Jacqueline Hamilton v. Standard Insurance Co.

Filing

UNPUBLISHED OPINION FILED. [10-30266 Affirmed ] Judge: CDK , Judge: FPB , Judge: JWE Mandate pull date is 01/06/2011 [10-30266]

Jacqueline HamiltonCaStandard Insurance Co. v. se: 10-30266 Document: 00511323740

Page: 1 Date Filed: 12/16/2010

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IN THE UNITED STATES COURT OF APPEALS United States Court of Appeals FOR THE FIFTH CIRCUIT Fifth Circuit FILED
December 16, 2010 N o . 10-30266 S u m m a r y Calendar Lyle W. Cayce Clerk

J A C Q U E L I N E HAMILTON, P la in t if f -A p p e lla n t , v. S T A N D A R D INSURANCE COMPANY, Defendant-Appellee.

A p p e a l from the United States District Court for the Western District of Louisiana U S D C No. 1:08-CV-1717

B e fo r e KING, BENAVIDES, and ELROD, Circuit Judges. PER CURIAM:* A t issue is whether Defendant-Appellee Standard Insurance Company a b u sed its discretion by denying Plaintiff-Appellant Jacqueline Hamilton's claim fo r benefits under her former employer's long-term disability plan. We hold that it did not, and therefore AFFIRM the district court's decision upholding S t a n d a r d 's denial of benefits.

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 R. 47.5, the court has determined that this opinion should not be published and is not precedent except under the limited circumstances set forth in 5TH CIR.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.

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Case: 10-30266 Document: 00511323740 Page: 2 Date Filed: 12/16/2010

No. 10-30266 H a m ilt o n worked at CenturyTel as a plant support technician from F e b r u a r y 1994 until the company was shut down in March 2006. Hamilton was e n r o lle d in her employer's Group Long-Term Disability Plan, an employee w e lfa r e benefit plan governed by the Employee Retirement Income Security Act o f 1974 (ERISA). In January 2002, Hamilton began suffering from medical issues. Hamilton c o n s u l t e d with neurologist Dr. Hajmurad, in March 2002, and underwent a n u m b e r of medical tests, such as a Magnetic Resonance Imaging (MRI), a b r a in s t e m auditory response test, an electroencephalogram (EEG), and a nerve c o n d itio n study. All of them came back negative. Dr. Hajmurad determined t h a t her medical issues were related to stress, depression, lack of sleep, carpel t u n n e l, and a twenty-percent-chance of multiple sclerosis (MS). To check further in t o the possibility of MS, he obtained a transesophageal echocardiography (T E E ), which also came back negative. Hamilton returned to work and had o c c a s io n a l absences under the Family and Medical Leave Act over the next three years. On March 1, 2006, Hamilton's employer informed her that it would be e lim in a t in g her position as part of a larger reduction in force. Her employer also n otified Hamilton that her long-term disability coverage would continue through h e r termination date. The following week, Hamilton returned to Dr. Hajmurad fo r another MRI and additional blood work. Dr. Hajmurad noted that the MRI s h o w e d deep white matter which he thought could suggest MS. Even though Dr. H a jm u r a d suspected MS, he did not think Hamilton's condition was disabling, a n d he completed family medical leave paperwork for Hamilton indicating that s h e was able to work, albeit intermittently. Hamilton stopped working on March 1 5 , 2006, and her employer terminated her on March 31, 2006. At around the same time, Hamilton changed her family physician from Dr. J o in e r to Dr. Forester. While her previous family physician had attributed 2

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No. 10-30266 H a m ilt o n 's complaints to stress and anxiety, Dr. Forester concluded, without a n y indication that he performed medical tests, that Hamilton had fibromyalgia, M S , and possibly Lyme disease. In April 2006, after Hamilton had been

t e r m in a t e d , Dr. Forester completed family medical leave paper work indicating t h a t Hamilton could not work at all. Hamilton submitted her long-term disability application claiming that she w a s unable to work due to MS, fibromyalgia, and Lyme disease. Standard had t w o board-certified physician consultants, a rheumatologist, and a neurologist, r e v ie w Hamilton's medical records. The records showed that the only actual d ia g n o s t ic test for Lyme disease came up negative, no actual exam had been p e r fo r m e d for fibromyalgia, and that, according to the neurologist, the MRIs did n o t indicate MS. Standard denied Hamilton's claim, explaining that there was in s u ffic ie n t medical evidence to support diagnoses of MS, fibromyalgia, or Lyme d is e a s e . Standard also notified Hamilton of her right to appeal the decision by w r it t e n request within 180 days. In 2007, Hamilton was seen by another physician, Dr. Bryant, an in t e r n is t , who diagnosed MS, fibromyalgia, carpal tunnel syndrome, and slow m e n ta tio n . That same year, Hamilton again consulted with her family

p h y s ic ia n , Dr. Forester, who continued to diagnose her with Lyme disease, and fib r o m y a lg ia . In February 2008, Dr. Forester noted symptoms of MS but a r e p e a t MRI indicated no change. In April 2008, almost two years after the initial denial of her benefits c la im , Hamilton filed an untimely appeal. Nevertheless, Standard agreed to r e v ie w it, including the new medical information Hamilton submitted, as well a s a determination by the Social Security Administration (SSA) that Hamilton w a s entitled to disability benefits as of September 1, 2006. Standard had the t w o original physician consultants review the new information to see if it altered t h e ir initial assessment. It did not. Standard then had two new consulting 3

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No. 10-30266 p h y s ic ia n s review the file, and they also concluded that the medical evidence did n o t support disability. Hamilton appealed the denial to the Western District of Louisiana. The m a g is tr a t e judge recommended that the district court deny the appeal and d is m is s the case. After independently reviewing the record, the district court h e ld that the administrator did not abuse its discretion by denying Hamilton's c la im . This appeal followed. This court reviews the district court's conclusion that Standard did not a b u s e its discretion de novo, applying the same standard as the district court. Crowell v. Shell Oil Co., 541 F.3d 295, 312 (5th Cir. 2008).* * A denial of benefits is not an abuse of discretion if it "is supported by substantial evidence and is not a r b it r a r y and capricious." Ellis v. Liberty Life Assurance Co. of Boston, 394 F.3d 2 6 2 , 273 (5th Cir. 2004). A benefit decision must be upheld if the decision is " b a s e d on evidence, even if disputable, that clearly supports the basis for its d e n ia l." Holland v. Int'l Paper Co. Ret. Plan, 576 F.3d 240, 246 (5th Cir. 2009) (c it a t io n and internal quotation marks omitted). Moreover, ERISA does not r e q u ir e the administrator to give deference to a treating physician's assessments w h e n confronted with contrary reliable evidence. See Black & Decker Disability P la n v. Nord, 538 U.S. 822, 834 (2003); Love v. Dell, Inc., 551 F.3d 333, 337 (5th C ir . 2008). Where, as here, the claims administrator's dual role in both

e v a lu a tin g and funding the disability claim creates an apparent conflict of in t e r e s t , courts "weigh the conflict of interest as a factor in determining whether t h e r e is an abuse of discretion in the benefits denial." Crowell, 541 F.3d at 312 (c it a t io n and internal quotation marks omitted). "Eligibility for benefits under any ERISA plan is governed . . . by the plain m e a n in g of the plan language." Threadgill v. Prudential Sec. Grp., Inc., 145
In this case, we need not review Standard's legal interpretation of the plan because it is uncontested. See Duhon v. Texaco, Inc., 15 F.3d 1302, 1307 n.3 (5th Cir. 1994).
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No. 10-30266 F .3 d 286, 292 (5th Cir. 1998). Here, the plan states that Hamilton is entitled to d i s a b ilit y benefits if she was disabled before the date of her termination. Therefore, the critical inquiry is whether Standard abused its discretion in h o ld in g that Hamilton did not meet the Plan's definition of disability before M a r c h 31, 2006. The Plan defines disability as being "unable to perform with r e a s o n a b le continuity the Material Duties of your Own Occupation." Standard denied Hamilton's claim based on a determination that there w a s a lack of objective medical evidence supporting Hamilton's claim. Standard d id not abuse its discretion by making such a determination. First, Hamilton's m e d ic a l records reveal that her test for Lyme Disease was negative, that H a m ilt o n never received any physical examination for fibromyalgia, and that m u l t ip le MRIs did not conclusively indicate MS. Second, four consulting

p h y s ic ia n s , two neurologists, and two rheumatologists, evaluated Hamilton's m e d ic a l records, found that there was insufficient evidence to substantiate H a m ilt o n 's claim, and concluded that Hamilton was not disabled. Given the r e lia b le contrary medical evidence, Standard was entitled to disagree with the o p in io n s of Hamilton's treating physicians. Hamilton also contends that Standard's refusal to credit the SSA's d is a b ilit y determination amounted to an abuse of discretion. An ERISA

a d m in is t r a t o r 's failure to consider a SSA disability determination is a factor a c o u r t ought to consider when determining whether the denial of benefits was an a b u s e of discretion. See Metro Life Ins. Co. v. Glenn, 128 S. Ct. 2343, 2351­52 (2 0 0 8 ); Moller v. El Campo Aluminum Co., 97 F.3d 85, 87­88 (5th Cir. 1996). However, because the eligibility criteria for SSA disability benefits differs from t h a t of ERISA plans, while an ERISA plan administrator should consider a SSA d e t e r m in a t io n , it is not bound by it. See, e.g., Schexnayder v. Hartford Life and A c c id e n t Ins. Co., 600 F.3d 465, 471 n.3 (5th Cir. 2010) (noting that the a d m in is t r a t o r is not required to "give any particular weight to the contrary 5

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No. 10-30266 fin d in g s " of the SSA). Here, Standard addressed SSA's determination. It

d iscou n ted that determination because the SSA concluded that Hamilton became d is a b le d as of September 1, 2006, long after her disability benefits ended on M a r c h 31, 2006, when she was terminated. Standard also declined to follow the S S A because the medical report Hamilton submitted to the SSA was based on h e r self-reported medical history and exceeded the findings of her treating p h y s ic ia n s . Therefore, the district court correctly concluded that Standard did n ot abuse its discretion by disregarding Hamilton's SSA disability

d e te r m in a tio n . On appeal, Hamilton argues that Standard's conflict of interest as both a d m in is t r a t o r and funding source for the Plan is relevant to determining w h e t h e r Standard abused its discretion by denying her application for benefits. We note that the magistrate judge's Report and Recommendation, which the d is t r ic t court adopted, erred when it applied a "modicum less deference" than a b u s e of discretion to Standard's determination. Glenn, 128 S. Ct. At 2350­51. Instead, the magistrate judge and district court should have treated Standard's c o n flic t as another factor in their review of Hamilton's benefit denial. See H o lla n d , 576 F.3d at 247 & n.3. But, as the appellee correctly points out, H a m ilt o n has provided no evidence that Standard's conflict played a role in its d e c is io n to deny benefits. See Glenn, 128 S. Ct. at 2351 (discussing factors to c o n s i d e r in evaluating administrator's conflict of interest). In the absence of s o m e indication that this factor played a role in the administrator's denial of b e n e fits , the judgment of the district court should be affirmed. Therefore, the court holds, after reviewing the record and considering d efen d a n t's dual role as insurer and plan administrator, that Standard's decision t o deny benefits is supported by substantial evidence and is not an abuse of d is c r e t io n . We AFFIRM.

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