many years,"2 to review
Dutkewych's "entire medical record." Dr. Sigal concluded that
Dutkewych's diagnosis of Lyme disease was "speculative." He noted
that Dutkewych's antecedent psychiatric disorder, substance abuse,
and diagnosis of fibromyalgia had been "overshadowed by his
treating physicians in favor of the premise that all of his
complaints [were] attributable to 'chronic Lyme disease.'"
In so concluding, Dr. Sigal discounted the positive
Western blot results at the IGeneX laboratory since, in his
experience, the laboratory "routinely reports positive results that
are not in agreement with clinical findings and . . . often reports
positive results in patients with no likelihood of exposure." He
2
Dutkewych argues that Dr. Sigal's "experience has been
confined to the position that chronic Lyme disease does not exist
and that individuals who are diagnosed with chronic Lyme disease
more likely than not suffer from fibromyalgia or mental illness."
-12-
also disagreed with Dr. Isselbacher's reading of the spinal fluid
analysis. "He noted that spinal fluid obtained on July 17, 2009
had normal glucose, a trivially elevated protein, and no
inflammatory white or red blood cells counted." He concluded that
it was "essentially normal." Dr. Sigal accordingly rejected the
diagnosis of chronic Lyme disease by "a small group of physicians,
considered local or regional Lyme disease experts . . . despite the
lack of explicit clinical and laboratory evidence and the lack of
response to month after month of multiple antibiotic
therapies . . . ."
In the termination letter, Standard stated that it could
not "conclude that a Physical Disease has been identified as
defined by the policy." Furthermore, "[e]ven if [it was] to accept
the diagnosis of Lyme disease, the consulting physician noted that
the claimant may be able to work at this time if his psychiatric
issues were appropriately dealt with." Importantly, Standard
explained that it was "unable to conclude that Mr. Dutkewych
remains Disabled as the result of a Physical Disease or Injury and
since LTD Benefits payable for Disability caused or contributed to
by Substance Abuse, a Mental Disorder or Other Limited Conditions
are limited to 24 months, his claim will close with [Standard's]
payment through June 1, 2011."
Standard explained that Dutkewych could request a review
of Standard's decision within 180 days. With his request for
-13-
review, Dutkewych would have the right to submit additional
information in support of his claim.
5. Dutkewych's Request for Review
On October 20, 2011, Dutkewych administratively appealed
Standard's decision to limit his benefits to two years. He
attached letters from his wife, his in-laws, two of his brothers,
and two of his treating physicians.
Each of his family members explained Dutkewych's
struggles with Lyme disease over the past few years. His mother-
in-law stated that "Mark's limitations are both physical and
intellectual." She wrote that "his depression is clearly a
reaction to his pain and fatigue rather than an endogenous
depression." His brother attested that Dutkewych had "gone
thr[ough] significant physical and mental changes over the past 2
years." As an example, his father-in-law related that "Mark cannot
read a simple novel without getting confused and . . . need[ing] to
re-read the pages that he just read five minutes earlier."
Dr. Sheila Statlender, a clinical psychologist who had
been treating Dutkewych since March 2010, submitted a report dated
March 28, 2011. Dr. Statlender stated that Dutkewych "has not
abused substances" since they began treatment. Significantly, she
diagnosed him with "Mood Disorder Due to Neuroborreliosis (central
nervous system Lyme disease), with Depressive Features" and noted
his "ongoing symptoms of anxiety and depression."
-14-
Similarly, Dr. Ruiz's letter, dated August 21, 2011,
found Dutkewych to have mental disorders, and attributed them to
his diagnosis of Lyme disease. Amongst Dutkewych's persistent
symptoms, Dr. Ruiz listed cognitive limitations, depression, and
anxiety. But, Dr. Ruiz wrote that "[d]epression and anxiety cannot
explain Mr. Dutkewych's joint and muscle pain, headaches,
neuropathy, lack of endurance and worsening fatigue upon exercise.
These symptoms, and Mr. Dutkewych's clinical presentation, are
consistent with Lyme disease."
Dutkewych sent Standard an additional report from a
neuropsychologist, Dr. Leo Shea, following evaluations on May 21,
2011, and June 4, 2011. Dr. Shea concluded that Dutkewych's
"significant decline" in cognitive capacities "cannot be explained
by depression alone." He concluded that "the cause of Mr.
Dutkewych's cognitive difficulties is primarily based in the
resultant neurologic sequelae of Lyme disease with central nervous
system involvement." Dr. Shea noted that Dutkewych's "cognitive
reserve has also been impacted by his history of serial
concussions, . . . obsessive compulsive diagnosis, and the
medications prescribed to attenuate these diagnosed conditions."
In addition, Standard had received a letter from
Dutkewych, dated April 27, 2011, that summarized his own medical
condition. "Since first contracting Lyme Disease," Dutkewych
wrote, "my symptoms have clustered in four primary areas: extreme
-15-
fatigue and lethargy, intense joint pain, cognitive issues and
depression/anxiety. To date all of these issues persist." "Of all
of the symptom areas," Dutkewych identified the cognitive issues as
"often the most troubling." Although he used to handle complex
public bond financing at the law firm, he wrote that he was now
forgetful, easily overwhelmed, and struggled with reading
comprehension. "Finally, despite working with my therapist weekly
and taking anti-depressant medication, depression and anxiety
continue to be an issue." Dutkewych noted that "[i]t is consistent
with Lyme Disease to have mental health issues that are rooted in
the illness."
6. Standard's Denial After Administrative Review
Based on Dutkewych's request, Standard's Administrative
Review Unit reviewed Standard's decision to terminate Dutkewych's
LTD benefits after 24 months. As part of this process, the
Administrative Review Unit asked two independent physicians, who
had not been involved in the earlier decision, to review
Dutkewych's medical file. Specifically, the Administrative Review
Unit asked Dr. Raymond Dattwyler,3 an immunologist and
rheumatologist, to comment on the laboratory findings in
Dutkewych's medical file, the CDC criteria, and the assessment of
3
Dutkewych notes that, "[l]ike Dr. Sigal, Dr. Dattwyler has
a long history with Lyme disease, as a member of the [Infection
Disease Society of America] and an outspoken voice against the
existence of chronic Lyme."
-16-
Dutkewych's condition. The Administrative Review Unit also asked
Dr. Bob Gant, a clinical neuropsychologist, to review the
information related to Dutkewych's claimed cognitive deficits, and
the findings of Dr. Shea.
In a report dated March 12, 2012, Dr. Dattwyler concluded
that "Dutkewych simply did not have the clinical manifestations
that I would expect to see in a patient with Lyme disease."
Critically to Dr. Dattwyler, "Dutkewych's Lyme serologies are
negative and none meet the CDC criteria." Dr. Dattwyler
specifically rejected "any test results from a lab that does not
adhere to CDC guidelines," such as the IGeneX tests. "Simply
stated his negative serologies and his clinical picture strongly
support the finding that Mr. Dutkewych does not have Lyme disease
now and never did."
In a report dated April 5, 2012, Dr. Gant stated that he
was "unable to establish a psychological or neuropsychological
diagnosis with the available information." "In my opinion," Dr.
Gant wrote in an addendum report issued on April 20, "Dr. Shea
administered an insufficiently brief examination to support his
conclusions regarding a diagnosis of Chronic Lyme Disease, work-
related limitations related to this disease, and his ultimate
conclusions regarding impaired work functioning." Dr. Gant
-17-
recommended a comprehensive and forensically sophisticated
neuropsychological examination to verify a definitive diagnosis.4
Both consulting physicians questioned the existence of
chronic Lyme disease as a diagnosis in general. In his report, Dr.
Dattwyler cautioned that "there is no acceptable definition of
'chronic Lyme disease,'" and that "[i]t is not accepted as a
diagnosis by mainstream medicine." Instead, "[t]he term 'chronic
Lyme disease' is being applied to patients with vague complaints
most of who[m] have never had Lyme disease." Dr. Gant
"concur[red]" with Dr. Dattwyler's statement that chronic Lyme
disease is not accepted by mainstream medicine. "In fact," Dr.
Gant wrote in his report, "available medical information indicates
that there is not medical consensus that Lyme disease is a credible
diagnosis to offer an individual with this claimant's clinical
history."
On May 4, 2012, the Administrative Review Unit issued a
letter to Dutkewych's counsel to inform her that it had completed
4
In the review letter, the Administrative Review Unit noted
that it had contacted Dutkewych's counsel and "offered to arrange
for a neuropyschological examination at The Standard's expense"
after receiving Dr. Gant's assessment. The Administrative Review
Unit and Dutkewych's counsel had discussed that the results would
not likely change the prior determination "because The Standard did
not find that a diagnosis of Lyme disease was supported in Mr.
Dutkewych's case and because all of the other possible causes of
impairment that were suggested by Dr. Gant related to psychiatric
disorders or the treatment [Dutkewych] received for his psychiatric
disorders." "Given the above," Dutkewych's counsel declined to
pursue the evaluation.
-18-
its independent review. The Administrative Review Unit found that
"the correct decision was to close [Dutkewych's] claim as [of] June
1, 2011 under the Disabilities Subject to Limited Pay Periods
Provision" of his Plan.
In the review letter, the Administrative Review Unit
reiterated that "the Disabilities Subject to Limited Pay Periods
provision of the [Plan] limits payment of LTD Benefits to 24 months
during your entire life time for a Disability caused or contributed
to by any one or more of the following . . . : 1) Mental Disorders,
2) Substance Abuse, or 3) Other Limited Conditions." The
Administrative Review Unit then summarized, in detail, Dutkewych's
medical history, the evidence that he had submitted in support of
his claim that he was disabled as a result of Lyme disease, and the
reports of Standard's consulting physicians. In addition, the
Administrative Review Unit noted the controversy within the medical
community "regarding the diagnosis and treatment of Lyme disease."
The Administrative Review Unit concluded that "it is entirely
reasonable and, in fact, prudent that The Standard evaluate
disability claims in the context of mainstream medical opinion."
Relying on the assessments of Drs. Dattwyler and Gant,
and the consistent assessments of Drs. Sigal and Goldenberg, the
Administrative Review Unit concluded that Dutkewych was not
disabled "as a result [of] Lyme disease." "Rather," it stated,
"the available medical evidence supports that [Dutkewych]'s mental
-19-
health conditions in combination with his chronic pain condition
(fibromyalgia) and substance abuse are the most likely cause of his
reported symptoms." The Administrative Review Unit agreed with
Standard's earlier decision to limit Dutkewych's benefits to 24
months under the Limited Conditions Provision as a result. The
Administrative Review Unit explained:
Because we do not find evidence to support
that Mr. Dutkewych was impaired from
performing his Own Occupation as of June 1,
2011 by a physical disease or injury (which
was independent from his mental disorders,
substance abuse and fibromyalgia with possible
chronic fatigue), we have determined that Mr.
Dutkewych does not qualify for additional LTD
benefits from The Standard, and that his claim
must remain closed.
C. Present Litigation
Following Standard's decision to terminate LTD benefits
after 24 months, Dutkewych sought review in the District of
Massachusetts. In his First Amended Complaint, filed on September
27, 2012, he asserted that, "[a]t the end of the two year limited
pay period for disabilities caused or contributed to by a Mental
Disorder, Mr. Dutkewych was disabled due to the symptoms of Lyme
disease, a Physical Disease under the terms of the Plan."
Dutkewych sought enforcement of the terms of the Plan for unpaid
benefits, and attorneys' fees and costs. Both parties moved for
summary judgment.
The district court held that Standard did not abuse its
discretion when it concluded that Dutkewych was not disabled by
-20-
Lyme disease, and terminated his benefits after 24 months.
Dutkewych, 2014 WL 1334169, at *10-12. "[W]hile there is evidence
in the record supporting a diagnosis of Lyme disease or chronic
Lyme disease," the court stated, "there is still substantial
evidence in the record supporting otherwise, upon which Standard
relied in making its determination that Dutkewych was not disabled
by Lyme disease." Id. at *9. In reaching its conclusion, the
court noted the qualified consulting physicians' opinions as to
Dutkewych's diagnosis with chronic Lyme disease, id. at *10-11, as
well as the "substantial evidence . . . that Dutkewych suffered
from non-physical impairments, such as depression," id. at *12. As
a result, the district court granted Standard's motion for summary
judgment and denied Dutkewych's motion for summary judgment. Id.
at *14. This appeal followed.
II. Analysis
We review the district court's grant of summary judgment
de novo. Cusson v. Liberty Life Assurance Co. of Bos., 592 F.3d
215, 223 (1st Cir. 2010). Although Dutkewych assigns various
errors to the district court's decision, "we need not attend
separately to each of these arguments." Fire & Police Pension
Ass'n of Colo. v. Simon, 2015 WL 500748, at *10 (1st Cir. Feb. 6,
2015). It is sufficient to affirm if we reach the same conclusion
on any basis. See id.-21-
Like the district court, our review of Standard's
decision is deferential.5 See Dutkewych, 2014 WL 1334169, at *1
n.1. "Where, as here, the administrator of an ERISA plan is imbued
with discretion in the interpretation and application of plan
provisions, its use of that discretion must be accorded deference."
Colby v. Union Sec. Ins. Co. & Mgmt. Co. for Merrimack Anesthesia
Assocs. Long Term Disability Plan, 705 F.3d 58, 61 (1st Cir. 2013).
A reviewing court must uphold Standard's decision unless it is
"arbitrary, capricious, or an abuse of discretion."6 Ortega-
Candelaria v. Johnson & Johnson, 755 F.3d 13, 20 (1st Cir. 2014)
(internal quotation marks and citation omitted). Under this
standard of review, "the plan administrator's determinations must
be 'reasoned and supported by substantial evidence.' In short,
they must be reasonable." Colby, 705 F.3d at 62 (citation
omitted).
5
The conflict of interest in Standard's position as both the
claim administrator and the payer of benefits "does not alter the
standard of review, but rather is 'but one factor among many that
a reviewing judge must take into account.'" Ortega-Candelaria v.
Johnson & Johnson, 755 F.3d 13, 27 (1st Cir. 2014) (quoting Metro.
Life Ins. Co. v. Glenn, 554 U.S. 105, 116 (2008)).
6
We have previously noted that "'[f]or purposes of reviewing
benefit determinations by an ERISA plan administrator, the
arbitrary and capricious standard is functionally equivalent to the
abuse of discretion standard.'" D & H Therapy Assocs., LLC v. Bos.
Mut. Life Ins. Co., 640 F.3d 27, 34 n.5 (1st Cir. 2011) (quoting
Wright v. R.R. Donnelley & Sons Grp. Benefits Plan, 402 F.3d 67, 74
n.3 (1st Cir. 2005)).
-22-
Dutkewych argues that "the contemporaneous medical record
demonstrates convincingly that [he] was disabled as a result of
chronic Lyme disease in June 2011 and is entitled to benefits from
that date, forward." Under the terms of the Plan, however, whether
or not that argument is correct, "[p]ayment of LTD Benefits is
limited to 24 months during your entire lifetime for a Disability
caused or contributed to by . . . Mental Disorders." We need not
and do not decide whether chronic Lyme disease is a valid diagnosis
in general, or as applied to Dutkewych specifically. Even if
Dutkewych was disabled as a result of chronic Lyme disease in June
2011, Standard's decision to limit his benefits to 24 months based
on the Mental Disorder Limitation was not arbitrary or capricious.
Dutkewych raises three objections to the application of
the Mental Disorder Limitation in his case. First, Dutkewych
argues that the record lacks substantial evidence that a mental
disorder caused or contributed to his disability in June 2011, when
his benefits were terminated. Next, Dutkewych argues that
Standard's application of the Mental Disorder Limitation
contradicts the "Rules for Disabilities Subject to Limited Pay
Periods" set forth in the Plan. Finally, Dutkewych argues that
Standard's reliance on the Mental Disorder Limitation arose only in
litigation and should be disregarded as a post-hoc rationalization.
We address and reject each argument in turn.
-23-
A. Substantial Evidence for Limitation
The Mental Disorder Limitation applies if "Mental
Disorders" "cause[] or contribute[] to" the claimant's disability.
"Mental Disorder," in turn, is defined as:
[A]ny mental, emotional, behavioral,
psychological, personality, cognitive, mood or
stress-related abnormality, disorder,
disturbance, dysfunction or syndrome,
regardless of cause . . . or the presence of
physical symptoms.
In this case, there is substantial evidence that Dutkewych's mental
illness, whether or not related to chronic Lyme disease,
contributed to his disability as of June 2011.7 The contrary
argument is flatly contradicted by his own admissions and the
numerous medical opinions from both his own and other doctors.
Reports from Dutkewych's own treating physicians
establish that he had ongoing mental disabilities, in addition to
his physical symptoms, as of the period around June 2011. In a
report dated March 28, 2011, Dr. Statlender stated that Dutkewych
"continues to experience a range of both physical and emotional
7
The parties dispute whether it is Standard's burden to
prove that Dutkewych was subject to the limited pay period, or
Dutkewych's burden to prove that he was not. Under traditional
insurance law principles, "once an insured has met [his] initial
burden of proving that a claim falls within the grant of coverage,
the burden shifts to the insurer to show that an exclusion defeats
coverage." Gent v. CUNA Mut. Ins. Soc'y, 611 F.3d 79, 83 (1st Cir.
2010). We noted the difficulty of characterizing a similar mental
illness provision as an exclusion or as a limitation on the
continuation of benefits in Gent. Id. Here, as in Gent, we need
not decide how to allocate the burden of proof since Standard would
prevail regardless. See id.-24-
symptoms," including "ongoing symptoms of anxiety and depression,"
and diagnosed him with "Mood Disorder Due to Neuroborreliosis
(central nervous system Lyme disease), with Depressive Features."
Likewise, in a report dated August 21, 2011, Dr. Ruiz listed
cognitive limitations, depression, and anxiety amongst "Dutkewych's
persistent symptoms." Finally, in Dutkewych's 2011
neuropsychological evaluation, Dr. Shea wrote that Dutkewych's
"presenting symptoms" included cognitive limitations, "anxiety and
depression that impacts his mood," and "severe fatigue." Testing
revealed that "Dutkewych suffers from significant cognitive
deficits, which are consistent with neurological Lyme disease that
has gone untreated for a prolonged period of time, and which
significantly impacts his professional career and has restricted
his ability to continue working at his designated position."
In addition, Dutkewych's own letter to Standard on April
27, 2011, highlighted the mental disorders with which he struggled.
He stated that his symptoms fell into "four primary areas: extreme
fatigue and lethargy, intense joint pain, cognitive issues and
depression/anxiety." "To date all of these issues persist." "Of
all of the symptom areas," Dutkewych wrote, "the cognitive issues
are often the most troubling to me." Like his physicians,
Dutkewych ascribed his physical symptoms, cognitive issues, and
mental health issues to Lyme disease.
-25-
Dutkewych maintains that these "symptoms" of chronic Lyme
disease cannot form the basis for the Mental Disorder Limitation.
He argues that "[e]xperiencing depression derivative of a physical
condition and being disabled by a psychiatric disorder are two very
different animals." He stresses that his treating physicians did
not attribute his disability to his psychiatric conditions in June
2011.
The Mental Disorder Limitation, however, is broadly
written. The Limitation applies if a mental disorder, regardless
of its own cause, "caused or contributed" to a claimant's
disability. It is clear from Dutkewych's own evidence that mental
disorders, regardless of cause, continue to contribute to his
disability. This is sufficient to trigger the Mental Disorder
Limitation based on the facts of this case and the wording of this
Plan.
In Schwob v. Standard Insurance Co., 248 F. App'x 22(10th Cir. 2007), the Tenth Circuit reached the same conclusion
when faced with an almost identical limitation. "At best," the
claimant's evidence indicated that "a mental disorder, such as
depression, could be secondary to Lyme disease, which she may or
may not have." Id. at 28. The Tenth Circuit concluded that, even
so, Standard was reasonable in applying the Mental Disorder
Limitation. Id. at 29. The court explained:
[E]ven if we accept the premise that [the
claimant]'s mental disorder is secondary to a
-26-
physical illness, this would not prevent
Standard from applying the mental-disorder
limitation to her claim. The Plan's
definition of mental disorder includes mental
disorders 'regardless of cause.' As long as
[the claimant]'s mental disorder contributed
to her disability, the limitation would apply
even if the mental disorder resulted from Lyme
disease or another physical disease.
Id. The same logic applies to the case at hand.
B. Rules for Applying Limitation
Dutkewych attempts to limit the application of the Mental
Disorder Limitation by pointing to the "unique, explicit rules for
the application of the Mental Disorders, Substance Abuse and Other
Limited Conditions provision." The Limited Conditions Provision
limits payment of LTD benefits to "24 months during your entire
lifetime for a Disability caused or contributed to by . . . : (1)
Mental Disorders; (2) Substance Abuse; or (3) Other Limited
Conditions." The "Rules" for the application of the Limited
Conditions Provision state:
1. If you are Disabled as a result of a
Mental Disorder or any Physical Disease or
Injury for which payment of LTD Benefits is
subject to a limited pay period, and at the
same time are Disabled as a result of a
Physical Disease, Injury, or Pregnancy that is
not subject to such limitation, LTD Benefits
will be payable first for conditions that are
subject to the limitation.
2. No LTD Benefits will be payable after the
end of the limited pay period, unless on that
date you continue to be Disabled as a result
of a Physical Disease, Injury, or Pregnancy
for which payment of LTD Benefits is not
limited.
-27-
Dutkewych argues that the Rules envision payment of
benefits after two years even if physical non-limited conditions
exist contemporaneously with limited conditions. Under Dutkewych's
reading of Rule One, benefits must be paid first for a limited
condition, "even if a physical disability coexists." Rule Two then
requires the insurer to continue paying benefits after the limited
pay period if the physical disability continues at that point. He
argues that "[t]his is irrespective of the fact that the physically
disabling condition may have caused (or continue to cause)
disabling mental illness, as defined under the Plan, as benefits
have already been paid out for the mental illness aspect of the
disability." In essence, Dutkewych argues that the Mental
Disability Limitation ceases to apply after the first two years of
benefits by operation of the Rules.
Standard maintains that the Mental Disability Limitation
continues to apply after two years if a physical non-limited
condition co-exists with a limited condition. In other words, if
a claimant is disabled as a result of mental illness and physical
disease, Rule One requires benefits to be paid for conditions that
are subject to the limitation first. Rule Two allows benefits to
continue only if the claimant continues to be disabled by a
physical disease at the end of the limited pay period. However,
the general limitation still applies at the conclusion of the 24-
month period. The interaction of the general limitation and Rule
-28-
Two means that a claimant can receive benefits after the limited
pay period only if he continues to be disabled due to a physical
disease separate from any limited condition.
We emphasize again our deferential review in this case.
The Plan allows Standard "to interpret the Group Policy and resolve
all questions arising in the . . . interpretation . . . of the
Group Policy." Accordingly, "the plan administrator's
interpretation of the plan 'will not be disturbed if reasonable.'"8
Conkright v. Frommert, 559 U.S. 506, 521 (2010) (citation omitted).
Standard's interpretation of the Mental Disability Limitation and
the Rules governing its application is "by no means unreasonable
and so must prevail." See Wallace v. Johnson & Johnson, 585 F.3d
11, 15 (1st Cir. 2009).
Other words of the general limitation support the
reasonableness of Standard's interpretation. The Plan states that
"[p]ayment of LTD Benefits is limited to 24 months during your
entire lifetime for a Disability caused or contributed to by . . .
Mental Disorders." (Emphasis added.) Dutkewych's argument that
the Mental Disability Limitation ceases to operate after those 24
months is unpersuasive, particularly when the Rules say no such
thing. Rule Two states that benefits will not be paid after the
8
Neither the Supreme Court nor this court has "spoken
directly to how courts should assess whether an administrator's
construction of a plan term is so unreasonable as to constitute an
abuse of discretion." D & H Therapy Assocs., 640 F.3d at 36. We
need offer no further elucidation in this case.
-29-
limited pay period unless the claimant has a non-limited physical
disease, injury, or pregnancy at that time. This does not compel
the opposite conclusion that benefits will be paid after the
limited pay period even if the claimant continues to suffer from a
limited mental disability.
Standard's reading of the Rules is further supported by
its consistency with another provision in the Plan. Elsewhere, the
Plan states:
If a period of Disability is extended by a new
cause while LTD Benefits are payable, LTD
Benefits will continue while you remain
Disabled. However . . . [t]he Disabilities
Excluded From Coverage, Disabilities Subject
To Limited Pay Periods, and Limitations
sections will apply to the new cause of
Disability.
In effect, Dutkewych is asking to extend his period of payments for
disability beyond 24 months due to a physical disease instead of
limited conditions. The Plan explicitly specifies that the Limited
Conditions Provision, and the subsumed Mental Disability
Limitation, will continue to apply.
C. Post-Hoc Rationalization
As a final salvo, Dutkewych mistakenly argues that
Standard's broad interpretation of the Mental Disability Limitation
"was never raised during the internal appeals process and stands in
direct contradiction to Standard's interpretation of the provision
at that time." Dutkewych urges us to "reject [Standard's] analysis
as a post-hoc rationalization undeserving of deference" under our
-30-
logic in Glista v. Unum Life Insurance Co. of America, 378 F.3d 113(1st Cir. 2004).
In Glista, we held an insurer to its explanation for
denying benefits articulated during its internal claims review
process. 378 F.3d at 132. There, the insurer had raised two bases
for its denial of relief in litigation -- the Treatment Clause and
the Symptoms Clause. Id. at 126. Our review of the record
revealed that the insurer had never relied on the Symptoms Clause
during its internal review process, and that "a reasonable
participant would have understood the denial to rest on the
Treatment Clause alone." Id. at 129. We held that reviewing
courts have "a range of options available" in such circumstances.
Id. at 116. In that case, we barred the insurer's argument on the
Symptoms Clause as a post-hoc rationalization. Id. at 128, 131.
According to Dutkewych, the same result is warranted
here. Dutkewych contends that, "[p]rior to litigation, Standard's
sole defense was that chronic Lyme does not exist as a disease."
Moreover, "[t]he only inquiry during the internal appeals process
was the cause of Mr. Dutkewych's disabling symptoms, and not
whether a limited condition caused or contributed to his
disability; in fact, this analysis was never once cited by Standard
during its review." This claim is contradicted by the
administrative record.
-31-
Standard has repeatedly stressed that Dutkewych's Plan
"limits payment of LTD Benefits to 24 months during [the
claimant]'s entire lifetime for a Disability caused or contributed
to by Mental Disorders, Substance Abuse or Other Limited
Conditions." In both its April 26, 2011, termination letter, and
its May 4, 2012, review letter, Standard explicitly premised its
decision on the Limited Conditions Provision.
In its original termination letter to Dutkewych, Standard
clearly explained the operation of the Limited Conditions Provision
and its reliance on the same. Standard wrote in the opening
paragraph:
Because the [Plan] limits payments for
Disability caused or contributed to by a
Mental Disorder, in order to continue to
receive LTD Benefits, Mr. [Dutkewych] must be
Disabled by a Physical Disease or Injury. The
Physical Disease(s) or Injury(ies) must be so
severe as to cause Disability in the absence
of Substance Abuse, a Mental Disorder or Other
Limited Condition.
(Emphasis added). In its analysis, Standard rejected Dutkeywch's
diagnosis of Lyme disease, but identified mental disorders as an
alternative basis for rejection of his disability claim in any
case:
Based on the information in the claim file, we
cannot conclude that a Physical Disease has
been identified as defined by the policy.
Even if we were to accept the diagnosis of
Lyme disease, the consulting physician noted
that the claimant may be able to work at this
-32-
time if his psychiatric issues were
appropriately dealt with.
Because Standard concluded that Dutkewych was not disabled as a
result of a physical disease, and because LTD Benefits are limited
for a "Disability caused or contributed to by" limited conditions,
Standard closed his claim on June 1, 2011.
In its subsequent review letter, Standard again rejected
Dutkewych's claim that he was disabled as a result of Lyme disease
and stressed the evidence of limited conditions in the record.
Standard wrote:
Based on a comprehensive review of all of the
information in Mr. Dutkewych's claim file, we
find that the available evidence does not
support that Mr. Dutkewych has been precluded
from performing his Own Occupation as a result
[of] Lyme disease. Rather the available
medical evidence supports that your client's
mental health conditions in combination with
his chronic pain condition (fibromyalgia) and
substance abuse are the most likely cause of
his reported symptoms.
That Standard's language suggested that limited conditions caused,
rather than merely contributed to, Dutkewych's disability is of no
moment since its reliance on the Limited Conditions Provision is
unassailable. In the very next sentence, Standard reiterated the
application of the Limited Conditions Provision to Dutkewych's
case:
Because we do not find evidence to support
that Mr. Dutkewych was impaired from
performing his Own Occupation as of June 1,
2011 by a physical disease or injury (which
was independent from his mental disorders,
-33-
substance abuse and fibromyalgia with possible
chronic fatigue), we have determined that Mr.
Dutkewych does not qualify for additional LTD
benefits from The Standard, and that his claim
must remain closed.
(Emphasis added).
Standard's reliance on and interpretation of the Limited
Conditions Provision took place before there was any litigation and
Dutkewych had adequate notice during the administrative process.
Indeed, when Standard offered to pursue additional
neuropsychological testing during the administrative review
process, Dutkewych's counsel refused specifically because the
results of such testing would support the already-imposed Limited
Conditions Provision, "and, thus, would not change the prior
determination on Mr. Dutkewych's claim." This case is a far cry
from Glista, in which the insurer articulated an entirely new basis
for the denial of benefits for the first time in litigation. See
378 F.3d at 129.
III. Conclusion
We conclude that Standard's limitation of Dutkewych's
benefits to 24 months was not arbitrary or capricious given the
substantial evidence in the record that mental disorders,
regardless of their cause, contributed to his disability as of June
1, 2011. We affirm the grant of summary judgment in favor of
Standard.
So ordered.
-34-