Susan Till v. Lincoln National Life Insurance Company , 678 F. App'x 805 ( 2017 )

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[DO NOT PUBLISH]
IN THE UNITED STATES COURT OF APPEALS
FOR THE ELEVENTH CIRCUIT
________________________
No. 16-14799
Non-Argument Calendar
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D.C. Docket No. 2:14-cv-00721-WKW-WC
SUSAN TILL,
Plaintiff-Appellant,
versus
LINCOLN NATIONAL LIFE INSURANCE COMPANY,
Defendant-Appellee,
GILLIARD HEALTH SERVICES, INC. DISABILITY PLAN, et al.,
Defendants.
________________________
Appeal from the United States District Court
for the Middle District of Alabama
________________________
(January 30, 2017)
Before JULIE CARNES, JILL PRYOR, and ANDERSON, Circuit Judges.
PER CURIAM:
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Plaintiff-appellant Susan Till (“Till”) filed suit pursuant to the Employee
Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C. § 1001 et seq.,
challenging the decision of defendant-appellee Lincoln National Life Insurance
Company (“Lincoln”) to deny her claim for long-term disability benefits. Lincoln
filed a motion for judgment as a matter of law to which Till responded with a
motion for summary judgment. After full briefing, the district court entered an
order granting Lincoln’s motion and denying Till’s. The district court also
subsequently denied Till’s motion to reconsider. After careful consideration of the
record on appeal, the parties’ briefs, and the relevant law, this Court concludes that
the decision is due to be affirmed.
I. Background
Till was previously employed as a radiology technologist by an employer
who purchased long-term disability insurance through Lincoln for its employees.
Till has a long history of back problems and has not worked since December 5,
2012, when she exacerbated her back condition. Till applied for long-term
disability benefits under the plan and Lincoln denied the claim. She
administratively appealed the decision twice, and Lincoln upheld the denial of
benefits on both appeals. Till then brought an ERISA suit in the Middle District of
Alabama challenging Lincoln’s denial of her claim. On dispositive cross-motions
the district court entered an exceptionally detailed seventy-four-page judgment in
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favor of Lincoln and against Till. The district court then denied several
postjudgment motions by Till, including a motion to reconsider. This appeal
followed.
II. Discussion
We begin by first examining Till’s claim that Lincoln’s decision was
arbitrary and capricious before turning to consideration of her claim that she was
denied a full and fair review. We review de novo a district court’s decision to
affirm a plan administrator’s ERISA benefits determination, applying the same
legal standards that governed the district court’s decision. Blankenship v. Metro.
Life Ins. Co., 644 F.3d 1350, 1354 (11th Cir. 2011).
A. The Administrator’s Decision—Arbitrary and Capricious Review
Although ERISA does not provide the standard by which courts are to
review the decisions of plan administrators, we have established the following six-
step framework:
(1) Apply the de novo standard to determine whether the claim
administrator’s benefits-denial decision is “wrong” (i.e., the court
disagrees with the administrator’s decision); if it is not, then end the
inquiry and affirm the decision.
(2) If the administrator’s decision in fact is “de novo wrong,” then
determine whether he was vested with discretion in reviewing claims;
if not, end judicial inquiry and reverse the decision.
(3) If the administrator’s decision is “de novo wrong” and he was
vested with discretion in reviewing claims, then determine whether
“reasonable” grounds supported it (hence, review his decision under
the more deferential arbitrary and capricious standard).
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(4) If no reasonable grounds exist, then end the inquiry and reverse
the administrator’s decision; if reasonable grounds do exist, then
determine if he operated under a conflict of interest.
(5) If there is no conflict, then end the inquiry and affirm the decision.
(6) If there is a conflict, the conflict should merely be a factor for the
court to take into account when determining whether an
administrator’s decision was arbitrary and capricious.
Blankenship, 644 F.3d at 1355 (citing Capone v. Aetna Life Ins. Co., 592 F.3d
1189, 1195 (11th Cir. 2010)). 1
At step four of our test, a conflict of interest exists “where the ERISA plan
administrator both makes eligibility decisions and pays awarded benefits out of its
own funds.” Id. (citing Metro. Life Ins. Co. v. Glenn, 554 U.S. 105, 112, 128 S. Ct.
2343, 2348 (2008)). Even if a conflict exists and, accordingly, a court reaches step
six, “the burden remains on the plaintiff to show the decision was arbitrary; it is
not the defendant’s burden to prove its decision was not tainted by self-interest.”
Doyle v. Liberty Life Assurance Co. of Bos., 542 F.3d 1352, 1360 (11th Cir.
2008). The severity of the conflict and the nature of the case will determine the
effect that a conflict of interest has in any given case and, accordingly, we look to
the conflict’s “inherent or case-specific importance.” Blankenship, 644 F.3d at
1355 (citing Glenn, 544 U.S. at 117, 128 S. Ct. at 2351–52).
1
In the context of ERISA cases, the phrases “arbitrary and capricious” and “abuse of
discretion” are used interchangeably. See Blankenship, 644 F.3d at 1355 n.5 (citing Jett v. Blue
Cross & Blue Shield of Ala., Inc., 890 F.2d 1137, 1139 (11th Cir. 1989)).
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Although courts must account for a structural conflict of interest, when one
exists, as “a factor” in the arbitrary and capricious review process, the basic
analysis still centers on whether a reasonable basis existed for the administrator’s
decision. See id. (citing Conkright v. Frommert, 559 U.S. 506, 521, 130 S. Ct.
1640, 1651 (2010) (“[T]he plan administrator’s interpretation of the plan ‘will not
be disturbed if reasonable.’ ”)). As both this Court and the Supreme Court have
noted, “the presence of a structural conflict of interest [is] an unremarkable fact in
today’s marketplace [and] constitutes no license, in itself, for a court to enforce its
own preferred de novo ruling about a benefits decision.” Id. at 1356; see also
Glenn, 544 U.S. at 120, 128 S. Ct. at 2353 (“The conflict of interest . . . is a
common feature of ERISA plans.”) (Roberts, C.J., concurring in part and
concurring in the judgment).
Lincoln concedes on appeal that the “ultimate issue for this Court . . . is
whether Lincoln’s decision to deny Till’s claim for benefits was at least a
reasonable [one]” and accordingly we will forego an analysis of whether the
administrator’s decision was de novo wrong under the first prong of our analysis.
Likewise, it seems clear to us at the second step—and Till does not credibly
dispute—that Lincoln had the discretionary authority under the clear language of
the policy “to manage th[e] Policy, interpret its provisions, administer claims and
resolve questions arising under it.” Accordingly, we will begin our analysis at step
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three and determine whether Lincoln’s decision to deny the claim was arbitrary
and capricious.
We have little trouble concluding that Lincoln’s final decision in this case
was reasonable. 2 The plan at issue in this case placed the burden on Till to provide
adequate documentation to support her claim. 3 Lincoln adequately considered all
of the medical information that had been submitted by Till and gathered through
Lincoln’s own independent investigation to conclude—with the concurrence of
two independent and board-certified specialists—that Till had failed to make a
sufficient showing of disability under the plan.
While we certainly take notice of the differing opinions offered by the
doctors for both Till and Lincoln, nothing in the record suggests to us that the
administrator’s decision to afford more or less weight to those opinions was
arbitrary and capricious. See Slomcenski v. Citibank, N.A., 432 F.3d 1271, 1279–
80 (11th Cir. 2005) (“Giving more weight to the opinions of some experts than to
2
This Court, in line with several other Circuit Courts of Appeal, will consider only the
reasonableness of an administrator’s final decision. See, e.g., Glazer v. Reliance Standard Life
Ins. Co., 524 F.3d 1241, 1245 (11th Cir. 2008) (holding that production of documents is required
only after “a final decision is reached”); see also, e.g., Khoury v. Group Health Plan, Inc., 615
F.3d 946, 952 (8th Cir. 2010) (“Courts reviewing a plan administrator’s decision to deny benefits
will review only the final claims decision . . . .”).
3
Despite not being obligated to do so, Lincoln apparently attempted to gather some
medical documentation relating to Till’s claim on their own. Any shortcomings in their attempts
to do so—which Till points to repeatedly on appeal—should have been apparent to Till before
the final decision was made. Therefore, even assuming—which we do without deciding—that
Lincoln’s mistakes initially led to some information being omitted from her file, Till still had the
opportunity and the obligation to supplement that information before a final decision was
reached.
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the opinions of other experts is not an arbitrary or capricious practice.”). This
includes Till’s disagreement with, among other things: (1) Lincoln’s treatment of a
medical opinion that she could not undergo a physical exam; (2) Lincoln’s
determination that her condition was not surgical in nature; and (3) Lincoln’s
determination that she was capable of light work.4 In light of the entire
administrative record, there is simply no evidence by which we could conclude that
the administrator’s conclusion was arbitrary and capricious.
Additionally, the description of Till’s occupation was committed to the
sound discretion of the administrator to be determined with reference to how it is
“performed in the national workforce; not as performed for a certain firm or at a
certain work site.” Even assuming that Lincoln’s classification of Till’s occupation
was based entirely on the much-maligned Dictionary of Occupational Titles
(“DOT”), 5 this Court—along with several other circuit courts—has held that
Lincoln was entitled to rely on the occupational descriptions contained therein. See
Stiltz v. Metro. Life Ins. Co., 244 F. App’x 260, 2007 WL 1600036, at *3 (11th
Cir. June 5, 2007) (holding that where “[t]he clear plan language allowed [the
administrator] to look beyond the requirements of ‘the specific position’ [plaintiff]
4
This list is meant to be illustrative only and is not an exhaustive catalogue of the full
scope of Till’s disagreements with Lincoln’s conclusions.
5
It is worth noting that the district court found that “Lincoln had considered Plaintiff’s
written job description, her employer’s description of Plaintiff’s job duties, and the description of
her occupation from the Department of Labor’s Dictionary of Occupation Titles (‘DOT’) to
determine the material and substantial duties of Plaintiff’s occupation.”
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held, [the administrator] was entitled to rely on the Dictionary of Occupational
Titles”). Given that Lincoln was contractually required to consider the manner in
which this job is performed in the national workforce, its decision to credit the
DOT over Till’s personal experience was not only reasonable, it was undeniably
correct. Moreover, and despite its flaws, we see no reason why Lincoln should
have been required to give more credit to the resources Till cites on appeal than to
the DOT. Once again, we will not disturb an administrator’s decision to credit one
piece of evidence over another without evidence that they abused the discretion
that had been committed to them.
Lastly, considering Lincoln’s conflict of interest as a factor at the final stage
of our analysis,6 we cannot conclude that the conflict rendered the decision
arbitrary and capricious. Lincoln’s conflicts of interest are typical of the insurance
industry and we have previously rejected attempts to prove that a benefits
“decision was tainted by self-interest” based on these standard industry practices.
See Blankenship, 644 F.3d at 1357 (“[W]e are not persuaded that the record in this
case shows that the conflict itself or the large size of [plaintiff’s] requested claims
create sufficient concern for a court to deem [the insurer’s] benefits decisions
6
Till urges this Court to reconsider the order of our six-step ERISA test and to conduct the
conflict-of-interest analysis before determining if the administrator’s decision was arbitrary and
capricious at step three. Even if we were inclined to modify the test, which we are not, we are not
at liberty to do so here. See United States v. Hanna, 153 F.3d 1286, 1288 (11th Cir. 1998) (“In
this circuit, only the court of appeals sitting en banc, an overriding United States Supreme Court
decision, or a change in the statutory law can overrule a previous panel decision.”).
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arbitrary and capricious.”); see also Leipzig v. AIG Life Ins. Co., 362 F.3d 406,
409 (7th Cir. 2004) (“[M]ost insurers are well diversified, so that the decision in
any one case has no perceptible effect on the bottom line. There is correspondingly
slight reason to suspect that they will bend the rules.”); Marrs v. Motorola, Inc.,
577 F.3d 783, 787 (7th Cir. 2009) (noting that an administrator’s financial interests
in maintaining a reputation for “fair dealing” may deter claim denials). Lincoln’s
conflicts are simply not of such a severity that they will turn an otherwise
reasonable decision into an arbitrary and capricious one.
B. Full and Fair Review
Till also alleges that Lincoln did not provide her a full and fair review of its
denial of benefits as required by ERISA. 7 An administrator of an ERISA plan is
statutorily required to “afford a reasonable opportunity to any participant whose
claim for benefits has been denied for a full and fair review . . . of the decision
denying the claim.” 29 U.S.C. § 1133(2) (2009). We have noted that an
“administrator must ‘[p]rovide . . . upon request . . . all documents, records, and
other information relevant to the claimant’s claim for benefits’ to qualify as a ‘full
and fair review.’ ” Glazer v. Reliance Standard Life Ins. Co., 524 F.3d 1241, 1245
(11th Cir. 2008) (quoting 29 C.F.R. § 2560.53-1(h)(2)(iii)). In order for a review
7
Till’s specific allegations are that Lincoln (1) failed to obtain evidence it told her it would
retrieve, (2) failed to inform her that this information had not been obtained, (3) failed to provide
evidence to its reviewers that was in its possession, (4) prematurely denied her claim, (5) failed
to conduct a reasonable investigation, and (6) failed to explain the meaning of “physical exam.”
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process to be “full and fair,” the procedures must “[p]rovide for a review that takes
into account all comments, documents, records, and other information submitted
by the claimant relating to the claim, without regard to whether such information
was submitted or considered in the initial benefit determination.” 29 C.F.R.
§ 2560.53-1(h)(2)(iv); see also Glazer, 524 F.3d at 1245. An administrator must
have substantial support to deny benefits and must promptly notify a plan
participant,
in writing and in language likely to be understood by laymen, that the
claim has been denied with the specific reasons therefor. The
[administrator] must also inform the participant of what evidence he
relied upon and provide him with an opportunity to examine that
evidence and to submit written comments or rebuttal documentary
evidence.
Grossmuller v. Int’l Union, United Auto. Aerospace & Agric. Implement Workers
of Am., 715 F.2d 853, 857–58 (3d Cir. 1983).
As the district court exhaustively catalogued, Till’s conclusory allegation
that she was denied a full and fair review of her claim are without support in the
record. Lincoln provided Till with written notice of its decision—and the basis
therefor—and provided her with a meaningful opportunity to dispute its findings.
Rather than taking the opportunity to submit additional medical evidence prior to
Lincoln’s final decision, Till responded to this notice by focusing almost entirely
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on the documentation that had already been provided. 8 Those arguments, which are
largely echoed on appeal here, speak to the merits of a decision which, we have
already decided above, was reasonable.
III. Conclusion
Given the deference that this Court owes to the discretionary decisions of a
plan administrator, we cannot conclude that the denial of benefits was an abuse of
discretion or that the procedures adopted by Lincoln denied Till a full and fair
review. 9 Accordingly, the well-reasoned decision of the district court is
AFFIRMED.
8
Having provided Till with a notice of its decision and the basis therefor, Lincoln’s
procedures easily overcome the first five of Till’s complaints on appeal. See supra note 7. As to
the final complaint on appeal—regarding Lincoln’s use of the term “physical exam”—Till’s
argument that her response letter “took issue with the vague, undefined term” is, at best, an
overstatement. The letter Till references in making this argument mentions the term “physical
exam” only in passing and never requests clarification as to what evidence might satisfy Lincoln
in this regard. In any event, any lack of clarity that may have arisen from Lincoln’s use of this
term does not rise to the level of harm that would have deprived Till of a “full and fair” review.
9
For the same reason, we cannot conclude that the district court’s decision to deny Till’s
motion for reconsideration was an abuse of discretion. To the extent that any of Till’s assertions
in that motion were properly before the district court—something we need not consider—the
court was well within its discretion to deny the motion.
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