Gorski v. ITT Long Term Disability Plan for Salaried Employees , 314 F. App'x 540 ( 2008 )

UNPUBLISHED
UNITED STATES COURT OF APPEALS
FOR THE FOURTH CIRCUIT
No. 07-1063
JANET R. GORSKI,
Plaintiff - Appellant,
v.
ITT LONG TERM DISABILITY PLAN FOR SALARIED EMPLOYEES;
METROPOLITAN LIFE INSURANCE COMPANY,
Defendants - Appellees.
Appeal from the United States District Court for the Eastern
District of North Carolina, at Greenville. James C. Dever III,
District Judge. (7:05-cv-00150-D)
Argued: September 24, 2008 Decided: November 3, 2008
Before MICHAEL and TRAXLER, Circuit Judges, and Richard L.
VOORHEES, United States District Judge for the Western District
of North Carolina, sitting by designation.
Reversed and remanded by unpublished per curiam opinion. Judge
Traxler wrote an opinion concurring in part and dissenting in
part.
ARGUED: Andrew O. Whiteman, HARTZELL & WHITEMAN, L.L.P.,
Raleigh, North Carolina, for Appellant. Theresa Jeszeck Baker,
METLIFE, Long Island City, New York, for Appellees. ON BRIEF:
Stephen A. Dunn, EMANUEL & DUNN, P.L.L.C., Raleigh, North
Carolina, for Appellees.
Unpublished opinions are not binding precedent in this circuit.
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PER CURIAM:
Janet R. Gorski appeals a district court order denying her
motion for summary judgment and granting summary judgment
against her in her action against the ITT Long Term Disability
(“LTD”) Plan for Salaried Employees (“the Plan”) and
Metropolitan Life Insurance Company (“MetLife”), alleging
wrongful termination of her LTD benefits. We reverse and remand
to the district court with instructions to reinstate Gorski’s
benefit award and consider her claims for prejudgment interest
and an award of attorney’s fees and costs.
I.
Gorski worked as a secretary at ITT Automotive in Auburn
Hills, Michigan, until February 1998. While at ITT, she
participated in the Plan, which provides LTD benefits. MetLife
insures the Plan and serves as claims administrator with
“discretionary authority to interpret the terms of the Plan and
to determine eligibility for and entitlement to Plan benefits in
accordance with the terms of the Plan.” J.A. 500. To qualify
for LTD benefits, participants must be “Totally Disabled,” which
the Plan defines as follows:
1) During the six-month qualifying period plus the
first 12 months in which you receive LTD benefits, you
are considered Totally Disabled if you are unable to
perform the regular duties of your occupation while
3
under the continuous and appropriate care of a
licensed physician and you are not employed elsewhere.
2) After the first 12 months in which you receive LTD
benefits, Total Disability means you are unable to
engage in any and every duty pertaining to any
occupation or employment for wage or profit for which
you are qualified, or become reasonably qualified by
training, education or experience.
J.A. 490. In order to continue to receive LTD benefits under
the Plan, participants must regularly submit proof of continued
disability.
In October 1997, Gorski received treatment from Dr. Young
Seo for “severe lower back pain” that she reported as resulting
from lifting her leg as she tried to put on her pants. J.A. 79.
She claims this injury was a reaggravation of a previous injury
that happened in early 1977 when she fell outside of ITT. Dr.
Seo diagnosed Gorski as having L5 nerve root irritation, a
bulging disc, and inflammation of the joint between L4 and L5,
and he treated her with spinal injections. Gorski missed
approximately one month of work, then returned to work for
approximately nine weeks before suffering a recurrence of her
symptoms on February 6, 1998. An MRI dated that day showed two
herniated discs. As a result, she received special injections,
pain medication, and physical therapy. She did not return to
work again.
Gorski applied for LTD benefits on August 11, 1998. Dr.
George R. Shell, a neurosurgeon, stated in an Attending
4
Physician Statement (“APS”) that Gorski had two herniated discs
and was scheduled for “lumbar cage fusion” surgery on August 18,
1998, which would render her “unable to perform any type of work
for at least 6 months.” J.A. 133-34. Shortly thereafter,
MetLife approved Gorski’s claim, as of August 11, 1998.
Nearly two months after the surgery, Gorski informed
MetLife that she was experiencing “[n]umb feet, legs & low back
nerve spasms [with] shooting pain down both legs” and that she
could not lift more than two pounds, sit for more than 30
minutes, or walk for a very long time without “excessive pain”
in her legs and lower back. J.A. 136. Dr. Schell reported that
Gorski had been doing very well until December 1998, when during
a bout with vomiting, she “felt something pop in her back” and
began having pain in her right leg and back. J.A. 310. On
March 19, 1999, Dr. Schell noted that Gorski “still seems quite
symptomatic.” J.A. 177. In that regard, Gorski reported that
although her legs were feeling better, she had burning pain in
her hips when she walked and discomfort when she sat as well.
Gorski underwent an MRI examination on June 22, 1999.
Meanwhile, Dr. Schell had provided MetLife in May 1999 with
his office notes, discharge records relating to the August 1998
surgery, and radiological reports. This prompted MetLife, on
July 27, 1999, to approve a continuance of Gorski’s LTD benefits
on the basis that she was unable to perform any occupation for
5
which she was qualified. Dr. Schell treated Gorski with
epidural injections and physical therapy until she moved to
North Carolina in December 1999.
In September 1999, MetLife arranged for an independent
medical examination of Gorski by Dr. Robert S. Levine, an
orthopedic surgeon. After examining Gorski and reviewing her
medical records, Dr. Levine diagnosed “status post laminectomy
and anterior fusion (cages) for ruptured disc” and “chronic pain
syndrome with significant depression.” J.A. 212. He
recommended that Gorski receive treatment at a multidisciplinary
pain center offering pain management, that she participate in a
functional reactivation program, and that she receive
psychological therapy. He determined that Gorski should be
capable of performing sedentary activities that involve no
bending and do not require her to lift more than five pounds.
He believed that she could have a functional capacities
evaluation and noted that he “felt that there are significant
ongoing psychological factors which would interfere with her
ability to perform and to return to gainful employment.” J.A.
212. Responding to Dr. Levine’s opinion, Dr. Schell informed
MetLife that while he did not reject Dr. Levine’s treatment
recommendations, he believed that Gorski might also need further
surgery sometime in the future.
6
When Gorski subsequently moved to North Carolina, she began
receiving treatment from Dr. George Huffmon, a neurosurgeon. On
June 15, 2000, Gorski underwent a CT scan, flexion/extension
scan, and bone scan. Reviewing the results, Dr. Huffmon
concluded that Gorski’s “4/5 right cage is kicked out laterally”
and seemed to be compressing at least one nerve root and
possibly two. J.A. 348. He recommended physical therapy and
surgery to have “pedicle screws from 4 to S1 and attempt to get
the cage out if we can’t clamp it down and put it back in
position.” J.A. 348. He noted, though, that Gorski was “very
reluctant” to undergo another surgery. J.A. 347. After
examining Gorski again on December 28, 2000, Dr. Huffmon
concluded that her pain was still preventing her from returning
to work. He sent her for a second opinion regarding possible
surgery to Dr. Mark Rodger, who determined that she was not a
good candidate for surgery and turned her care over to a primary
care physician and pain management specialist.
On May 25, 2001, MetLife asked Gorski for additional
information concerning her treatment. Gorski wrote that she
suffered from “spas[]ming in [her] low[er] back, shooting pain
into [her] right leg, [a] numb right foot, [and] stinging pain
in [her] toes.” J.A. 259. She also reported that her right leg
was weak, she could not lift it very much, and that it would
give out, causing her to fall if she did not have someone or
7
something to support her. She noted that, since her surgery,
she had been depressed and suffered irritable bowel syndrome,
increased occurrences of dizziness, and urinary incontinence.
She also wrote that no accommodation would allow her to return
to work because she could not “even clean [her] house or lift
groceries” and that even “holding a full gallon of milk is a
chore.” J.A. 261. She stated that she “ha[s] to lay down in a
fetal position to take the pressure off . . . when [she]
stand[s] for 20-25 min[utes,] sometimes even less.” J.A. 261.
She stated that she could not “believe how everything has a tie
to [her] lower back.” J.A. 261 (emphasis in original).
As part of its ongoing review, MetLife also conducted
videotape surveillance of Gorski. MetLife’s investigator filmed
Gorski on August 28, 2001, leaving her home, driving to a
grocery store, and shopping with another female and child
without visible medical aides or devices, before driving home.
Gorski’s gait appeared normal, and she did not appear to be in
pain. On October 9, 2001, he observed her watering plants in
her front yard, which included her carrying gallon jugs of water
in each hand and bending at the knees and at the waist to pour
water from the jugs, again without any apparent pain or
difficulty.
MetLife also reviewed an APS from Dr. Huffmon, dated August
2, 2001, diagnosing “L4-5 radiculopathy, post laminectomy
8
syndrome” and again indicating his view that treatment should
include “fusion [with] pedicle screws.” J.A. 268. Dr. Huffmon
concluded that Gorski was “[u]nimproved” and disabled for any
occupation. J.A. 269. He listed restrictions for all
activities except grasping, handling, finger dexterity, and
concentrated visual attention.
Dr. William J. Faircloth also completed an APS form in
January 2002. Like Dr. Huffmon, he concluded that Gorski’s
nerve root compression, resulting in lower back pain, right leg
pain, and numbness, rendered her disabled for any occupation.
He noted that even her sitting ability was limited.
On April 16, 2002, MetLife sought clarification from Dr.
Faircloth regarding his conclusion that Gorski’s ability to sit
was limited, asking in particular whether Gorski could “sit for
45 minutes, break, and resume sitting for another 45 minutes,
through[]out an 8 hour work day” and, if she could not, to
specify her sitting capability. J.A. 408. Dr. Faircloth
responded that he was unable to make that determination. When
MetLife asked for clarification, Dr. Faircloth’s office
responded that he could not answer the questions because he had
not seen Gorski often enough. At his most recent examination of
her, on February 13, 2002, he had noted that she was exercising
regularly and had no new or specific complaints.
9
MetLife subsequently informed Gorski, via a letter dated
June 4, 2002, that it was terminating her benefits as of that
date since she was no longer disabled within the meaning of the
Plan. The letter referenced Dr. Faircloth’s inability to
determine the extent of her sitting limitations, the fact that
she was regularly exercising on February 13, 2002, and the
investigator’s surveillance report. It also noted her
vocational history, including her associate degree in business
administration and her strong background in administrative,
secretarial, and bookkeeping jobs. Considering the skills
needed to be an administrative assistant and that the job is
“sedentary and require[s] lifting, carrying, pushing and pulling
of [only] 10 pounds occasionally,” J.A. 288, MetLife concluded
that Gorski could perform her prior job. The letter recommended
that if Gorski appealed the decision, she should provide recent
physical exam findings, recent diagnostic testing results, her
current treatment plan and response, restrictions and
limitations preventing her from working, her prognosis for when
she could return to work, and any other information or
documentation that would support a finding of disability.
Gorski appealed her benefits termination on September 19,
2002, submitting additional medical records, including, among
other things, office notes of an outpatient consultation in July
2000 with neurosurgeon Thomas Melin, who noted that “the L4/5
10
cage on the right appears to be somewhat laterally displaced and
posteriorly displaced.” J.A. 306. On December 4, 2002, Gorski
sent MetLife a note from Dr. Huffmon stating that Gorski “can
sit for 45 minutes and take a 10 minute break to lay down [and]
then resume sitting for up to 4 hours a day—there is No Job this
woman can perform.” J.A. 408 (emphasis in original). Gorski
also sent MetLife notes from Dr. Richard Leighton regarding his
examination of her on August 8, 2002. He wrote that “[m]anual
motor strength testing showed some weakness of the plantar
flexors and dorsiflexors on the right which are 4/5. She has
point tenderness over the trochanteric bursa on the left but has
reasonable fluid ROM.” J.A. 409. He also reported that x-rays
showed “a bit of posterior displacement of one of the cages.”
J.A. 409. He noted, concerning her history, that she had
“numbness, weakness, prior fractures, back pain, ringing in her
ears, blood in her stool, lumps, balance problems, depression,
sleep disorder, and easy bruising.” J.A. 411. He added that
Gorski walks with a cane and has “[p]ain [that] comes and goes.”
J.A. 411. He described her as “[w]alk[ing] with an antalgic
gait and slightly off balance.” J.A. 411.
MetLife subsequently referred Gorski’s file on December 23,
2002, to Network Medical Review for an independent physician
consultation review. Dr. M. Marc Soriano reported conducting a
“thorough review” of the medical records MetLife had provided
11
him. J.A. 426. He specifically discussed the September 13,
1999, examination performed by Dr. Levine and the notes from Dr.
Leighton’s August 8, 2002, examination, stating about them that
Gorski’s “subjective complaints have remained significant
despite the fact that the objective exams are unremarkable.”
J.A. 426. Dr. Soriano concluded that Gorski’s “examinations are
all replete with subjective complaints but no significant
objective findings . . . that would support an impairment,” J.A.
426, and that Dr. Huffmon’s opinion that Gorski could sit for
only 45 minutes an hour for four hours per day was “not
substantiated in the clinical documentation,” J.A. 427. Dr.
Soriano determined from his review that Gorski could sit, stand,
or walk continuously for one hour and could sit, stand, and walk
for all eight hours of an eight-hour period. In light of
Gorski’s prior surgery and her continuing complaints of pain,
Dr. Soriano concluded that Gorski “should be limited to
sedentary to light duty positions.” J.A. 427. He finally
stated that “Gorski’s complaints remain only subjective and are
disproportionate to any objective findings on x-rays or physical
exam findings.” J.A. 427. Dr. Soriano’s report made no mention
of the dislodged surgical hardware that several of the other
doctors concluded was irritating her surrounding nerve tissue
and causing her to suffer significant pain in her lower back and
right leg.
12
MetLife sent Gorski’s attorney a letter dated January 20,
2003, stating that it had denied Gorski’s appeal. The letter,
relying on the Plan, Gorski’s job description, the limitations
that Dr. Huffmon and Dr. Faircloth had identified, and Dr.
Soriano’s report, concluded that “the medical documentation in
[MetLife’s] file does not support a disability, as defined in
the plan.” J.A. 421.
Gorski then initiated the current action in federal court
on August 12, 2005, under 29 U.S.C.A. § 1132(a)(1)(B) (West
1999) of the Employee Retirement Income Security Act of 1974
(“ERISA”), for wrongful denial of benefits. She requested LTD
benefits from June 4, 2002 to the judgment date, prejudgment
interest, a determination that she is entitled to continue to
receive benefits for as long as she remains eligible, and
attorney’s fees and costs.
Considering cross-motions for summary judgment, the
district court denied Gorski’s motion and granted MetLife’s
motion. The court applied a modified abuse-of-discretion
standard of review to MetLife’s decision in light of MetLife’s
status as both the insurer of LTD benefits and the fiduciary
with discretionary authority to determine benefits eligibility.
The court concluded that despite the conclusions of Drs. Huffmon
and Faircloth that Gorski could not return to work, MetLife’s
decision to uphold its benefits denial was reasonable as a
13
matter of law. The court pointed out that Dr. Faircloth could
not say that Gorski could not work throughout an eight-hour day,
sitting 45 minutes at an interval with breaks in between, and
that Dr. Huffmon did not explain his view that Gorski could sit
only in 45-minute increments for a total of four hours. The
court also recognized that although Gorski’s doctors identified
objective evidence indicating Gorski would suffer chronic lower
back pain, in the end, their opinions that she could not do her
old job depended on the veracity of Gorski’s self-reported
limitations. The court noted that independent physician
consultant Dr. Levine concluded that Gorski could engage in
sedentary activities following pain management therapy, and that
Dr. Soriano concurred in that assessment. The district court
finally added that the video surveillance reasonably could be
viewed as further evidence that Gorski’s limitations were not as
great as Drs. Huffmon and Faircloth believed.
II.
A.
We review the grant of summary judgment de novo, viewing
all of the facts in the light most favorable to the nonmovant.
See EEOC v. Navy Fed. Credit Union, 424 F.3d 397, 405 (4th Cir.
2005). Summary judgment is appropriate when “the pleadings,
depositions, answers to interrogatories, and admissions on file,
14
together with the affidavits, if any, show that there is no
genuine issue as to any material fact and that the moving party
is entitled to a judgment as a matter of law.” Fed. R. Civ. P.
56(c); see Celotex Corp. v. Catrett, 477 U.S. 317, 322-23
(1986).
In reviewing the denial of benefits under an ERISA plan, a
district court’s first task is to consider de novo whether the
relevant plan documents confer discretionary authority on the
plan administrator to make a benefits-eligibility determination.
See Johannssen v. District No. 1-Pacific Coast Dist., MEBA Pen.
Plan, 292 F.3d 159, 168 (4th Cir. 2002). “When a plan by its
terms confers discretion on the plan’s administrator to
interpret its provisions and the administrator acts reasonably
within the scope of that discretion, courts defer to the
administrator’s interpretation.” Colucci v. Agfa Corp.
Severance Pay Plan, 431 F.3d 170, 176 (4th Cir. 2005). The
parties agree that the Plan confers discretionary authority upon
MetLife, as the plan administrator, to make benefit decisions
according to the terms of the plan. Under the abuse-of-
discretion standard, the reviewing court will not disturb the
plan administrator’s decision as long as it was reasonable.
Such a decision is reasonable “if it is the result of a
deliberate, principled reasoning process and if it is supported
by substantial evidence,” Stup v. UNUM Life Ins. Co. of Am., 390
15
F.3d 301, 307 (4th Cir. 2004) (internal quotation marks
omitted), which is “evidence which a reasoning mind would accept
as sufficient to support a particular conclusion,” LeFebre v.
Westinghouse Elec. Corp., 747 F.2d 197, 208 (4th Cir. 1984)
(internal quotation marks omitted).
However, when the plan administrator’s own business
interests will be directly affected by its decision regarding
the benefits claim, a conflict of interest arises that “may
operate to reduce the deference given to a discretionary
decision of that fiduciary to the extent necessary to neutralize
any untoward influence resulting from that conflict.”
Blackshear v. Reliance Standard Life Ins. Co., 509 F.3d 634, 639
(4th Cir. 2007) (internal quotation marks & alteration omitted).
In effect, we use a “sliding-scale standard of review” when a
genuine conflict exists: “‘[t]he more incentive for the
administrator . . . to benefit itself by a certain
interpretation of benefit eligibility . . ., the more
objectively reasonable the administrator[’s] . . . decision must
be and the more substantial the evidence must be to support
it.’” Stup, 390 F.3d at 307 (quoting Ellis v. Metro. Life Ins.
Co., 126 F.3d 228, 233 (4th Cir. 1997)); see also Metro. Life
Ins. Co. v. Glenn, 128 S. Ct. 2343, 2350 (2008) (explaining that
when plan administrator both evaluates benefits claims and pays
those claims, the resulting conflict of interest “should be
16
weighed as a factor in determining whether there is an abuse of
discretion” (internal quotation marks omitted)).
Because MetLife insures the very plan it administers, the
district court concluded that MetLife was operating under a
conflict of interest. MetLife does not challenge the district
court’s application of the modified abuse-of-discretion standard
under the circumstances, and we agree that this standard of
review was appropriate. See Stup, 390 F.3d at 307.
B.
With these principles in mind, we turn to the substantive
questions. The issue decided by MetLife and litigated before
the district court was whether Gorski could “perform the
sedentary duties of an administrative assistant.” J.A. 513.
Resolution of this question became dependent on the legitimacy
and extent of Gorski’s back pain. In this regard, Gorski has
produced evidence clearly demonstrating that dislodged surgical
hardware was irritating nerve tissue surrounding the hardware,
causing her substantial pain and other problems as well. On
that point, Gorski produced the report of Dr. Huffmon that a CT
scan and flexion and extension films showed that her 4/5 cage
was “kicked out laterally,” apparently “compressing her right 4
nerve root and maybe even catching her right 5 nerve root as
well,” resulting in “[l]ow back pain and right leg pain.” J.A.
17
348. Gorski presented an APS from Dr. Faircloth essentially
agreeing with Dr. Huffmon’s assessment. Dr. Leighton further
noted that Gorski’s x-rays showed “a bit of posterior
displacement of one of the cages.” J.A. 409. Drs. Huffmon and
Faircloth both concluded that Gorski was disabled from any
occupation, and Dr. Faircloth specifically opined that Gorski
“can sit for 45 minutes and take a 10 minute break to lay down
[and] then resume sitting for up to 4 hours a day.” J.A. 408.
Gorski herself represented that no accommodation could allow her
to return to the workplace in light of the severity of her lower
back pain. Thus, Gorski clearly satisfied her initial burden of
producing substantial evidence that she was disabled from
performing any job.
In nonetheless upholding its termination of Gorski’s
disability benefits, MetLife noted that Gorski’s job description
for her previous job as sales secretary required her “to sit for
3-4 hours, stand, walk, and climb for 1-2 hours per work shift.”
J.A. 420. The job also “required some repetitive use of the
hands and the use of the neck and head” but only “occasional
lifting or carrying up to 10 lbs.” J.A. 420. MetLife concluded
that while Drs. Faircloth and Huffmon opined that Gorski could
not perform any job, the specific limitations that the doctors
identified regarding her functionality did not preclude her
working in her prior job as an administrative assistant.
18
MetLife also relied on Dr. Soriano’s conclusions that “Gorski
did not have any impairment based upon objective findings,” that
she could perform sedentary work, and that Dr. Huffmon’s sitting
restrictions of 45 minutes on, followed by 10-minute breaks, for
up to 45 minutes were not supported by Gorski’s recent physical
examinations. J.A. 421.
Gorski argues that MetLife acted unreasonably in basing its
final decision to terminate her benefits on Dr. Soriano’s
opinion. MetLife does not deny that it relied on Dr. Soriano’s
opinion, but maintains that its reliance was reasonable. We
agree with Gorski.
The crux of Dr. Soriano’s opinion is that there are no
objective findings to support Gorski’s complaints of pain and
that Gorski exaggerates the level of pain. Indeed, as noted,
Dr. Soriano went so far as to say that Gorski “does not have any
impairment based upon objective findings.” J.A. 426 (emphasis
added); see J.A. 427 (“[S]he has no obvious objective
impairment”).
The problem with Dr. Soriano’s opinion is that Dr. Soriano
never explained on what basis he doubted the veracity of Gorski,
whom he had never examined. To the extent that he did not
believe that Gorski’s physical problems would cause the intense
pain of which she complained, he never revealed why he rejected
the view of the other doctors that dislodged surgical hardware
19
was irritating surrounding nerve tissue, resulting in
debilitating pain for Gorski. In fact, he never discussed at
all the June 2000 CT scan and flexion and extension films that
several doctors reported as depicting the dislodged hardware and
resulting nerve root impingement and as supporting Gorski’s
claims regarding the extent of her pain. Without such a
discussion, Dr. Soriano’s report is simply an unreasoned and
unexplained rejection of the objective evidence in the record,
Gorski’s claims regarding her level of pain and functionality,
and the opinions of Drs. Huffmon and Faircloth that she was
totally disabled. MetLife was not justified in rejecting the
opinions of Drs. Faircloth and Hoffman as well as Gorski’s
statements on the basis of such a flawed report. See Stup, 390
F.3d at 308 (“[W]hile an administrator does not necessarily
abuse its discretion by resolving an evidentiary conflict to its
advantage, the conflicting evidence on which the administrator
relies in denying coverage must be ‘substantial’--especially
when . . . the administrator has an economic incentive to deny
benefits.”). Thus, it cannot be said that MetLife’s decision
was “the result of a deliberate, principled reasoning process.”
Id. at 307; see Black & Decker Disability Plan v. Nord, 538 U.S.
822, 834 (2003) (“Plan administrators . . . may not arbitrarily
refuse to credit a claimant’s reliable evidence, including the
opinions of a treating physician.”); Buffonge v. Prudential Ins.
20
Co. of Am., 426 F.3d 20, 30-31 (1st Cir. 2005) (holding that
denial was not “reasoned” when it relied in part on
fundamentally flawed medical reports).
MetLife contends that it acted reasonably in upholding its
termination of Gorski’s benefits because the record contains
conflicting evidence concerning whether she could perform her
job as an administrative assistant. In this regard, MetLife
argues that the functional limitations reported by Drs. Huffmon
and Faircloth would not prevent Gorski from undertaking many of
the duties of a secretary, and MetLife notes that Dr. Levine had
also concluded that Gorski should be capable of doing some
sedentary activities. MetLife further argues that Dr. Huffmon
did not provide any explanation for his asserted sitting
limitations for Gorski or even indicate that he had examined her
in the several months preceding his assertion. Finally, MetLife
points to the video surveillance as a basis for discrediting
Gorski’s claimed pain and limitations, on which the other
doctors’ opinions of her limitations were based.
We conclude that MetLife’s “substantial evidence” argument
misses the mark. Importantly, the defect in MetLife’s final
decision was not that the evidence before it was insufficient to
support a hypothetical decision to deny benefits, but rather,
that the actual decision that MetLife issued was not reasoned
and principled. See id. (holding that insufficiently reasoned
21
decision denying benefits would be overturned regardless of
whether substantial evidence could have supported a reasoned
decision denying benefits). And, because we cannot conclude
with any certainty that MetLife would have reached the same
decision had it completed an appropriate analysis of Dr.
Soriano’s report and the assumptions underlying his conclusions,
the decision terminating Gorski’s benefits must be overturned.
See id. at 31 (suggesting that plan administrator’s reliance on
faulty evidence might be ignored if other evidence before the
administrator “compelled or virtually compelled” the
administrator to deny the claim).
C.
Having determined that MetLife’s decision constituted an
abuse of discretion, we now turn to the question of the
appropriate remedy. “[T]he administration of benefit and
pension plans should be the function of the designated
fiduciaries, not the federal courts.” Bernstein v. CapitalCare,
Inc., 70 F.3d 783, 788 (4th Cir. 1995). Therefore, it is
generally the case that when a plan administrator’s decision is
overturned, a remand for a new determination is appropriate.
See Flinders v. Workforce Stabilization Plan of Phillips
Petroleum Co., 491 F.3d 1180, 1194 (10th Cir. 2007) (explaining
that “[i]f the plan administrator failed to make adequate
22
factual findings or failed to adequately explain the grounds for
the decision, then the proper remedy is to remand the case for
further findings or additional explanation”); cf. Sheppard &
Enoch Pratt Hosp., Inc. v. Travelers Ins. Co., 32 F.3d 120, 125
(4th Cir. 1994) (noting that remand is appropriate if the court
concludes that the administrator lacked adequate evidence to
make a decision); Berry v. Ciba-Geigy Corp., 761 F.2d 1003, 1007
(4th Cir. 1985) (same). However, “if the evidence in the record
clearly shows that the claimant is entitled to benefits, an
order awarding such benefits is appropriate.” Flinders, 491
F.3d at 1194.
Here, a remand to MetLife for a new determination is not
necessary because the record reflects that Gorski was clearly
entitled to continued benefits. Although Dr. Levine opined in
late 1999 that Gorski should be capable of performing sedentary
activities that involve no bending and do not require her to
lift more than five pounds, both Dr. Huffmon and Dr. Faircloth,
in August 2001 and January 2002, respectively, opined that
Gorski was disabled for any occupation. Because Dr. Soriano’s
analysis was incomplete, there simply was no basis by which
MetLife could have discredited Dr. Huffmon’s and Dr. Faircloth’s
medical opinions. The videotape surveillance was not sufficient
in this regard. The fact that it showed Gorski bending,
carrying water jugs, driving, and walking for a relatively short
23
time with no apparent discomfort does not cast significant doubt
on the opinions of her physicians that she was not physically
able to work for a sustained period of time. We therefore
conclude that the only reasonable decision available to MetLife
was to reverse its earlier decision discontinuing Gorski’s
benefits.
III.
In sum, we reverse the order of the district court granting
summary judgment to MetLife and denying Gorski’s summary
judgment motion, and we remand to the district court with
instructions to reinstate Gorski’s benefit award and consider
her claims for prejudgment interest and an award of attorney’s
fees and costs.
REVERSED AND REMANDED
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TRAXLER, Circuit Judge, concurring in part and dissenting in
part:
I agree with the majority’s decision reversing the district
court’s order granting MetLife’s summary judgment motion and
denying Gorski’s motion, and I concur in Parts IIA and IIB of
the majority opinion. However, because I believe that the
district court should remand the matter to MetLife for a new
benefits determination, I respectfully dissent from the majority
decision to the extent that it orders reinstatement of Gorski’s
benefits.
A remand to MetLife is appropriate in my view because
MetLife could have reasonably denied Gorski’s appeal even
without relying on Dr. Soriano’s opinion. The requirements for
Gorski’s prior job, as described by MetLife in its letter
denying her appeal, called for Gorski to sit for only three to
four hours per shift. Even accepting as correct Dr. Huffmon’s
opinion that Gorski can sit for only 45 minutes before taking a
10-minute break from sitting, for up to four hours per day, it
is not clear that that limitation would prevent her from meeting
the job’s requirements. Moreover, as the district court noted,
Dr. Huffmon did not explain how he arrived at that limitation,
nor did he even state that he had performed a recent examination
on which his opinion was based.
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MetLife could reasonably have deemed the lack of any
explicit connection between Dr. Huffmon’s asserted sitting
limitation and Gorski’s then-current physical condition to be
particularly important in light of MetLife’s specific request
for “[r]ecent physical exam findings,” J.A. 288, and in light of
several indications that Gorski’s symptoms may have either
improved in the last year or perhaps been exaggerated in the
first place. Those indications include Gorski’s February 13,
2002, statement to Dr. Faircloth that she was exercising
regularly and had no new or specific complaints, the notes from
Dr. Leighton’s August 8, 2002, exam not indicating any severe
current symptoms, and the video surveillance of Gorski in
October 2001 showing her carrying gallon water jugs, bending
over, walking around, all with no apparent hesitation or
discomfort. In light of all of these factors, I believe it was
certainly reasonable for MetLife to require Gorski to present
proof of her then-current physical condition, and it would have
been reasonable for MetLife to determine that she had failed to
do that to its satisfaction.
I would therefore reverse the order of the district court
granting summary judgment to MetLife and denying Gorski’s
summary judgment motion, and I would remand to the district
court with instructions to remand to MetLife for a new benefits
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determination. I respectfully dissent from the majority opinion
to the extent that it reaches a contrary result.
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