Cathleen Kennedy v. Lilly Extended Disability Plan , 856 F.3d 1136 ( 2017 )

In the
United States Court of Appeals
For the Seventh Circuit
____________________
No. 16-2314
CATHLEEN KENNEDY,
Plaintiff-Appellee,
v.
THE LILLY EXTENDED DISABILITY PLAN,
Defendant-Appellant.
____________________
Appeal from the United States District Court for the
Southern District of Indiana, Indianapolis Division.
No. 1:13-cv-01103-WTL-TAB — William T. Lawrence, Judge.
____________________
ARGUED MARCH 30, 2017 — DECIDED MAY 18, 2017
____________________
Before POSNER, MANION, and HAMILTON, Circuit Judges.
POSNER, Circuit Judge. This case is about fibromyalgia, “a
common and chronic disorder characterized by widespread
pain, diffuse tenderness, and a number of other symptoms.
The word ‘fibromyalgia’ comes from the Latin term for fi-
brous tissue (fibro) and the Greek [terms] for muscle (myo)
and pain (algia). … [F]ibromyalgia can cause significant pain
and fatigue, and it can interfere with a person’s ability to
carry on daily activities. … Scientists estimate that fibrom-
2 No. 16-2314
yalgia affects 5 million Americans age 18 or older.” National
Institute of Arthritis and Musculoskeletal and Skin Diseases,
“Questions and Answers about Fibromyalgia,” July 2014,
www.niams.nih.gov/Health_Info/Fibromyalgia/default.asp
(visited May 16, 2017, as were the other websites cited in this
opinion). “‘Chronic’ means that the pain lasts a long time—
at least 3 months or longer. Many people experience fibrom-
yalgia pain for years before being diagnosed. ‘Widespread’
means that it is felt all over, in both the upper and lower
parts of the body. However, many people with fibromyalgia
feel their pain in specific areas of their body, such as in their
shoulder or neck. And ‘Tenderness’ means that even a small
amount of pressure can cause a lot of pain.” Lyrica, “Fibrom-
yalgia [Frequently Asked Questions],” www.lyrica.com/
frequently-asked-questions#fibromyalgia.
As further explained by the Mayo Clinic, “Fibromyalgia
is a disorder characterized by widespread musculoskeletal
pain accompanied by fatigue, sleep, memory and mood is-
sues. Researchers believe that fibromyalgia amplifies painful
sensations by affecting the way your brain processes pain
signals. Symptoms sometimes begin after a physical trauma,
surgery, infection or significant psychological stress. In other
cases, symptoms gradually accumulate over time with no
single triggering event. Women are much more likely to develop
fibromyalgia than are men. Many people who have fibromyal-
gia also have tension headaches, temporomandibular joint
(TMJ) disorders, irritable bowel syndrome, anxiety and de-
pression.” Mayo Clinic, “Fibromyalgia,” www.mayoclinic.
org/diseases-conditions/fibromyalgia/home/ovc-20317786
(emphasis added).
No. 16-2314 3
There used to be considerable skepticism that fibromyal-
gia was a real disease. No more. See, besides the websites
already cited, Anne Underwood, “The Long Search for Fi-
bromyalgia Support,” New York Times, Sept. 23, 2009,
www.nytimes.com/ref/health/healthguide/esn-fibromyalgia-
ess.html; and Valencia Higuera, “Fibromyalgia: Real or Im-
agined?,” Healthline Newsletter, Aug. 17, 2016, www.
healthline.com/health/fibromyalgia-real-or-imagined.
And finally the American College of Rheumatology of-
fers the following harrowing description of the disease: “Fi-
bromyalgia is a neurologic chronic health condition that
causes pain all over the body and other symptoms. Other
symptoms of fibromyalgia that patients most often have are:
Tenderness to touch or pressure affecting muscles and some-
times joints or even the skin. Severe fatigue. Sleep problems
(waking up unrefreshed). Problems with memory or think-
ing clearly. Some patients also may have: Depression or anx-
iety. Migraine or tension headaches. Digestive problems: ir-
ritable bowel syndrome (commonly called IBS) or gas-
troesophageal reflux disease (often referred to as GERD). Ir-
ritable or overactive bladder. Pelvic pain. Temporomandibu-
lar disorder—often called TMJ (a set of symptoms including
face or jaw pain, jaw clicking, and ringing in the ears).”
American College of Rheumatology, “Fibromyalgia,” www.
rheumatology.org/I-Am-A/Patient-Caregiver/Diseases-Cond
itions/Fibromyalgia.
Eli Lilly and Company is a global pharmaceutical corpo-
ration headquartered in Indianapolis. And it is familiar with
fibromyalgia because it markets a drug called Cymbalta (a
trade name for Duloxetine) for treating the disease. It has re-
tained an expert on fibromyalgia, Dr. Daniel Clauw of the
4 No. 16-2314
University of Michigan, a physician and professor of rheu-
matology, to advise it on the disease, and he has pointed out
that many persons afflicted with fibromyalgia “end up need-
ing to stop working because of this condition” and that the
disease “is not only very common but is typically also very
disabling.”
So much for background; now for the case:
Cathleen Kennedy, the plaintiff, was hired by Lilly in
1982 and rose rapidly, eventually becoming an executive di-
rector in the company’s human resources division, with a
monthly salary of $25,011. But at the beginning of 2008 she
was forced to quit work because of disabling symptoms of
fibromyalgia. As a participant in the company’s Extended
Disability Benefits plan, she requested benefits upon ceasing
to work, and effective May 1, 2009, was approved for month-
ly benefits of $18,972.44. Three and a half years later, howev-
er, her benefits were terminated, precipitating this suit by
her against Lilly’s self-funded Extended Disability Plan
based on the Employee Retirement Income Security Act of
1974 (ERISA), 29 U.S.C. §§ 1001 et seq., which so far as per-
tains to this case sets minimum standards for voluntarily es-
tablished health and pension plans in private industry. See
Metropolitan Life Insurance Co. v. Glenn, 554 U.S. 105, 115
(2008). Lilly’s disability plan has discretion to deny claims
that it deems not to meet its standard, but a reviewing court
will overturn a denial of benefits if the plan’s decision is un-
reasonable. Edwards v. Briggs & Stratton Retirement Plan, 639
F.3d 355, 360 (7th Cir. 2011).
The plan states that an employee has a “disability” if un-
able “to engage, for remuneration or profit, in any occupa-
tion commensurate with the Employee’s education, training,
No. 16-2314 5
and experience.” Kennedy’s benefits were revoked by Lilly’s
Employee Benefits Committee (the administrator of the
plan), on the ground that her fibromyalgia was not disa-
bling.
The district judge granted summary judgment in favor of
Ms. Kennedy and awarded her $537,843.81 in past benefits
(benefits she should have received but did not) and pre-
judgment interest, and in addition the judge ordered Lilly to
reinstate Kennedy’s disability benefits retroactive to Decem-
ber 2012 and resume the payment of her monthly benefits.
Lilly based its unsuccessful case in the district court on evi-
dence presented by a number of doctors (oddly not includ-
ing Dr. Clauw), but the evidence turned out to be a hodge-
podge. For example, Lilly sent Kennedy to be examined by a
Dr. Schriber in Dayton, Ohio, more than 100 miles from
Kennedy’s home in Indianapolis. The doctor conducted a
physical exam of her that lasted all of five minutes. He testi-
fied that the “American College of Rheumatology does not
consider fibromyalgia to be disabling on a long-term basis.”
That, as we know from our earlier quotation from the ACR
is false; and Lilly itself appears not to have relied on Dr.
Schriber’s opinion in its decision to terminate Kennedy’s
benefits.
A psychiatrist named Dr. Osman advised Lilly that Ken-
nedy “from a psychiatric standpoint … has no restrictions or
limitations,” but based this on her having been diagnosed
with Major Depressive Disorder and Anxiety Disorder ra-
ther than with fibromyalgia, a disease about which as a psy-
chiatrist he could not be expected to offer an authoritative
opinion; apparently he offered no opinion. Another psychia-
trist, Dr. Goldman, opined similarly. And a urologist, Dr.
6 No. 16-2314
Davi, after reviewing Kennedy’s medical records, told Lilly
that she was not disabled from working “from a urology
perspective,” which Kennedy does not dispute and in any
event seems irrelevant.
Kennedy’s general internist, Dr. Condit, testified that
she’s permanently disabled, basing this opinion on his diag-
noses of her nonarticular rheumatism (musculoskeletal
aches and pains not traceable to joints), fibromyalgia, sleep
disorder, depression, irritable bowel syndrome, restless leg
syndrome, and her symptoms of pain and fatigue.
Dr. Condit retired and Dr. Steven Neucks became Ken-
nedy’s treating rheumatologist. He testified to her “pain,
poor quality sleep, fatigue, and difficulty concentrating,”
remarked that “because of her fibromyalgia and degenera-
tive arthritis, as well as her underlying discomfort, I do not
think that she can work a regular work schedule,” and add-
ed that he “thought [that] at [her] last visit [to him] her func-
tion level had declined slightly and that her anxiety was sig-
nificantly worse.” And he commended her for her “con-
sistency and lack of attempt to over dramatize her limita-
tions,” adding that “is I believe, suggestive of forthright
presentation.”
Dr. Dayton Payne, reviewing Ms. Kennedy’s disability
claim but not examining her, opined that she was able to re-
turn to her past job, while acknowledging mention in the
medical record of fatigue, irritable bowel, interstitial cystitis,
depression, anxiety, attention deficit disorder, diffuse ten-
derness, and tender points. Dr. Payne appears not to have
credited these symptoms, saying that “all of the laboratory
data in this file are normal.” But as the district judge pointed
out, it is error to demand laboratory data to credit the symp-
No. 16-2314 7
toms of fibromyalgia—the crucial symptoms, pain and fa-
tigue, won’t appear on laboratory tests. Hawkins v. First Un-
ion Corp. Long-Term Disability Plan, 326 F.3d 914, 919 (7th Cir.
2003).
Another doctor hired by the company, Dr. Dikranian, a
rheumatologist, reviewed Kennedy’s medical records and
expressed skepticism about whether she had fibromyalgia at
all. But as with Dr. Schriber even Lilly seems not to have
credited Dr. Dikranian’s evaluation. The company’s Em-
ployee Benefits Committee didn’t mention his conclusions in
its decision, and is represented by Lilly as having grudging-
ly “acknowledged that Kennedy does have fibromyalgia and
that fibromyalgia has caused her “some restrictions and limi-
tations” (emphasis added).
All deficiencies in its evidence to one side, Lilly has failed
to indicate what job or kind of job, and at what level, Kenne-
dy would be capable of performing if the company is per-
mitted to cancel her benefits. Dr. Neucks opined that Ken-
nedy “could do [only] a low stress, non-high cognitive func-
tioning job at about 30 hours a week,” which equals six
hours a day. Neucks further opined that she would experi-
ence “flares” that would prevent her from working for one
or two days a month, further shrinking her job prospects
and presumably her salary. “Fibromyalgia is ... characterized
by chronic, widespread pain, fatigue, cognitive impairments,
poor sleep, and mood difficulties. … These symptoms ... ap-
pear to undergo periods of exacerbation or worsening, often
colloquially referred to as ‘flares’ by patients and their health
care providers.” Ann Vincent et al., “Fibromyalgia Flares: A
Qualitative Analysis,” 17 Pain Medicine 463 (2016),
8 No. 16-2314
http://academic.oup.com/painmedicine/article-lookup/doi/
10.1111/pme.12676.
Ms. Kennedy was informed by a liaison to the Employee
Benefits Committee that if she could work 20 hours per week
as a secretary she would not be considered disabled. Yet in
its written decision the Committee said only that Kennedy
could work in “various non-executive positions in compen-
sation, benefits, and other human resources fields,” which is
both vague and inconsistent with the medical evidence. If
Dr. Neucks is correct about the flares (and there is no evi-
dence that he’s not), Kennedy wouldn’t be able to work any
regular schedule. Another questionable aspect of Lilly’s case
is the company’s conflict of interest, by reason of its being
both the initial adjudicator of an employee’s benefits claim
(via Lilly’s Employee Benefits Committee) and the payor of
those benefits. See Metropolitan Life Insurance Co. v. Glenn,
supra, 554 U.S. at 108. By cutting off Kennedy’s benefits the
company has saved itself about $2.5 million. Big as Lilly is,
that’s not a trivial loss.
The judgment of the district court is
AFFIRMED.
No. 16‐2314 9
MANION, Circuit Judge, dissenting. Cathleen Kennedy chal‐
lenges her plan administrator’s decision to terminate her ben‐
efits under an ERISA disability plan. Under the plan, Kennedy
is entitled to benefits if she is unable to perform “any occupa‐
tion consistent with [her] education, training, and experience”
because of illness or injury treated by a physician. The plan
contains  discretionary  language,  meaning  we  can  overturn
the administrator’s decision only if it was arbitrary and capri‐
cious.  Mote  v.  Aetna  Life  Ins.  Co.,  502  F.3d  601,  606  (7th  Cir.
2007). Nevertheless, the court sets it aside. Because I conclude
that  the  administrator’s  decision  was  within  the  bounds  of
reasonableness,  I  would  sustain  it.  Therefore,  I  respectfully
dissent.
Where ERISA disability plans contain language granting
the plan administrator discretionary authority, our power to
set aside the administrator’s decision is substantially limited.
We  may  “overturn  the  administrator’s  decision  only  where
there is an absence of reasoning to support it.” Jackman Finan‐
cial Corp. v. Humana Ins. Co., 641 F.3d 860, 864 (7th Cir. 2011).
We are not to substitute our judgment for that of the adminis‐
trator  so  long  as  the  administrator  has  made  “an  informed
judgment and articulate[d] an explanation for it that is satis‐
factory in light of the relevant facts.” Herman v. Cent. States,
Se. & Sw. Areas Pension Fund, 423 F.3d 684, 692 (7th Cir. 2005)
(quoting Carr v. Gates Health Care Plan, 195 F.3d 292, 294 (7th
Cir. 1999)). In other words, the decision must stand unless it
is  “downright  unreasonable.”  Id.  (quoting  Carr,  195  F.3d  at
294). This is not a rubber stamp, but it is quite deferential. See
id. at 693.
The  administrator’s  decision  in  this  case  contains  suffi‐
cient evidence to sustain it under that standard. With respect
10  No. 16‐2314
to limitations caused by fibromyalgia (the main dispute here),
the  administrator  relied  on  reports  from  Drs.  Neucks  and
Condit, both of whom were Kennedy’s treating rheumatolo‐
gist at one point, as well as a record review by Dr. Payne. In
2010,  Dr.  Neucks  concluded  that  Kennedy  had  “average  fi‐
bromyalgia,”  with  relatively  high  functioning  and  normal
movement. He said that Kennedy could work a lower‐stress
job  for  about  30  hours  per  week  with  some  limitations,  but
that  her  condition  did  not  preclude  the  performance  of  any
job. In 2012, once Dr. Neucks had replaced Dr. Condit as treat‐
ing  rheumatologist,  he  indicated  once  again  that  Kennedy
could not perform her old job because of its high stress and
cognitive  demands.  In  2013,  he  opined  that  Kennedy  could
not work a regular schedule or perform high‐stress activities.
He never stated that Kennedy was totally disabled from doing
any work.1
After a record review, Dr. Payne concluded that Kennedy’s
medical records did not support restrictions or limitations on
1 The court thinks that the “any occupation” standard is too harsh. It
finds unfair that Kennedy might have to take a part‐time position or a job
below her pay grade and forego disability benefits (which she, quite ra‐
tionally,  probably  doesn’t  want  to  do  given  the  significant  sum  she  re‐
ceives in benefits each month). But it’s not our place to rewrite the lan‐
guage of the plan, and the administrator has discretion to interpret it.
Moreover, the court faults the administrator for its failure to indicate
which jobs Kennedy could do with her restrictions. Of course, the admin‐
istrator did say that she could potentially do “various non‐executive posi‐
tions in compensation, benefits, and other human resources fields.” The
court says this is both vague and inconsistent with the medical evidence.
However,  as  I  explain  throughout  the  dissent,  the  conclusion  that  Ken‐
nedy  could  perform  in  a  lower‐stress  position  (with  some  accommoda‐
tions for flare‐ups) is a reasonable interpretation of the evidence.
No. 16‐2314  11
activities. The court says that Dr. Payne erred by requiring la‐
boratory  data  to  confirm  Kennedy’s  diagnosis  of  fibromyal‐
gia, but that’s not quite right. He acknowledged the diagnosis,
but  his  relevant  conclusion  was  about  Kennedy’s  functional
limitations. While the amount of pain someone experiences is
entirely subjective, “how much an individual’s degree of pain
or fatigue limits [her] functional abilities ... can be objectively
measured.” Williams v. Aetna Life Ins. Co., 509 F.3d 317, 322 (7th
Cir. 2007); see also Boardman v. Prudential Ins. Co. of Am., 337
F.3d 9, 17 n.5 (1st Cir. 2003) (“While the diagnoses of chronic
fatigue syndrome and fibromyalgia may not lend themselves
to objective clinical findings, the physical limitations imposed
by the symptoms of such illnesses do lend themselves to ob‐
jective analysis.”). Social Security administrative law judges
make these determinations  every day in cases where claim‐
ants report pain but can still do some work. In short, it was
not improper for the administrator to rely on Dr. Payne’s con‐
clusion that Kennedy’s medical records did not support func‐
tional limitations, irrespective of the diagnosis of fibromyal‐
gia.
There was also other evidence apart from the doctors that
indicated Kennedy could work in some occupations. She self‐
reported in a questionnaire to Anthem that she exercised of‐
ten (and Dr. Neucks reported in 2010 that Kennedy could jog
three  miles).  And,  speaking  of  Social  Security,  that  Admin‐
istration found that Kennedy was not disabled under a similar
standard to “any occupation” on February 13, 2012. We have
upheld an administrator’s decision to deny benefits in several
cases  despite  a  contrary  Social  Security  decision,  so  the  ad‐
ministrator  in  this  case  should  have  been  entitled  to  rely  in
part on a negative Social Security finding. See, e.g., Mote, 502
F.3d at 610; Black v. Long Term Disability Ins., 582 F.3d 738, 748
12  No. 16‐2314
(7th Cir. 2009). That is especially true when the Social Security
decision bolsters other competent evidence on the record.2
Nobody  disputes  that  Kennedy  has  fibromyalgia.  Yet,
most people with fibromyalgia can work. Hawkins v. First Un‐
ion Corp. Long‐Term Disability Plan, 326 F.3d 914, 916 (7th Cir.
2003).  I  cannot  agree  that  the  administrator’s  determination
that Kennedy is one of those still able to work was arbitrary
and  capricious.  “Although  others  reviewing  [Kennedy’s]
medical  condition  in  the  first  instance  may  reasonably  con‐
clude  that  she  is  disabled  ...  our  standard  of  review  in  this
matter is deferential, and we [should not] say that [the admin‐
istrator’s] determination was unreasonable.” Black, 582 F.3d at
748. The record contains sufficient evidence to uphold the de‐
cision. Therefore, I would reverse the judgment of the district
court.
I respectfully dissent.
2 The court also references the administrator’s conflict of interest. We
have held that conflicts of interest for self‐funded ERISA plans “may act
as a tiebreaker in finding that the determination was arbitrary and capri‐
cious” depending on the circumstances of the case. Black, 582 F.3d at 748
(citing Metropolitan Life Ins. Co. v. Glenn, 554 U.S. 105, 118 (2008)). But in
Black, we rejected the employee’s argument that a conflict of interest re‐
quired the administrator to give more weight to a positive Social Security
determination. Id. Here, we have a negative Social Security finding and
other  evidence  by  which  the  administrator  could  have  rationally  found
that Kennedy is not disabled. The self‐funded nature of the plan does not
override that deferential standard of review.