Angel Dix v. Louisiana Hlth Svc & Indem Co.

Filing

UNPUBLISHED OPINION FILED. [14-31200 Affirmed and Remanded] Judge: PEH , Judge: EHJ , Judge: SAH. Mandate pull date is 06/19/2015 [14-31200]

Case: 14-31200

Document: 00513059561

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Date Filed: 05/29/2015

IN THE UNITED STATES COURT OF APPEALS
FOR THE FIFTH CIRCUIT
United States Court of Appeals
Fifth Circuit

No. 14-31200
Summary Calendar

FILED
May 29, 2015
Lyle W. Cayce
Clerk

ANGEL DIX,
Plaintiff - Appellant
v.

BLUE CROSS AND BLUE SHIELD ASSOCIATION LONG TERM
DISABILITY PROGRAM,
Defendant - Appellee

Appeal from the United States District Court
for the Middle District of Louisiana
USDC No. 3:12-CV-319
Before HIGGINBOTHAM, JONES, and HIGGINSON, Circuit Judges.
PER CURIAM:*
This is an appeal from the district court’s grant of summary judgment in
favor of Blue Cross and Blue Shield Association Long Term Disability Program
(“the Program”). The district court correctly held that the plan administrator’s
decision to deny disability payments to Angel Dix was not an abuse of
discretion. However, because the district court named the incorrect defendant

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 R. 47.5, the court has determined that this opinion should not
be published and is not precedent except under the limited circumstances set forth in 5TH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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(“Blue Cross/Blue Shield of Louisiana”) in its order, we AFFIRM the
judgment, but REMAND with instructions to correct the name of the
defendant.
I.

Factual Background

This case arose out of the termination of disability benefits to Dix under
the Blue Cross Blue Shield of Louisiana’s (“BCBSL”) long-term disability
program, which is governed by ERISA. Dix’s employer, BCBSL, and other
independent Blue Cross and Blue shield organizations participate in the
Program by paying into a trust which in turn funds the Program. The Blue
Cross and Blue Shield Association (“the Association”) is an Illinois not-forprofit corporation which provides fiduciary administrative services to BCBSL
and other Blue Cross and Blue Shield Organizations through its National
Employees Benefits Committee (“NEBC”) and National Employees Benefits
Administration (“NEBA”). NEBA and NEBC (the “Administrator”) administer
the Program at issue in this case. The parties agree that the Administrator
has discretionary authority to approve or deny benefits.
Dix was an employee of BCBSL from 2006 to 2007. In 2007, Dix began
experiencing back pain and applied for disability benefits on June 13, 2007.
Dix was deemed disabled following examination and began receiving disability
benefits. On July 7, 2010, Dix was notified that she would no longer be
receiving disability payments, as the Administrator had found that the medical
evidence no longer supported a finding of disability. Dix appealed the decision
to deny benefits to the Assistant Secretary of NEBC, Barbara Grant, who
affirmed the denial.
In reviewing Dix’s claim, Grant considered the medical opinions of
numerous treating and reviewing physicians, and the findings of an
independent medical evaluation and a vocational expert’s report. Reviewing
physician Dr. Scott Kale found Dix not disabled and capable of work with
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accommodations.

Dix claims that Dr. Kale lied about speaking with her

treating physicians, Dr. Kevin McCarthy and Dr. Elizabeth Russo-Stringer.
On January 27, 2012, Dix submitted to the Administrator medical
records, X-rays, and MRIs from Dr. McCarthy, affidavits from Dr. McCarthy
and Dr. Russo-Stringer stating that they do not recall speaking with Dr. Kale,
and the first page of a favorable Social Security Administration (“SSA”)
decision.

The Administrator declined to add the documents to the

administrative record on the basis that they were either cumulative or not
available at the time Dix exhausted her administrative remedies. Dix filed
suit and the district court granted summary judgment in favor of the Program.
II.

Standard of Review

This court reviews summary judgments de novo in ERISA cases,
applying the same standards as the district court. Robinson v. Aetna Life Ins.
Co., 443 F.3d 389, 392 (5th Cir. 2006).
When, in an ERISA case, the language of the plan grants discretion to
an administrator to interpret the plan and determine eligibility for benefits, a
court will reverse the administrator’s decision only for abuse of discretion.
McCorkle v. Metropolitan Life Ins. Co., 757 F.3d 452, 457 (5th Cir. 2014). Here,
the parties do not dispute that the plan grants discretionary authority to the
plan administrator. “A plan administrator abuses its discretion where the
decision is not based on evidence, even if disputable, that clearly supports the
basis for its denial.” Id. (quoting Holland v. Int’l Paper Co. Ret. Plan, 576 F.3d
240, 246 (5th Cir. 2009), (internal quotation marks omitted). We reach a
finding of abuse of discretion only when the plan administrator acted
arbitrarily or capriciously. Id. A decision is arbitrary or capricious if made
without a rational connection between the known facts and the decision. Id.
The administrator's decision to deny benefits must be supported by
substantial evidence.

Holland, 576 F.3d at 246.
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Substantial evidence is

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merely “more than a scintilla, less than a preponderance, and is such relevant
evidence as a reasonable mind might accept as adequate to support a
conclusion.” McCorkle, 757 F.3d at 457 (quoting Ellis v. Liberty Life Assurance
Co. of Boston, 394 F.3d 262, 273 (5th Cir. 2004)) (internal quotation marks
omitted).

A court’s “review of the administrator’s decision need not be

particularly complex or technical; it need only assure that the administrator's
decision falls somewhere on a continuum of reasonableness—even if on the low
end.” Holland, 576 F.3d at 247.
III.

Discussion

On appeal, Dix reasserts that the Administrator had a conflict of
interest; that the administrative record should have included documents,
including a favorable SSA disability award, that Dix failed to submit to the
Administrator for over a year after its final decision; and that the termination
of benefits was an abuse of discretion and unsupported by substantial evidence.
We consider each issue in turn.
A. Conflict of Interest
The parties disagree about whether the Administrator operated under
a structural conflict of interest when it terminated Dix’s disability payments.
The district court found that the Administrator had a conflict of interest when
it evaluated Dix’s claim because it both funded the disability program and
made benefits eligibility decisions. This was incorrect.
A conflict of interest exists when a plan administrator both evaluates
claims for benefits and pays benefits claims. Metro. Life Ins. Co. v. Glenn,
554 U.S. 105, 112 (2008). “If the administrator has a conflict of interest, we
weigh the conflict of interest as a factor in determining whether there is an
abuse of discretion in the benefits denial, meaning we take account of several
different considerations of which conflict of interest is one.” Holland, 576 F.3d
at 247.
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Here, Dix’s employer, BCBSL, paid into a trust which in turn funded the
payment of benefits under the Program. The Association determined eligibility
for benefits through NEBA and NEBC. Although the district court found that
“BCBS’s Board of Directors comprised the committee charged with
administering the disability plan,” the record shows that it was the
Association’s board of directors which comprised the eligibility committee, not
the board of directors of the Program or of BCBSL. These facts show that a
structural conflict of interest did not exist because the Association, through
NEBA and NEBC, made benefits eligibility decisions, while the Program paid
benefits claims, 1 and BCBSL had no financial interest in individual disability
determinations.
B. Supplementing the Administrative Record
Dix argues that the district court should have allowed her to supplement
the administrative record with additional medical records, affidavits from
Dr. McCarthy and Dr. Russo-Stringer, and a favorable Social Security
Administration decision.

In Vega, the Fifth Circuit held that “[t]he

administrative record consists of relevant information made available to the
[plan] administrator prior to the complainant’s filing of a lawsuit and in a
manner that gives the administrator a fair opportunity to consider it.” Vega v.
Nat’l Life Ins. Servs., Inc., 188 F.3d 287, 300 (5th Cir. 1999).
Here, the Administrator gave Dix ample opportunity to supplement the
administrative record prior to making a final decision on Dix’s benefits
eligibility appeal.

Grant asked Dix whether she would like to submit

additional documentation, and even gave Dix an extension on the deadline for
Assuming arguendo that the district court correctly found that a structural conflict
of interest exists, the court nevertheless found that the decision to deny Dix’s benefits was
not arbitrary and capricious, even when factoring the conflict of interest into its analysis. We
agree with the district court, that, even if a conflict of interest exists, it does not change the
outcome reached here.
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submitting documentation. Dix failed to submit any of the documentation she
now seeks to include in the administrative record before the administrator
made the final decision. Dix only sent the additional documents to Grant after
Dix had exhausted her administrative remedies, approximately one year and
three months after the Administrator issued its final decision in her appeal.
Given this history, Dix did not make the documents she now seeks to introduce
into the record available in a manner that gave the plan administrator a fair
opportunity to consider them. See Hamburg v. Life Ins. Co. of North America,
470 F. App’x 382 (5th Cir. 2012) (upholding the district court’s refusal to
remand a case to the plan administrator to supplement the administrative
record where the benefits claimant failed to submit documentation to the plan
administrator during the 18 months in which he was pursuing an appeal). Dix
argues that it was arbitrary and capricious for the Administrator not to
consider a SSA decision (made after the plan administrator upheld denial of
her claim) finding Dix disabled.

Because the SSA decision was properly

excluded from the administrative record, we do not consider it in determining
whether the Administrator’s denial was arbitrary and capricious.
C. The Administrator’s Decision
The district court very thoroughly analyzed whether the Administrator’s
decision was arbitrary and capricious. “The job of weighing valid, conflicting
professional medical opinions is not the job of the courts; that job has been
given to the administrators of ERISA plan administrators.” Corry v. Liberty
Life Assurance Co. of Boston, 499 F.3d 389, 401 (5th Cir. 2007). Here, the
Administrator based its decision on the medical opinions of several physicians
and an independent medical evaluation finding Dix capable of sedentary
employment. Although Dix disputes the accuracy and completeness of these
medical findings, she cannot meet her burden to show that the Administrator’s
decision was not based on substantial evidence.
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Accordingly, the

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Administrator’s decision was not arbitrary and capricious, and there was no
abuse of discretion in denying Dix’s claim.
Although the district court’s judgment is correct, the court named the
wrong party in its order granting summary judgment. For this reason, we
AFFIRM the judgment, but REMAND with instructions to name as the
defendant Blue Cross and Blue Shield Association Long Term Disability
Program.

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