Simoneaux v. Continental Casualty Co. , 101 F. App'x 10 ( 2004 )

United States Court of Appeals
Fifth Circuit
F I L E D
UNITED STATES COURT OF APPEALS June 9, 2004
FOR THE FIFTH CIRCUIT
Charles R. Fulbruge III
Clerk
04-30083
Summary Calendar
GLENN SIMONEAUX,
Plaintiff-Appellant,
VERSUS
CONTINENTAL CASUALTY COMPANY; CNA GROUP LIFE ASSURANCE COMPANY,
Defendants-Appellees.
Appeal from the United States District Court
For the Eastern District of Louisiana
(03-CV-400-F)
Before SMITH, DUHÉ, and WIENER, Circuit Judges.
PER CURIAM:1
This ERISA case presents the question of Petitioner-Appellant
Glenn Simoneaux’s entitlement to long-term disability benefits with
Defendant Continental Casualty Insurance Company, Administrator of
a Group Disability Plan for Simoneaux’s employer, CF Industries,
Inc. Simoneaux was employed by CF Industries until he became
disabled with heart disease on February 25, 2002. After receiving
short-term disability benefits, Petitioner applied for long-term
1
Pursuant to 5TH CIR. R. 47.5, the Court has determined that
this opinion should not be published and is not precedent except
under the limited circumstances set forth in 5TH CIR. R. 47.5.4.
disability benefits with Continental Casualty, who as Plan
Administrator denied long-term benefits. After exhaustion of
administrative remedies, Simoneaux petitioned the district court
for review. The parties jointly submitted the administrative
record on cross-motions for summary judgment, stipulating that the
issues were whether or not the Plan Administrator abused its
discretion and/or whether or not its decision to deny long-term
benefits under the Plan was arbitrary and capricious.2 The
district court would not disturb the Plan Administrator’s
determination, and we affirm.
The district court can hold a decision to be arbitrary only if
it is “‘made without a rational connection between the known facts
and the decision or between the found facts and the evidence.’”3
A court upholds the findings of the Plan Administrator if they are
supported by “substantial evidence.”4 We review the cross motions
for summary judgment de novo, applying the same standard as the
district court.5
This case turns on the Plan Administrator’s factual
2
Rawle 642.
3
Meditrust Finan. Servs. Corp. v. Sterling Chems., Inc., 168
F.3d 211, 215 (5th Cir. 1999) (quoting Bellaire General Hosp. v.
Blue Cross Blue Shield of Michigan, 97 F.3d 822, 828 (5th Cir.
1996).
4
Meditrust, 168 F.3d at 215.
5
Id. at 214; Sweatman v. Commercial Union Ins. Co., 39 F.3d
594, 601 (5th Cir. 1994).
2
determination that Simoneaux did not suffer from a functional
impairment that would preclude him from performing the duties of
his employment. One of the eligibility requirements for benefits
is a physical impairment such that the participant is continuously
unable to perform the material and substantial duties of his
regular occupation.6 The long-term aspect is that the impairment
must continue during the elimination period – 180 days – and for
twenty-four months thereafter.7
Simoneaux contends that Continental improperly disregarded the
opinions of his treating physician and an independent medical
examiner that Simoneaux was permanently disabled from any work.
Defendant contends that the evaluating physician’s report did not
include sufficient findings to support a disability within or
beyond the elimination period. According to Defendant, a
generalized statement that plaintiff is “permanently disabled for
any exertive or stressful work” that is unsupported by the medical
tests, records, or findings is insufficient. We agree.
Continental reviewed Simoneaux’s medical record and determined
that Simoneaux was diagnosed with ischemic heart disease, that the
only medical procedure done was a heart catheter and stent
replacement, reported in March 2002 to have been successful; that
the duration of any physical impairment for the procedure would not
6
Rawle 188-89.
7
Id.
3
exceed seven to ten days in accordance with ADC Guidelines; and
that Simoneaux had no follow-up medical procedures.8
Continental collected information from the employer about the
physical demands of Simoneaux’s job. Investigation revealed that
Simoneaux was a chemical operator who would make equipment rounds
and would periodically climb ladders and check machinery. He was
also required to turn large valves and could use help from
coworkers to turn or adjust valves.9 Continental also interviewed
Simoneaux, who revealed that he was capable of taking care of
himself, that he drove, that he exercised, and that he helped with
work around the house and took care of and played with the pets.10
To perform its review and evaluation, Continental used
Disability Specialist Gwen Hayslip and Registered Nurse Johanna
Cobb. Continental concluded that Simoneaux had no functional
impairment that would have prevented him from performing the
material and substantial duties of his job beyond the six-month
elimination period. Continental’s Appeals Committee upheld the
conclusion, finding that the heart catheterization procedure
resulted in blockage going from 80-90% to zero.11
As Plan Administrator Continental had discretion to determine
8
Rawle 63.
9
Rawle 67-69.
10
Rawle 151-152.
11
Rawle 70.
4
benefit eligibility. The record demonstrates a “rational
connection”12 between the facts developed and the Plan
Administrator’s decision to deny benefits. It obtained and
evaluated information presented by the employer, healthcare
professionals, and Simoneaux himself, as well as additional
submissions during the appeals process. Continental was neither
irrational nor arbitrary in failing to give overriding weight to
the treating physician’s statement that Simoneaux was totally
disabled, a generalized statement not supported by objective
medical findings.13 Accordingly, the decision is properly upheld.
AFFIRMED.
12
See Medi-trust, 168 F.3d at 215.
13
See Gooden v. Provident Life & Accid. Ins. Co., 250 F.3d 329,
333-34 (5th Cir. 2001) (letter from treating physician stating that
patient was disabled, unaccompanied by medical evidence, did not
undermine Plan Administrator’s decision finding no disability);
Sweatman, 39 F.3d at 601-02 (finding no abuse of discretion where
Plan Administrator utilized professionals to review and evaluate
all the medical records, despite plaintiff’s contention that Plan
Administrator “attached insufficient weight to her doctor’s
opinions and too much weight to the results of its own [deficient]
investigation”).
5