Cortez v. General Mills, Inc., et al
OPINION AND ORDER: Plaintiff Enrique Cortez's Motion for Judgment on the Administrative Record 28 is DENIED. Defendants General Mills, Inc. and General Mills, Inc. Long-Term Disability Income Plan's Motion for Judgment on the Administrative Record 33 is GRANTED. LET JUDGMENT BE ENTERED ACCORDINGLY. See Order for specifics. (Written Opinion). Signed by Judge Eric C. Tostrud on 11/13/2023. (RMM)
UNITED STATES DISTRICT COURT
DISTRICT OF MINNESOTA
File No. 22-cv-1552 (ECT/JFD)
OPINION AND ORDER
General Mills, Inc., and General Mills, Inc.
Long-Term Disability Income Plan,
Robert J. Leighton, Jr. and Denise Yegge Tataryn, Nolan Thompson Leighton & Tataryn
PLC, Hopkins, MN, and Jodell M. Galman, Galman Law Offices, Hugo, MN, for Plaintiff
Andrew J. Holly and Ashley C. Repp, Dorsey & Whitney LLP, Minneapolis, MN, for
Defendants General Mills, Inc. and General Mills, Inc. Long-Term Disability Income Plan.
In this ERISA lawsuit, Plaintiff Enrique Cortez seeks to recover long-term disability
benefits under an employee welfare benefit plan (the “Plan”) sponsored and administered
by his former employer, General Mills. Mr. Cortez applied for benefits in 2017, and his
claim was approved. In May 2021, after paying benefits for roughly four years, the Plan
determined that Mr. Cortez was no longer disabled and terminated his benefits. In line
with the Plan’s administrative procedures, Mr. Cortez appealed the decision to terminate
his benefits. An appeal committee affirmed the initial termination decision, prompting Mr.
Cortez to file this case.
Mr. Cortez and Defendants have filed competing motions seeking judgment on the
administrative record pursuant to Federal Rules of Civil Procedure 39(b) and 52(a)(1). In
doing so, the parties have made clear that they wish the Court to exercise its factfinding
function and enter judgment on the basis of the administrative record and briefs filed in
connection with the motions. Judgment will be entered for Defendants because substantial
evidence supported the decision to terminate Mr. Cortez’s long-term disability benefits.
The Plan provides benefits to covered General Mills employees who suffer a “Total
Disability.” AR 5.2 As relevant here, a covered employee suffers a “Total Disability”
when, after exhaustion of company-provided short-term disability benefits or six months
of state-provided disability benefits, the employee is unable to perform the “Essential
Functions of his or her Own Occupation . . . and . . . is unable to earn 80% or more of his
. . . pre-disability monthly base earnings.” AR 9. “Essential Functions” are duties that are
“substantial, not incidental, . . . fundamental to the occupation and cannot be reasonably
omitted or changed.” AR 7. “Own Occupation” includes the employee’s “occupation or
any reasonably related occupation as it is recognized in the general workplace.” AR 8.
After an employee has received 18 months of long-term disability benefits, the Plan
requires the employee to be not merely disabled from his “Own Occupation,” but also to
This opinion describes the factual findings and legal conclusions required by Rule
52(a)(1). Citations to the administrative record (or “AR”) are to CM/ECF pagination found
in the upper right corner (and not to a document’s original pagination or to Bates labels
assigned during the case).
The Plan document in the administrative record has an effective date of March 1,
2019. AR 2. The parties agree that “the Court can consider the 2019 Plan document to be
the operative plan document with respect to Plaintiff’s disability claim.” ECF No. 51; see
ECF No. 52.
be “unable to perform, for income, the Essential Functions of Any Occupation, and . . .
unable to earn 60% or more of his . . . pre-disability monthly base earnings.” AR 9. “Any
Occupation” means “an occupation for which the [employee] is reasonably suited, or could
become suited, by the [employee’s] education, training or experience with or without
The “Long-Term Disability Committee” (or
“Committee”) administers the Plan and possesses responsibility and discretion to interpret
the Plan and determine benefits claims. See AR 6, 13, 21, 29–30. A “Claims Appeal
Committee” (or “Appeal Committee”) possesses final responsibility and discretion to
review appeals by claimants whose benefits claims have been denied. AR 6, 22–24, 30.
March 2017 – June 2017: The Committee approves Mr. Cortez’s initial benefit
claim.3 Mr. Cortez filed his claim for long-term disability benefits in March 2017. AR
717–18. He claimed to have been unable to work beginning October 13, 2016. AR 717.
In response to a question on the Plan’s standard claim form asking Mr. Cortez to describe
his disabling symptoms, Mr. Cortez wrote: “Radiating back pain & neuropathy down legs,
Achilles tendinopathy & major depressive disorder, plus more than a dozen prescription
medications + side effects.” AR 717. The combination, he wrote, was “physically &
mentally crippling.” AR 717. At the time of his claim, Mr. Cortez was working for General
Mills as an engineer in a research-and-development area. AR 721. In a letter dated April
An “LTD Case Specialist” with a third-party benefits administrator, Sedgwick,
coordinated the day-to-day administration of Mr. Cortez’s claim and made
recommendations to the Committee regarding various matters, including investigative
steps and benefits decisions. See AR 735–36, 746 (identifying Kim Finley with Sedgwick
as the “Disability Representative” assigned to Mr. Cortez’s claim). No one suggests that
Sedgwick must or should be a party to this case.
19, 2017, the Committee notified Mr. Cortez of its decision to approve his claim, but only
through June 30, 2017. AR 735–36. The Committee explained—as it would again in
several subsequent letters—that it would review Mr. Cortez’s eligibility for benefits at
regular intervals and that Mr. Cortez’s failure to provide periodically updated medical
information might result in the suspension of his benefits. AR 735.
June 2017 – September 2019: The Committee periodically reviews and approves
Mr. Cortez’s claim based on records from his treating providers. The record shows that
Mr. Cortez’s claim fell into something of a pattern from June 2017 to September 2019.
The Committee periodically reviewed Mr. Cortez’s ongoing eligibility for benefits. See
AR 743–747 (June 2017 review); 787–98 (September 2017 review); 805–11 (December
2017 review); 823–30 (May 2018 review); 854–65 (September 2018 review); 875–81
(March 2019 review). The Committee obtained and reviewed medical and treatment
records from, and forms completed by, Mr. Cortez’s various health-care providers. See,
e.g., AR 753–65 (treatment records); 766–67 (attending physician statement). During this
period, the Committee repeatedly approved Mr. Cortez’s claim through a date between
roughly ninety days and six months out from its approval decision. See AR 744, 788, 806,
824, 855, 876.
September 2019 – February 2020: Though two non-treating providers determine
that Mr. Cortez can return to work, the Committee approves Mr. Cortez’s ongoing claim.
As part of its September 2019 review, the Committee arranged for Mr. Cortez to be
examined by two non-treating providers—a psychologist and an orthopedic surgeon. AR
897. The Committee approved Mr. Cortez’s claim through December 2019 as it awaited
reports from these examinations. In a report dated November 19, 2019, the psychologist,
Mary Kenning, Ph.D., opined that Mr. Cortez’s depression symptoms “seem[ed] to be in
substantial remission.” AR 909, 915. She opined “that part[-]time work, up to half[-]time,
seems reasonable” and that Mr. Cortez “seem[ed] ready to return to work in the next six
weeks.” AR 916. In a report dated November 27, 2019, the orthopedic surgeon, Paul T.
Wicklund, M.D., opined that Mr. Cortez was “not disabled from his present job or any job”
and that, “[f]rom an orthopedic standpoint, Mr. Cortez [was] capable of working full-time.”
AR 920, 924. In December 2019, the Committee approved Mr. Cortez’s claim through
January 2020 to give his treating physicians time to respond to the reports of Dr. Kenning
and Dr. Wicklund. AR 927. In late December, Mr. Cortez’s mental-health-care providers
confirmed they agreed with Dr. Kenning’s evaluation and recommendations. AR 936–37.
As of mid-January 2020, the providers who treated Mr. Cortez’s physical problems
evidently had not responded, AR 939–40, though Mr. Cortez and his spouse had expressed
concerns regarding Dr. Wicklund’s report, AR 942–43. Notwithstanding the Sedgwick
staff person’s recommendation that Mr. Cortez’s benefits be terminated effective February
1, 2020, the Committee decided to approve benefits through February 29, 2020, “to await
further medical.” AR 940.
February 2020 – April 2021: The Committee approves Mr. Cortez’s ongoing claim.
During this period, the Committee made a series of decisions approving Mr. Cortez’s
benefits claim. All but one of these decisions approved benefits going forward one month
at a time; the exception was the Committee’s decision in November 2020 to approve
benefits through January 2021. See AR 948 (February 2020); 954 (March 2020); 962
(April 2020); 976 (May 2020); 982 (June 2020); 991 (July 2020); 1007 (August 2020);
1022 (September 2020); 1030 (October 2020); 1083 (November 2020); 1098 (January
2021); 1111 (February 2021); 1268 (April 2021). Several events during this period hold
particular significance to this case:
In April and May 2020, the Committee requested and received completed
“Attending Physician Statement” forms from two of Mr. Cortez’s treating
A psychiatric provider, physician assistant Leah Streitman,
indicated that Mr. Cortez was not able to return to work, but she also noted
her agreement with Dr. Kenning’s November 2019 recommendations to the
effect that Mr. Cortez possessed the ability to return to work at least
See AR 964–65; see also AR 937.
An internal medicine
physician, David Macomber, M.D., indicated that Mr. Cortez was not able to
return to work. AR 969–70.
Beginning in February 2020, the Committee’s approval of Mr. Cortez’s
claim was accompanied by a decision to investigate the availability of
part-time work. AR 948.4 As far as the record shows, the availability of
As it appears in the record, the description of this decision reads: “Agreement to
approve benefits through 03/31/2020 and verbal warning regarding lack of medical
documentation. GMI to reach out to ER regarding potential rtw role.” AR 948. To be
clear, I understand “GMI” to mean “General Mills, Inc.” At the hearing on these motions,
Defendants’ counsel suggested that “ER” likely meant either “employer” or General Mills’
human resources department. I understand “rtw” to be shorthand for “return to work.”
Regardless, the record shows beyond dispute that the Committee’s February 2020 approval
came with the expectation that Mr. Cortez’s possible return to part-time work would be
part-time work remained the subject of inquiry through the Committee’s June
2020 benefits decision. At that time, though the Committee recognized the
value a “staged return to work” might hold for Mr. Cortez, it also realized
that any income Mr. Cortez might earn from part-time work likely would not
impact his Plan benefits. AR 982. The subject of part-time work appears to
have dropped off the table at that time.
Effective July 1, 2020, the Committee determined that Mr. Cortez remained
disabled and benefits-eligible only because of a mental illness. AR 982,
986–88. The basis for this determination is not obvious, but it seems the
Committee accepted Dr. Wicklund’s determination that Mr. Cortez was not
disabled from an orthopedic standpoint. See AR 982. Had the Committee’s
“disabled by mental illness only” determination held, its effect would have
been to cap Mr. Cortez’s eligibility for further benefits at 24 months from
July 1, 2020. AR 987. The determination did not hold, however. Claim
notes show that the mental-health-only eligibility determination was lifted at
the Committee’s meeting in July 2020. AR 991. Again, the basis for this
reversal is not clear, but it appears to have stemmed from the fact that Mr.
Cortez was continuing to receive care from “pain and back specialists.” AR
In October 2020, Mr. Cortez underwent a neuropsychological evaluation by
Douglas Whiteside, Ph.D., a clinical neuropsychologist. AR 1086–89. Mr.
Cortez’s treating internist, Dr. Macomber, requested the evaluation. AR
1086. Dr. Whiteside’s examination showed largely normal results, leading
Dr. Whiteside to conclude that Mr. Cortez did not suffer from
neuropsychological or cognitive deficits. See AR 1086–87. Dr. Whiteside
found evidence that Mr. Cortez suffered from “significant anxiety
symptoms” and “acknowledged a history of depression.” AR 1087. Dr.
Whiteside ultimately concluded that Mr. Cortez’s “etiology is multifactorial,
including his depression/anxiety symptoms, chronic pain, obstructive sleep
apnea, and possible medication effects.” AR 1087.
In January 2021, Ms. Streitman determined that Mr. Cortez was “cleared to
work from a mental health standpoint.” AR 1285. In Ms. Streitman’s
opinion, Mr. Cortez was capable of returning to work eight hours per day
without limitations beginning January 29, 2021. AR 1285.
April 2021 – May 2021: The Committee terminates Mr. Cortez’s benefits. In April
2021, Mr. Cortez was examined by a non-treating neurologist, Beth Ann Staab, M.D. AR
1281–84. Prior to the examination, Dr. Staab reviewed Mr. Cortez’s “extensive medical
records from 2016 through 2021.” AR 1281. In a note documenting the examination, Dr.
Staab summarized Mr. Cortez’s last occupation at General Mills, recounted Mr. Cortez’s
belief that “he is no longer able to work due to constant pain in his neck and back which
he feels is distracting” and the “fog” he experiences from “his pain and his medications
needed to control his pain,” and summarized Mr. Cortez’s medical history. AR 1281–83.
Dr. Staab diagnosed Mr. Cortez as having cervical and lumbar degenerative disc disease,
anxiety, depression, obesity, “complaints of difficulty with focus/attention,” diabetes, and
“[l]eft ulnar neuropathy across the elbow status post ulnar nerve transposition.” AR 1283.
She noted that Mr. Cortez’s pain was “consistent with the minor degenerative changes
noted on imaging.” AR 1284. Dr. Staab concluded:
In my medical opinion, Mr. Cortez is not disabled from his
present job as [a] result of his neck and back pain. Mr. Cortez
expressed concern regarding cognitive impairment due to
chronic pain and medications used to treat chronic pain.
Neuropsychometric testing did not show significant
impairment which would preclude him from successfully
completing his job.
AR 1284. Dr. Staab opined that Mr. Cortez could return to full-time work and that, due to
the non-physical nature of his occupation, it would not be necessary to impose restrictions
on Mr. Cortez’s occupational activities. AR 1284. In a letter dated May 25, 2021, the
Committee notified Mr. Cortez of its determination that he was no longer eligible for
benefits and that his last day of benefits would be May 31, 2021. See AR 1292–94. This
decision, the letter explained, was based on Dr. Staab’s examination and opinions and the
November 2019 examinations conducted by Dr. Kenning and Dr. Wicklund. AR 1292.
November 2021 – April 2022: Mr. Cortez appeals the Committee’s decision to
terminate benefits, and the Appeal Committee denies the appeal. Through counsel, Mr.
Cortez submitted his administrative appeal in November 2021. AR 35–36. In his appeal,
Mr. Cortez quoted extensively from records supporting his claim.
summarize, Mr. Cortez argued: (1) that the decision to terminate benefits was incorrect
because his conditions had “worsened throughout 2020 and 2021” and that the absence of
documented improvements made the Committee’s decision comparable to ERISA benefits
determinations the Eighth Circuit and federal district courts have found were arbitrary, AR
48–53; (2) that the Committee improperly “cherry-pick[ed] information” to terminate
benefits, AR 53; (3) that the Committee failed to account for the cumulative effect of Mr.
Cortez’s many health problems, AR 55; (4) that the Committee was required to—but did
not—attribute weight to Mr. Cortez’s subjective complaints, AR 56–58; and (5) that the
Committee’s decision was at odds with the decision to award Mr. Cortez Social Security
disability benefits, AR 58. A screenshot shows—and Defendants do not dispute—that Mr.
Cortez’s appeal was delivered to the Appeal Committee at a P.O. Box on November 18,
2021. ECF No. 31-1 at 3. In a letter dated March 10, 2022, however, the Appeal
Committee claimed not to have received Mr. Cortez’s appeal until that day (March 10).
AR 37.5 The Appeal Committee met to review Mr. Cortez’s appeal on March 30, 2022,
AR 1301, and in a letter dated April 11, it informed Mr. Cortez of its decision to deny his
appeal, ECF No. 37-1. In this letter, the Appeal Committee explained it had determined
that Mr. Cortez was not disabled by physical or mental-health conditions, that evidence
provided by one of Mr. Cortez’s treating physicians suggesting that Mr. Cortez was
disabled was outweighed by other, stronger evidence, that Mr. Cortez’s combination of
conditions did not cause him to be disabled, and that his receipt of Social Security disability
benefits had no bearing on his claim for Plan benefits. ECF No. 37-1.
In its response brief, General Mills asserts that Mr. “Cortez’s appeal was (through
no fault of [Mr.] Cortez’s) directed to an incorrect mail box at General Mills due to a
miscommunication.” Defs.’ Resp. Mem. [ECF No. 48] at 2 n.1. According to General
Mills, after Mr. Cortez inquired about the status of his appeal, “the miscommunication was
discovered,” and Mr. Cortez resubmitted his appeal. Id.
Mr. Cortez files this case, and the parties file their motions. In his complaint, Mr.
Cortez asserts a claim under the Employee Retirement Income Security Act of 1974, 29
U.S.C. § 1001, et seq. (“ERISA”), seeking recovery of “all benefits due under the Plan”
pursuant to ERISA’s civil enforcement provision, § 1132(a)(1)(B), attorneys’ fees pursuant
to § 1132(g), and pre-judgment interest. Compl. [ECF No. 1] at 1 ¶ 1, and at 3 ¶¶ 1–3. As
noted, Mr. Cortez and Defendants have filed competing motions seeking judgment on the
administrative record pursuant to Federal Rules of Civil Procedure 39(b) and 52(a)(1).
ECF Nos. 28, 33. Through the filing of these motions, the parties have made clear that
they wish the Court to “exercise its factfinding function . . . to decide the case on the
administrative record.” Avenoso v. Reliance Standard Life Ins. Co., 19 F.4th 1020, 1026
(8th Cir. 2021). In this circumstance, a district court may weigh evidence, make credibility
determinations, and make findings on disputed factual questions. See id. at 1024, 1026.
Suits brought under § 1132(a)(1)(B) to recover benefits allegedly due to a
participant are reviewed de novo unless the benefit plan gives the administrator
discretionary authority to determine eligibility for benefits. Firestone Tire & Rubber Co.
v. Bruch, 489 U.S. 101, 115 (1989). If the plan grants the administrator such discretion,
then “review of the administrator’s decision is for an abuse of discretion.” Johnston v.
Prudential Ins. Co. of Am., 916 F.3d 712, 714 (8th Cir. 2019) (quoting McClelland v. Life
Ins. Co. of N. Am., 679 F.3d 755, 759 (8th Cir. 2012)). Here, there is no question the Plan
vests the Committee and the Appeal Committee with discretion to determine
benefits-eligibility questions. See AR 13, 21–22, 29–30. Ordinarily, the presence of this
discretion-granting language is enough to warrant abuse-of-discretion review.
Mr. Cortez argues, however, that abuse-of-discretion review does not apply and that
his claim should be reviewed de novo. To support this argument, Mr. Cortez relies on
claims-procedures regulations promulgated by the Department of Labor, 29 C.F.R. §§
2560.503-1(i)(3)(i) and 2560.503-1(l)(2)(i). See Pl.’s Mem. [ECF No. 45] at 30–31. The
first cited regulation—§ 2560.503-1(i)(3)(i)—says that a disability-benefits plan must issue
an appeal determination not later than 45 days after it receives a claimant’s request for
review. The second cited regulation reads as follows:
(2) Plans providing disability benefits.
(i) In the case of a claim for disability benefits, if the plan fails
to strictly adhere to all the requirements of this section with
respect to a claim, the claimant is deemed to have exhausted
the administrative remedies available under the plan, except as
provided in paragraph (l)(2)(ii) of this section. Accordingly,
the claimant is entitled to pursue any available remedies under
section 502(a) of the Act on the basis that the plan has failed to
provide a reasonable claims procedure that would yield a
decision on the merits of the claim. If a claimant chooses to
pursue remedies under section 502(a) of the Act under such
circumstances, the claim or appeal is deemed denied on review
without the exercise of discretion by an appropriate fiduciary.
29 C.F.R. § 2560.503-1(l)(2)(i). In Mr. Cortez’s view, the Plan’s failure to strictly adhere
to the 45-day appeal-determination deadline in § 2560.503-1(i)(3)(i) triggers de novo
review under § 2560.503-1(l)(2)(i).
This is not correct, at least on this case’s facts. A subsequent rule in the same section
says that § 2560.503-1(l)(2) applies to disability-benefit claims “filed under a plan after
April 1, 2018[.]” 29 C.F.R. § 2560.503-1(p)(3) (emphasis added). As several courts have
explained, this means § 2560.503-1(l)(2)(i) does not apply if the initial benefit claim was
filed before that date; it doesn’t matter if the challenged adverse benefit determination
occurred after that date. Zall v. Standard Ins. Co., 58 F.4th 284, 292–93 (7th Cir. 2023);
Card v. Principal Life Ins. Co., No. 5:15-cv-139-KKC, 2023 WL 5706202, at **8–9 (E.D.
Ky. Sept. 5, 2023); Taylor v. Unum Life Ins. Co. of Am., No. 21-cv-331-JWD-EWD, 2023
WL 2766018, at **12–13 (M.D. La. Mar. 31, 2023); Brewer v. Unum Grp. Corp.,
622 F. Supp. 3d 1113, 1119, 1122 (N.D. Ala. 2022); Martin v. Guardian Life Ins. Co. of
Am., No. 5:20-cv-507-DCR, 2021 WL 2516083, at *2 (E.D. Ky. June 15, 2021); Bustetter
v. Standard Ins. Co., 529 F. Supp. 3d 693, 702 n.3 (E.D. Ky. 2021); Smith v. Hartford Life
and Accident Ins. Co., 421 F. Supp. 3d 416, 418–20 (E.D. Ky. 2019); see Fessenden v.
Reliance Standard Life Ins. Co., 927 F.3d 998, 1003 n.3 (7th Cir. 2019) (Barrett, J.). Here,
as noted, Mr. Cortez filed his long-term-disability-benefit claim in March 2017. AR
717–18. Therefore, § 2560.503-1(l)(2)(i) does not apply to trigger de novo review in this
Under the applicable 2002 regulations, the Eighth Circuit has made clear that “the
administrator’s decisional delay on appeal does not in and of itself trigger de novo review.”
McIntyre v. Reliance Standard Life Ins. Co., 972 F.3d 955, 964–65 (8th Cir. 2020). In
McIntyre, the court acknowledged that other circuits permitted de novo review of ERISA
benefits denials “in the face of an administrator’s ‘decisional delay’ beyond the deadline
prescribed in ERISA’s implementing regulations of the plan itself.” Id. at 963 (footnote
omitted). The court explained:
Such a rule, however, is not the law of our circuit.
Consider Johnson [v. United of Omaha Life Ins, 775 F.3d 983
(8th Cir. 2014)], in which the district court found procedural
irregularities present and concluded (mistakenly . . .) that de
novo review thus was warranted under Woo. 775 F.3d at 988.
As relevant here, one of the procedural irregularities was the
administrator’s “failure to timely process the [beneficiary’s]
claims.” Id. (brackets omitted). Specifically, the beneficiary
appealed the initial denial of her long-term disability claim on
August 27, 2010. See Johnson v. United of Omaha Life Ins.,
No. 8:11CV296, 2013 WL 942511, at *9-10 (D. Neb. Mar. 11,
2013). The administrator denied the appeal on January 28,
2011, meaning the appeal was pending for 154 days. See id. at
*11. Under both the terms of the policy at issue there as well
as the governing regulations at the time, the administrator was
required to issue a decision within forty-five days of receipt of
the appeal, with only one forty-five-day extension of that initial
forty-five-day period permitted, for a maximum total of ninety
days. See 29 C.F.R. § 2560.503-1(i)(1)(i) (2009); id. §
2560.503-1(i)(3)(i). Tolling of this deadline was permitted in
limited circumstances, see id. § 2560.503-1(i)(4), but it does
not appear the administrator in Johnson had any basis to argue
for tolling, see Johnson, 2013 WL 942511, at *10-11. Thus,
just like Reliance here, the administrator in Johnson failed to
issue a decision regarding the appeal within the prescribed
timeframe. This untimeliness (and a number of other
procedural irregularities) notwithstanding, we reversed the
district court and “determined the abuse-of-discretion standard
was the appropriate standard for the district court to
apply.” Johnson, 775 F.3d at 988-89.
Id. at 964 (footnote omitted). The court explained that “under circuit law, de novo review
is not triggered in this context unless the administrator wholly fails to act on an appeal and
that failure raises serious doubts about the result reached by the plan administrator in its
initial denial.” Id. at 965 (cleaned up). “Deciding an appeal after a prescribed deadline is
obviously not a wholesale failure to act on an appeal.” Id. The Eighth Circuit reaffirmed
these principles in a successive appeal in McIntyre. McIntyre v. Reliance Standard Life
Ins. Co., 73 F.4th 993, 1002–03 (8th Cir. 2023). In light of the McIntyre decisions and
other controlling Eighth Circuit cases, it would be a mistake to review Mr. Cortez’s claim
The Eighth Circuit applies two distinct tests to determine whether an ERISA plan
administrator’s benefits determination was reasonable and not an abuse of discretion.
First, to determine whether an administrator’s interpretation of plan terms was reasonable,
the court applies the five-factor test from Finley v. Special Agents Mutual Benefit
Association, 957 F.2d 617, 621 (8th Cir. 1992). King v. Hartford Life & Accident Ins. Co.,
414 F.3d 994, 999 (8th Cir. 2005) (en banc); see also id. at 1014 (Gruender, J., dissenting).
The five factors to be considered ask whether the administrator’s interpretation: (1) is
consistent with the goals of the plan; (2) renders any language of the plan meaningless or
internally inconsistent; (3) conflicts with ERISA; (4) is consistent with the administrator’s
prior determinations regarding the terms at issue; and (5) is contrary to the clear language
of the plan. Peterson ex rel. E v. UnitedHealth Grp. Inc., 913 F.3d 769, 775–76 (8th Cir.
2019). “While these non-exhaustive factors ‘inform our analysis,’ the ultimate question
remains whether the plan interpretation is reasonable.” Id. at 776 (quoting King, 414 F.3d
Second, to determine whether an administrator reasonably applied its interpretation
to the facts of any particular case, the test is whether the decision is “supported by
substantial evidence.” Johnston, 916 F.3d at 714 (quoting Green v. Union Sec. Ins. Co.,
646 F.3d 1042, 1050 (8th Cir. 2011)). “Substantial evidence is more than a scintilla but
less than a preponderance.” Id. (quoting Green, 646 F.3d at 1050); see also Jones v. Aetna
Life Ins. Co., 856 F.3d 541, 547–48 (8th Cir. 2017) (citations omitted) (same).
Other considerations are relevant to both tests. “If an administrator also funds the
benefits it administers . . . the district court ‘should consider that conflict as a factor’ in
determining whether the administrator abused its discretion.” Jones, 856 F.3d at 548
(quoting Silva v. Metro. Life Ins. Co., 762 F.3d 711, 718 (8th Cir. 2014)). “A decision
supported by a reasonable explanation . . . should not be disturbed, even though a different
reasonable interpretation could have been made.” Waldoch v. Medtronic, Inc., 757 F.3d
822, 832–33 (8th Cir. 2014) (alteration in original) (citation and internal quotation marks
omitted), as corrected (July 15, 2014); see also Prezioso v. Prudential Ins. Co. of Am., 748
F.3d 797, 805 (8th Cir. 2014) (“We must affirm if a reasonable person could have reached
a similar decision, given the evidence before him, not that a reasonable person would have
reached that decision.” (citation and internal quotation marks omitted)). “[A] reviewing
court must focus on the evidence available to the plan administrators at the time of their
decision and may not admit new evidence or consider post hoc rationales.” Waldoch, 757
F.3d at 829–30 (citation and internal quotation marks omitted). “Courts reviewing a plan
administrator’s decision to deny benefits will review only the final claims decision, and
not the ‘initial, often succinct denial letters,’ in order to ensure the development of a
complete record.” Khoury v. Grp. Health Plan, Inc., 615 F.3d 946, 952 (8th Cir. 2010)
(citing Galman v. Prudential Ins. Co. of Am., 254 F.3d 768, 770–71 (8th Cir. 2001); Wert
v. Liberty Life Assurance Co. of Boston, 447 F.3d 1060, 1066 (8th Cir. 2006)).
Here, resolving the parties’ motions requires applying just the second test. Though
Defendants argue that they are entitled to judgment under the first test and its Finley factors,
Defs.’ Mem. [ECF No. 46] at 21–23, neither Mr. Cortez nor Defendants identify a disputed
Plan interpretation, and Mr. Cortez’s arguments seem clearly and exclusively directed
toward showing that the decision to terminate his benefits lacked substantial evidentiary
support, see Pl.’s Mem. at 22–30, 36–39. The issue, then, is whether the decision to
terminate Mr. Cortez’s benefits was supported by substantial evidence.
Substantial evidence supported the Appeal Committee’s determination that Mr.
Cortez was not totally disabled due to a mental-health condition or conditions. See ECF
No. 37-1 at 5–7. (a) In January 2021, Mr. Cortez’s treating provider, Ms. Streitman,
concluded that Mr. Cortez was “cleared to work from a mental health standpoint.” AR
1285. Ms. Streitman determined specifically that Mr. Cortez could return to work eight
hours per day without limitation beginning January 29, 2021. AR 1285. It is difficult to
imagine stronger evidence. (b) Dr. Whiteside’s neuropsychological evaluation is better
understood to support Ms. Streitman’s conclusion. Dr. Whiteside evaluated several aspects
of Mr. Cortez’s neuropsychological functioning. AR 1086–87. These included Mr.
Cortez’s “attention/concentration,” “verbal memory functioning,” “[e]xpressive and
receptive language,” and “executive” functioning. AR 1086–87. Generally, Dr. Whiteside
measured each of these aspects to be “within expected limits.” AR 1086. Dr. Whiteside
noted that Mr. Cortez’s verbal memory functioning and executive functioning were only
“very” mildly variable or “mildly variable.”
Though Dr. Whiteside
acknowledged that Mr. Cortez suffered from depression, anxiety, and chronic pain, among
other health issues, AR 1087, he nowhere expressed the opinion that Mr. Cortez was
disabled by a mental-health-related condition. AR 1087–89. To the contrary, several of
Dr. Whiteside’s recommendations concern Mr. Cortez’s behavior in a work environment,
permitting the reasonable inference that Dr. Whiteside more likely believed that Mr. Cortez
was capable of working. AR 1088–89 (referring to a “clutter-free work environment,” a
“quiet work environment,” and a tendency to procrastinate because Mr. Cortez considers a
“task . . . to be overwhelming”). (c) Though her examination occurred roughly eighteen
months before the Appeal Committee’s decision, Dr. Kenning’s opinions also may
reasonably be understood to support Ms. Streitman’s conclusion. As of November 2019,
Dr. Kenning thought that Mr. Cortez was capable of working “up to half[-]time” and that
he should be ready “to return to work in the next six weeks.” AR 916. Ms. Streitman
agreed with Dr. Kenning’s opinions at that time, AR 937, and Ms. Streitman’s subsequent
conclusion that Mr. Cortez was not disabled by a mental-health condition aligns with Dr.
Kenning’s prediction that Mr. Cortez should be capable of returning to full-time work in
the near future.6
Defendants argue that “although the Appeal Committee did not reach this issue, it
is worth noting that [Mr.] Cortez has exhausted his right to any continuing LTD benefits
based upon his mental illness.” Defs.’ Resp. Mem. at 7. Not so. The Plan caps benefits
at 24 months for a beneficiary whose disability is “primarily due to Mental Illness.” AR
True, the Committee determined that Mr. Cortez remained disabled and
benefits-eligible due only to a mental illness effective July 1, 2020. AR 982, 986–88. But
the Committee reversed that determination less than one month later at its July 2020
meeting. AR 991. In other words, as far as the Committee was concerned, Mr. Cortez
remained benefits-eligible for nearly the entire period he received benefits due to mental
illness and a physical condition. The Appeal Committee’s silence regarding the issue thus
Substantial evidence also supported the Appeal Committee’s determination that Mr.
Cortez was not disabled by a physical condition. (a) Dr. Staab’s examination provides the
strongest support. The tests Dr. Staab conducted during her examination returned normal
results. AR 1282–83. Her description of Mr. Cortez’s medical history and complaints is
reasonably thorough, seemingly accurate, and faithful to Mr. Cortez’s medical history. AR
Dr. Staab’s review of Mr. Cortez’s past imaging results showed “minor
degenerative changes.” AR 1284. And Dr. Staab concluded that Mr. Cortez’s symptoms
were consistent with these changes. AR 1284. Dr. Staab found that neck and back pain
did not disable Mr. Cortez from performing his own occupation at General Mills on a
full-time basis. AR 1284. Though Mr. Cortez had expressed concern to Dr. Staab
regarding his “cognitive impairment due to chronic pain and medications used to treat
chronic pain[,]” Dr. Staab explained that “[n]europsychometric testing did not show
significant impairment which would preclude him from successfully completing his job.”
AR 1284. And Dr. Staab concluded that Mr. Cortez’s neck and back pain did not warrant
restrictions because, as Mr. Cortez described it, his job was not physical and did “not
require significant bending, twisting or lifting.” AR 1284. (b) The physician who had
primary responsibility for treating Mr. Cortez’s physical complaints, Dr. Macomber, did
not provide the Committee or Appeal Committee with evidence undermining Dr. Staab’s
conclusions and did not fairly respond to the Committee’s requests for information. At
times, Dr. Macomber did not opine that neck or back pain caused Mr. Cortez to be disabled.
makes perfect sense. Even if it were correct, Defendants’ assertion would amount to a
not-to-be-considered “post hoc rationale.” Waldoch, 757 F.3d at 830.
In an attending-physician-statement form he completed in August 2020, for example, Dr.
Macomber listed only “depression” and “headaches” as Mr. Cortez’s disabling conditions.
AR 998. Consistent with this form, in a record documenting an office visit on August 4,
2020, Dr. Macomber noted Mr. Cortez’s report that “his lower back complaints are stable.”
AR 1229. In an attending physician statement dated December 6, 2020, Dr. Macomber
identified only “Anxiety” as Mr. Cortez’s disabling condition. AR 1093; see also AR 969
(listing “Depression” and “Headaches” as Mr. Cortez’s disabling conditions). Other times,
Dr. Macomber did not respond or fairly answer requests for relevant information. The
record includes, for example, no information showing that Dr. Macomber took issue with
Dr. Staab’s opinions. And when asked to provide particular information regarding Mr.
Cortez’s work limitations and restrictions, Dr. Macomber declined. AR 1095. Rather than
answer a series of specific questions, Dr. Macomber wrote only “Not yet.” AR 1095; see
also AR 971 (declining to answer the same questions).
Finally, substantial evidence supported the Appeal Committee’s determination that
Mr. Cortez was not “unable to earn 60% or more of his . . . pre-disability monthly base
earnings.” AR 9; see ECF No. 37-1 at 10. Ms. Streitman and Dr. Staab determined that
Mr. Cortez was capable of returning to full-time work in his own occupation. AR 1284–85.
From these conclusions alone, it logically follows that Mr. Cortez was able to earn more
than 60% of his pre-disability earnings. The Appeal Committee’s recognition that Mr.
Cortez possesses “impressive academic credentials and work experience,” though not
necessary, adds support for the conclusion. ECF No. 37-1 at 10.7
Mr. Cortez advances several arguments to show that the Appeal Committee’s
decision was flawed, but none of these arguments are persuasive.
(a) Mr. Cortez’s opening brief includes many excerpts from medical records
describing his health problems. Pl.’s Mem. at 4–20. These excerpts support Mr. Cortez’s
claim. On abuse-of-discretion review, however, the fact that the administrative record
includes evidence supporting Mr. Cortez’s claim—even evidence on which a reasonable
administrator might have approved the claim—does not show an abuse of discretion.
Waldoch, 757 F.3d at 832–33. It would be different if these excerpts undermined the
substantiality of the evidence on which the Appeal Committee based its decision. But Mr.
Cortez does not explain, and it is not apparent, how these excerpts might carry that burden.
(b) Mr. Cortez criticizes the Appeal Committee’s reliance on Dr. Wicklund’s
November 2019 examination. Mr. Cortez points out that the Plan continued to pay benefits
for roughly eighteen months after Dr. Wicklund’s examination and report. Pl.’s Mem. at
22–23 (“Defendants have not made it clear how an [examination] in 2019 is relevant to
[Mr.] Cortez’[s] conditions in May of 2021.”). Mr. Cortez criticizes Dr. Wicklund for
ignoring objective evidence, including imaging, that supported his complaints of pain. Id.
Relevant to this issue, the Plan authorized the Committee and Appeal Committee to
“make reasonable estimates and determinations when determining whether the earnings
thresholds . . . have been exceeded” and made clear that “absolute precision shall not be
required.” AR 10.
at 23. And Mr. Cortez faults the Committee for failing to ask Dr. Wicklund to address his
“co-morbid conditions” more broadly. Id. Mr. Cortez has a point. Dr. Wicklund’s
examination and report do not contribute much.
Dr. Wicklund seems not to have
questioned whether Mr. Cortez suffered from his assertedly disabling conditions; he noted
specifically that Mr. Cortez suffered from “degenerative disk disease” and “[m]ajor
depressive disorder,” AR 923, and he recognized that Mr. Cortez “has multiple medical
problems which need to be dealt with[,]” AR 924. Dr. Wicklund appears merely to have
concluded that Mr. Cortez’s physical problems were not “orthopedic” in nature. He noted,
for example, that Mr. Cortez’s “current treatment plan is medically-based and not
orthopedically-based.” AR 924. He agreed that the treatment plan was “appropriate but
unrelated to any ongoing orthopedic injury.” AR 924. In other words, Dr. Wicklund’s
finding that Mr. Cortez was then capable of working full-time “[f]rom an orthopedic
standpoint” appears quite narrow.
(c) Mr. Cortez faults the Appeal Committee’s decision for contradicting the opinion
of the Plan’s retained medical consultant, Paul Anderson, M.D.
Pl.’s Mem. at 28
(“Defendants’ Own Expert Opines that Cortez Cannot Perform His Own
Occupation.”). Dr. Anderson served as a consultant to the Appeal Committee; he had no
vote on the Appeal Committee’s decision to terminate Mr. Cortez’s benefits. ECF 31-1 at
18 ¶ 4. Dr. Anderson described his work in connection with Mr. Cortez’s claim in a
Prior to the hearing on Mr. Cortez’s claim, I was provided a
copy of the administrative record, and I reviewed the medical
opinions of the various physicians included in the file
consistent with my training and expertise. During the hearing
on Mr. Cortez’s appeal, I noted that I had reviewed the medical
reports generated by the various physicians in the record
concluding that Mr. Cortez’s medical situation did not preclude
him from performing the essential duties of any occupation. I
informed the Appeal Committee that I found the reports to be
comprehensive, that the physicians’ credentials appeared to be
appropriate for the reports they were providing. I likewise
responded to questions about the effect that certain
medications that Mr. Cortez was taking, opining that they
might affect him in the performance of his own occupation, but
they would not preclude him from performing the essential
functions of any occupation. I noted that the level of activity
reflected in the record was not consistent with his claims that
he was totally disabled. I also explained the nature of the
cognitive tests in the record and concluded that they did not
reflect the profound level of disability claimed by Mr. Cortez.
To the contrary, they suggested that [he] had the ability to
function and had relatively strong cognitive capacity. I
concluded based upon my review of the records, Mr. Cortez’s
medical situation did not preclude him from performing the
essential functions of any occupation.
ECF No. 31-1 at 18–19 ¶ 5. Dr. Anderson’s testimony and conclusions do not help Mr.
Cortez. Dr. Anderson found that Mr. Cortez was not disabled. It is true that Dr. Anderson’s
conclusion differed from the Appeal Committee’s in that he found Mr. Cortez could
perform the essential functions of any occupation, where the Appeal Committee
determined Mr. Cortez could perform his own occupation. Regardless, had the Appeal
Committee accepted this conclusion, it is difficult to understand how it might have reached
a decision to approve Mr. Cortez’s claim. Mr. Cortez does not address this question.
Perhaps recognizing that Dr. Anderson’s testimony does not help him, Mr. Cortez also
disputes the reasonableness of Dr. Anderson’s conclusions. Mr. Cortez argues that Dr.
Anderson’s finding that Mr. Cortez’s “level of activity reflected in the record was not
consistent with his claims that he was totally disabled” lacks support. Pl.’s Mem. at 29. I
disagree. A reasonable person could infer from several record documents that Mr. Cortez
engaged in activities that were not consistent with his complaints. See, e.g., AR 1071 (“10
hours to Dallas without substantial break and his neck did fine (14 hours total).”); AR 1224
(noting that Mr. Cortez and his wife were “redoing their deck” and that, “[i]f it weren’t for
the additional physical work, his pain would be better”).
(d) Mr. Cortez argues that there was no change in his medical conditions that might
have justified the decision to terminate his benefits. An ERISA plan’s decision to pay
benefits does not “operate forever as an estoppel so that an [administrator] can never
change its mind.” McOsker v. Paul Revere Life Ins. Co., 279 F.3d 586, 589 (8th Cir. 2002).
“[T]he previous payment of benefits is a circumstance that must weigh against the propriety
of an [administrator’s] decision to discontinue those payments” if there is not significant,
new information regarding the participant’s health available to the plan. Id. Here, the Plan
was presented with significant, new information. This included Ms. Streitman’s January
2021 determination that, from a mental-health perspective, Mr. Cortez was cleared to work
full-time and without restrictions beginning January 29, 2021. AR 1285. It also included
Dr. Staab’s examination and resulting opinions in April 2021 that “Mr. Cortez is not
disabled from his present job as [a] result of his neck and back pain” and that
“[n]europsychometric testing did not show significant impairment which would preclude
him from successfully completing his job[,]” AR 1284. McOsker and another case on
which Mr. Cortez relies as support for this argument, Roehr v. Sun Life Assurance
Company of Canada, 21 F.4th 519 (8th Cir. 2021), are distinguishable. The assertedly new
evidence in those cases was insubstantial. The new evidence in McOsker consisted of an
ambiguous treatment note suggesting that the participant “could return to work but not at
pre-disability level of functioning.” 279 F.3d at 589. The Eighth Circuit characterized this
as a “highly ambiguous . . . opinion.” Id. In Roehr, the plan insurer “relied on virtually
the same medical records for a decade” to justify its decision to pay benefits, and then
“used essentially the same records” to justify its decision to terminate benefits. 21 F.4th at
525–26. Ms. Streitman and Dr. Staab’s opinions were unambiguous and new. They
distinguish this case from McOsker and Roehr. There is more. The Plan adjudicated Mr.
Cortez’s benefits claim through a series of decisions approving benefits for defined
periods—usually one month at a time, though occasionally longer. The Committee’s notes
often reflect uncertainty regarding what precise conclusions to draw from Mr. Cortez’s
treating providers’ records and a recognition of the need for additional evidence to evaluate
the claim. The Committee’s notes also reflect a willingness to pay Mr. Cortez benefits
while additional evidence was obtained and Mr. Cortez’s treating providers were allowed
the opportunity to respond. In other words, a careful review of the administrative record
shows that this is not one of those cases where an administrator unequivocally approved a
claim, paid benefits for a comparatively lengthy period, and then changed its mind for an
insubstantial reason. Cf. Kecso v. Meredith Corp., 480 F.3d 849, 854 (8th Cir. 2007)
(“[T]he record suggests that Meredith simply agreed to pay LTD benefits to Kecso while
it sought to reconcile the conflicting medical information by obtaining all of Kecso’s
relevant medical records.”).
(e) Mr. Cortez argues that the Committee and Appeal Committee acted as his
adversary. Pl.’s Mem. at 36. This argument is not specific and therefore difficult to address
with any particularity. Regardless, the record does not support a factual finding that the
Committee or Appeal Committee acted as Mr. Cortez’s adversary or otherwise breached
its fiduciary duty. The better reading of the lengthy record is that the investigative steps
and decisions taken with respect to Mr. Cortez’s claim reflected a genuine effort to fairly
adjudicate the claim.
The period between September 2019 and February 2020 is
emblematic. During that time, the Committee received the opinions of Dr. Kenning and
Dr. Wicklund along with the Sedgewick staff person’s recommendation to terminate Mr.
Cortez’s benefits effective February 1, 2020. See supra at 4–5. It seems fair to presume
that an adversarial administrator would have accepted this recommendation and terminated
benefits at that time, but the Committee did not. It approved Mr. Cortez’s claim through
February 29, 2020, to give Mr. Cortez’s treating providers a fair opportunity to respond to
Dr. Kenning and Dr. Wicklund’s reports. AR 940. These are not decisions one would
expect from an adversary.
(f) Mr. Cortez argues that his receipt of Social Security disability benefits shows
that the Appeal Committee’s decision to deny his claim for Plan benefits was an abuse of
discretion. “Although the Social Security Administration’s determination is not binding,
it is admissible evidence to support an ERISA claim for long-term disability benefits.”
Avenoso v. Reliance Standard Life Ins. Co., 19 F.4th 1020, 1027 (8th Cir. 2021) (quoting
Riedl v. Gen. Am. Life Ins., 248 F.3d 753, 759 n.4 (8th Cir. 2001)); see also Waldoch, 757
F.3d at 833 (noting that that Social Security “disability awards are not binding on ERISA
plan administrators”); Farfalla v. Mut. of Omaha Ins. Co., 324 F.3d 971, 975 (8th Cir.
2003) (“[A]n ERISA plan administrator or fiduciary generally is not bound by an SSA
determination that a plan participant is disabled, even when the plan’s definition of disabled
is similar to the definition the SSA applied.”) (cleaned up). Here, Mr. Cortez’s reliance on
his receipt of Social Security disability benefits does not show that the Appeal Committee
abused its discretion. Begin with the general proposition that, under abuse-of-discretion
review, the mere presence of a different or competing determination says relatively little
because different decisionmakers might reasonably reach different determinations on the
same evidence. Waldoch, 757 F.3d at 832–33. Mr. Cortez does not explain why or how
the Social Security Administration’s favorable decision shows an abuse of discretion by
the Appeal Committee. There is another problem. There is no evidence showing that the
Social Security Administration reached its decision based on a review of the same evidence
that was before the Appeal Committee. See Jackson v. Metro. Life Ins. Co., 303 F.3d 884,
889 (8th Cir. 2002) (“It is not certain that the SSA still would have concluded
that Jackson was entitled to disability benefits had it reviewed the same record that was
We do not know, for example, whether the Social Security
Administration was presented with Ms. Streitman or Dr. Staab’s reports or conclusions or
other evidence on which the Appeal Committee based its decision.
Therefore, based on the foregoing, and on all the files, records, and proceedings
herein, IT IS ORDERED THAT:
Plaintiff Enrique Cortez’s Motion for Judgment on the Administrative
Record [ECF No. 28] is DENIED.
Defendants General Mills, Inc. and General Mills, Inc. Long-Term Disability
Income Plan’s Motion for Judgment on the Administrative Record [ECF No. 33] is
Judgment shall be entered in favor of Defendants General Mills, Inc. and
General Mills, Inc. Long-Term Disability Income Plan on the claims of Plaintiff Enrique
Cortez under the Employee Retirement Income Security Act of 1974, 29 U.S.C. § 1001, et
seq., with prejudice and on the merits.
LET JUDGMENT BE ENTERED ACCORDINGLY.
Dated: November 13, 2023
s/ Eric C. Tostrud
Eric C. Tostrud
United States District Court
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