Hilton v. UNUM Life Insurance Company of America
Filing
67
MEMORANDUM OPINION and ORDER.ORDERED that Defendant's Motion for Summary Judgment 21 is GRANTED; that Plaintiff's Cross-Motion for Summary Judgment 58 is DENIED. Signed by District Judge Gerald Bruce Lee on 8/22/2013. (rban, )
IN THE UNITED STATES DISTRICT COURT FOR THE
EASTERN DISTRICT OF VIRGINIA
ALEXANDRIA DIVISION
JANET S. HILTON,
Plaintiff,
Case No. l:12-CV-866 (GBL/JFA)
v.
UNUM LIFE INSURANCE COMPANY OF
AMERICA,
Defendant.
MEMORANDUM OPINION AND ORDER
THIS MATTER is before the Court on Defendant UNUM Insurance Company of
America's ("UNUM") Motion for Summary Judgment (Doc. 21) and Plaintiff Janet Hilton's
("Hilton") Cross Motion for Summary Judgment (Doc. 58). This case involves the interpretation
and application of an express limitation to Plaintiffs long-term disability benefits by the
administrator of an employee welfare benefit plan governed by the Employee Retirement Income
Security Act ("ERISA"), 29 U.S.C. §§ 1001-1461 et seq. 1001. There are three issues before the
Court.
The first issue is whether Defendant UNUM reasonably interpreted and applied its policy
language, temporally limiting Plaintiffs benefits based on her condition being primarily
supported by self-reported symptoms. The Court holds that based on the administrative record
before it at the time, UNUM did not abuse its discretion or act unreasonably because UNUM
properly exercised its discretion in terminating Ms. Hilton's benefits based on its reasonable
interpretation of its own policy language, which the Court affords great deference, and because
the administrative record reveals that migraine headaches are not objectively verifiable, such that
Plaintiffs condition falls within the purview of the policy's limitation.
The second issue is whether UNUM's decision-making process was reasoned and
principled. The Court concludes that UNUM's process was reasoned and principled because
UNUM investigated Ms. Hilton's claim using both the information contained in Plaintiffs
medical claim file and the medical evaluation of her claim. Therefore, the Court concludes that
UNUM's process was reasoned and principled.
The third issue is whether UNUM improperly based its decision on a conflict of interest.
The Court concludes that UNUM did not make its decision based on a conflict of interest, and
the administrative record did not indicate that UNUM had bias toward Plaintiff. The Court also
reaches this conclusion because UNUM consulted with two board-certified physicians to address
Ms. Hilton's appeal and analyzed Ms. Hilton's medical documentation in generating its decision
to Ms. Hilton's claim.
I.
A.
BACKGROUND
Statement of Facts
Ms. Hilton began working for the American Society of Civil Engineers ("ASCE") on or
around October 2, 2000. She served as the ASCE Art Director. (Compl. ^ 5.) ASCE entered
into an insurance contract with UNUM that provided long-term disability insurance benefits.
(Id at K6.) The Disability Insurance Plan ("the Plan") constitutes an "employee welfare benefit
plan" and is subject to various provisions of ERISA. (Id. 1f 7.) Ms. Hilton was a plan participant
and at all times, UNUM was the claims fiduciary for administration of the claims for disability
benefits under the terms of the Plan. (Id. If 9.) UNUM made all of the decisions regarding Ms.
Hilton's claim for disability benefits. (Id 1ffl 8-10.)
Ms. Hilton suffers from migraine headaches. On December 5, 2008, UNUM approved
Plaintiffs long-term disability benefits based on this condition, and payments to Ms. Hilton
began on October 16, 2008. (Id at f 12.) On October 21, 2010, UNUM terminated Ms. Hilton's
benefits, stating that she reached the maximum twenty-four month period of payment for
disabilities based primarily on self-reported symptoms. (Id. at 113.) Pursuant to the Plan, "selfreported symptoms" are defined as:
the manifestations of your condition which you tell your physician, that
are not verifiable using tests, procedures or clinical examinations
standardly accepted in the practice of medicine. Examples of self-reported
symptoms include but are not limited to headaches, pain, fatigue, stiffness,
soreness, ringing in ears, dizziness, numbness and loss of energy.
(ARatl20.)
Ms. Hilton appealed the termination of her benefits to UNUM on April 21, 2011.
Plaintiff also underwent two prior MRIs showing the existence of white-matter abnormalities.
Based on this MRI finding, Plaintiff argued on appeal that her migraines were not based
primarily on self-reported symptoms because her condition was verifiable by MRI. Plaintiff
contends that with objective verification of migraines by these MRI studies, the self-reported
limitation does not apply. By definition, manifestations of the disabling condition that are
verifiable by testing are excluded from the limitation. Where there exists objective tests or
clinical examinations standardly accepted in the practice of medicine, Unum's self-reported
symptom limitation does not apply. (Def.'s Mot. Summ. J. at 13, Doc. 22.)
UNUM assigned an Appeals Specialist, Ms. Mininni, to conduct a review of Ms. Hilton's
appeal. (Administrative Record [hereinafter "AR"] at 2022-23.) Ms. Mininni consulted a board-
certified physician, Dr. Schnars, who provided a clinical summary of Ms. Hilton's treatment.
(AR at 2036-39.) The summary indicates that Ms. Hilton's symptoms are specifically listed as
self-reported symptoms according to the Policy and as a result, her benefits are limited to twenty-
four months. (AR at 2114.) Ms. Mininni asked Dr. Schnars to respond to a series of questions.
In response to whether the medical evidence in the file support disabling restrictions as of
10/15/2010, Dr. Schnars noted that "there are no physical disabling restrictions supported." (AR
at 2039.)
In response to the question of whether there is sufficient medical evidence to
substantiate a diagnosis of migraine, Dr. Schnars answered, in part, "early description of
headaches at initial evaluation describe chronic daily headaches with migraine component and
the diagnosis of migraine headache or other primary type headaches is based on historical
information." (Id.) In response to whether the available medical evidence (such as signs,
diagnostics, and physical exam findings) correlate with the insured reported level of functional
loss, Dr. Schnars answered, "there are no physical exam findings, laboratory or diagnostic testing
to correlate with severity of reported symptoms or loss of functionality and self-reports of
severity of pain and function are depended upon by treating physician for assessment and
medication adjustment." (Id.)
In addition to Dr. Schnars' summary, UNUM also included a consultation of Plaintiffs
claims with another board-certified physician, Dr. Re. The three questions posed to Dr. Re and
his responses thereto are set forth below:
What are the client's symptoms ofmigraine/chronic daily headaches?
The medical records do not document the character of the headaches very
well. No auras111 are described and no location is noted other than to state
that she has sharp shooting pains in her head. No precipitating factors are
noted i.e. light, sound or smells. She did report associated nausea, vertigo,
and poor sleep. She described her headaches as migraines that varied
from weekly to daily. A variety of functional complaints were contributed
to her headaches. There was some history of self-medicating with alcohol
and problems with excessive use of pain relievers.
1An "aura" is a sensation, as of a glowing light or an aroma, preceding an attack of migraine or
epilepsy. Merriam-Webster Dictionary 89 (2nd ed. 2001).
4
Can the symptoms be verified by diagnostics, medical data, etc. ?
No. Diagnostic studies are used to rule out other causes of headache such
as a tumor, vascular disease, inflammatory disorder or an infectious
process. There are no specific lab or X-ray studies that are diagnostic of
Migraine. Although some micro-vascular changes have been described in
patients with migraine they are not specific and do not correlate with
severity of frequency. They do not predict outcome or help with treatment
regimens.
Does the MRI ofthe brain (white matterfindings) support symptoms ofmigraine?
No. There is no known correlation with the non-specific white matter
findings that are described in patients with migraines and their reported
symptoms.
Given the impression on MRI is there a correlation between small vessel disease in the
presence of diabetes, HTN, with migraine, vasculitis, or possibly demyelinatingprocess
supported by thefindings?
Yes. Changes in the cerebral white matter have been described in all of
the entities listed above and have been attributed to micro vascular
changes. They can be helpful in supporting a diagnosis, but are not
diagnostic of any one specific entity. They do not predict severity of
disease and do not correlate with any specific sign or symptom.
Therefore, most radiologists and neurologists when they see these changes
give a series of possible diagnoses rather than one specific diagnosis.
Based on the file reviews and Dr. Re's responses, UNUM denied Ms. Hilton's appeal on
July 14, 2011, concluding that Ms. Hilton's disability was only supported by self-reported
symptoms and she was therefore ineligible to receive any additional coverage for her disability.
(AR at 2111.) To date, Ms. Hilton has complied with and exhausted all administrative appeals.
On August 3, 2013, Ms. Hilton filed a Complaint in this Court to appeal UNUM's final
decision denying her long-term disability benefits. (See Doc. 1.) In her Complaint, Plaintiff
argues that UNUM unreasonably and wrongfully denied her long-term disability benefits due to
her under the terms of the Plan. (Compl. | 28, Doc. 1.) Specifically, Plaintiff alleges that
UNUM abused its discretion in applying the self-reported symptoms provision to her claim when
an objective test exists to confirm the migraines, namely the MRI documenting white matter
changes in the brain, which are common with migraine patients. (Id at f 22.) Further, Plaintiff
alleges that UNUM further abused its discretion by failing to apply the portion of the definition
as to verification by "procedures or clinical examinations standardly accepted in the practice of
medicine." (Id atf 23.)
Importantly, on April 15, 2013, Ms. Hilton objected to rulings made by Magistrate Judge
Davis in his denial of Ms. Hilton's Motion to Compel production of documents and responses to
interrogatories. (PL's Rule 72(a) Objections to Magistrate Judge's Order on Mot. to Compel,
Doc. 49.) The Court affirmed the Magistrate Judge's ruling and denied Ms. Hilton's Motion to
Compel Production of Documents and Responses to Interrogatories, thereby limiting summary
judgment to the administrative record. (Id.) On March 1, 2013, UNUM filed its present Motion
for Summary Judgment. (PL's Mot. Sum. J., Doc. 21.) On May 28, Ms. Hilton responded in
opposition to UNUM's Motion for Summary Judgment and also filed a Cross Motion for
Summary Judgment as a Matter of Law. (Def.'s Cross Mot. Sum. J., Doc. 58.) These Motions
are now ripe for the Court's review.
II.
A.
STANDARD OF REVIEW
Rule 56 Summary Judgment Motion
Under Federal Rule of Civil Procedure 56, the Court must grant summary judgment if the
moving party demonstrates that there is no genuine issue as to any material fact, and that the
moving party is entitled to judgment as a matter of law. Fed. R. Civ. P. 56(c) (2013).
In reviewing a motion for summary judgment, the Court views the facts in a light most
favorable to the non-moving party. Boitnott v. Corning, Inc., 669 F.3d 172, 175 (4th Cir. 2012)
(citingAnderson v. Liberty Lobby, Inc., All U.S. 242, 255 (1986)). Once a motion for summary
judgment is properly made and supported, the opposing party has the burden of showing that a
genuine dispute exists. Matsushita Elec. Indus. Co. v. Zenith Radio Corp., 475 U.S. 574, 586-87
(1986); Bouchat v. Baltimore Ravens Football Club, Inc., 346 F.3d 514, 522 (4th Cir. 2003)
(citations omitted). "[T]he mere existence of some alleged factual dispute between the parties
will not defeat an otherwise properly supported motion for summary judgment; the requirement
is that there be no genuine issue of material fact." Emmett v. Johnson, 532 F.3d 291, 297 (4th
Cir. 2008) (quoting Anderson, All U.S. at 247-48).
A "material fact" is a fact that might affect the outcome of a party's case. Anderson, All
U.S. at 248; JKC Holding Co. v. Wash. Sports Ventures, Inc., 264 F.3d 459, 465 (4th Cir. 2001).
Whether a fact is considered to be "material" is determined by the substantive law, and "[o]nly
disputes over facts that might affect the outcome of the suit under the governing law will
properly preclude the entry of summary judgment." Anderson, All U.S. at 248; Hooven-Lewis v.
Caldera, 249 F.3d 259, 265 (4th Cir. 2001).
A "genuine" issue concerning a "material" fact arises when the evidence is sufficient to
allow a reasonable jury to return a verdict in the nonmoving party's favor. Resource Bankshares
Corp. v. St. Paul Mercury Ins. Co., 407 F.3d 631, 635 (4th Cir. 2005) (citing Anderson, All U.S.
at 248). Rule 56(e) requires the nonmoving party to go beyond the pleadings and by its own
affidavits, or by the depositions, answers to interrogatories, and admissions on file, designate
specific facts showing that there is a genuine issue for trial. Celotex Corp. v. Catrett, All U.S.
317,324(1986).
B.
District Court's Review of ERISA Appeal
District courts have a framework for reviewing the denial of benefits under ERISA plans.
Where the terms of an employee benefit plan provide discretionary authority to determine a
claimant's entitlement to benefits or to construe the terms of a plan, the fiduciary's decision is
granted deference and will be overturned only where there is an abuse of discretion. Firestone
Tire and Rubber Co. v. Bruch, 489 U.S. 101, 109 (1989). In such a case, the court will apply an
abuse of discretion standard of review. Feder v. Paul Revere Life Ins. Co., 228 F.3d 518, 522
(4th Cir. 2000). In an abuse of discretion standard of review, evidence to be considered by a
district court is limited to the administrative record, which consists of the claim file and the plan
documents. Williams v. Metropolitan Life Ins. Co., 609 F.3d 622, 631 (4th Cir. 2010).
In reviewing the administrative record, a district court should not disturb a reasonable
administrative decision, even if the court itself would have reached a different conclusion. Haley
v. Paul Revere Life Ins. Co., 11 F.3d 84, 89 (4th Cir. 1996). District courts assess reasonableness
by determining whether the administrative decision is the result of a deliberate, principled
reasoning process supported by substantial evidence. Evans v. Eaton Corp., 514 F.3d 315, 322
(4th Cir. 2008). Accordingly, the district court reviews a denial of benefits deferentially to
determine if an abuse of discretion occurred, such that it can be shown that the determination
was arbitrary and capricious.
Firestone Tire and Rubber Co., 489 U.S. at 113.
The non
exclusive factors a court may consider when determining whether an abuse of discretion
occurred include:
(1) the language of the plan; (2) the purpose and goals of the plan; (3) the
adequacy of the materials considered to make the decision and the degree
to which they support it; (4) whether the fiduciary's interpretation was
consistent with other provisions in the plan and with earlier interpretations
of the plan; (5) whether the decision-making process was reasoned and
principled; (6) whether the decision was consistent with the procedural
and substantive requirements of ERISA; (7) any external standard relevant
to the exercise of discretion; and (8) the fiduciary's motives and any
conflict of interest it may have.
Champion v. Black & Decker (U.S.) Inc., 550 F.3d 353, 359 (4th Cir. 2008) (citing Booth v. WalMart Stores, Inc. Assocs. Health & Welfare Plan, 201 F.3d 335, 342-43 (4th Cir.2000)).
III.
DISCUSSION
The Court holds that UNUM did not abuse its discretion in terminating Ms. Hilton's
disability benefits because UNUM acted reasonably in interpreting and applying the language of
the Plan and classifying Ms. Hilton's migraine headaches as a condition "primarily based on
self-reported symptoms." Additionally, the Court finds that UNUM's decision-making process
was reasoned and principled in light of UNUM's reliance on the opinion of two board-certified
physicians. Furthermore, the Court opines that, contrary to Plaintiffs position, UNUM did not
make its decision based on a conflict of interest, but rather acted reasonably in reviewing
Plaintiffs claims.
As an initial matter, the Court holds that the Plan conveyed UNUM discretionary
authority to interpret and apply the terms of its Plan, thereby affording UNUM deferential review
of its decisions. An ERISA plan administrator, fiduciary, or trustee is empowered to exercise all
his authority in a discretionary manner subject only to review for arbitrariness and
capriciousness. Firestone Tire and Rubber Co., 489 U.S. at 113. The Policy grants UNUM
discretionary authority to make benefit determinations including determining eligibility for
benefits and interpreting and enforcing the provisions of the Policy. (AR at 127.) Additionally,
the certificate of coverage provides that, "when making a benefit determination under the Policy,
UNUM has discretionary authority to determine your eligibility for benefits and to interpret the
terms and provisions of the Policy." (AR at 98.) Therefore, because the Policy grants UNUM
discretionary authority, the Court will only overturn UNUM's decision upon an abuse of
discretion. Firestone, 489 U.S. at 109.
An abuse of discretion is determined by a standard where the court analyses whether the
administrative decision is reasonable. Haley, 11 F.3d at 89. The Court analyzes reasonableness
using the non-exclusive Booth factors such as:
(1) the language of the plan; (2) the purpose and goals of the plan; (3) the
adequacy of the materials considered to make the decision and the degree
to which they support it; (4) whether the fiduciary's interpretation was
consistent with other provisions in the plan and with earlier interpretations
of the plan; (5) whether the decision-making process was reasoned and
principled; (6) whether the decision was consistent with the procedural
and substantive requirements of ERISA; (7) any external standard relevant
to the exercise of discretion; and (8) the fiduciary's motives and any
conflict of interest it may have.
Champion, 550 F.3d at 359 (citing Booth, 201 F.3d at 342-43).
Here, Ms. Hilton, a plan
participant in an ERISA-established plan, was denied long-term benefits after twenty-four
months. Ms. Hilton suffers from migraine headaches, which UNUM classified as "headache" in
the Plan's definition of self-reported symptoms.2
In analyzing the reasonableness of the
administrator's decision, the parties primarily focus on two Booth factors, namely (1) the
language of the plan and (5) whether the decision-making process was reasoned and principled.
Accordingly, the Court looks to these two factors in reviewing the parties' cross-motions.
A.
The Language ofthe Plan
The Court finds that UNUM did not abuse its discretion when interpreting and applying
the language of its Plan. In Kennedy v. Plan Administratorfor DuPont Savings & Investment
Plan, 555 U.S. 285, 300 (2009), the Supreme Court applied the "plan documents rule," under
which plan administrators look solely at "the directives of the plan documents" in determining
how to disburse benefits. This rule follows the plain text of the ERISA statute, which instructs
Pursuant to Defendant's Plan, "self-reported symptoms" are defined as "the manifestations of
your condition which you tell your physician, that are not verifiable using tests, procedures or
clinical examinations standardly accepted in the practice of medicine. Examples of self-reported
symptoms include but are not limited to headaches, pain, fatigue, stiffness, soreness, ringing in
ears, dizziness, numbness and loss of energy." (AR at 120.)
10
employers to distribute benefits "in accordance with the documents and instruments governing
the plan." Boyd v. Metropolitan life Ins. Co., 636 F.3d 138, 140-41 (4th Cir. 2011).
Plan
administrators are granted primary interpretive authority over an ERISA plan according to the
plan documents rule, which preserves the careful balancing upon which ERISA is based.
Firestone, 489 U.S. at 109. When interpreting the language of the plan, courts have said that it
must be given its common and ordinary meaning as a reasonable person in the position of the
plan participant would have understood the words, not as the actual participant would have
understood or desired. Parker v. Kraft Foods Global, Inc., No. 3:07cv87, 2010 WL 1929555, at
♦13
(W.D.N.C. May 12, 2010).
To qualify for benefits beyond the 24-month limit under UNUM's policy, Plaintiffs
condition that forms the basis for her claim must not be based on a disability primarily based on
self-reported symptoms. (AR at 120; Def.'s Mem. Supp. Def.'s Mot. Summ. J. at 23.) Self-
reported symptoms are those manifestations of Plaintiff s condition that are not verifiable using
test, procedures, or clinical examinations, including but not limited to headaches. (AR at 900.)
UNUM contends that Plaintiffs migraine headache condition falls within the self-reported
limitation because headaches, and more specifically migraine headaches, are self-reported
manifestations not verifiable by medical testing. (AR at 1201.) Specifically, UNUM determined
that no test or procedure can diagnose migraines and, contrary to Plaintiffs representation,
MRI's are used only to rule out organic causes of the headaches, including the neuroimaging that
Plaintiff argues objectively verifies migraine headaches. (Def.'s Mem. Supp. Def.'s Mot. Summ.
J. at 25, Doc. 22.)
Several courts have evaluated similar claims based upon nearly identical plan limitations.
In Huberts v. ATA Holdings Corp. Welfare Benefit Plan, No. l:07-cv-287, 2008 WL 687127, at
11
*4 (S.D. Ind. Mar. 10, 2008), the court evaluated UNUM's interpretation and application of the
same policy limitation. There, UNUM determined that the plaintiff was no longer entitled to
long-term disability benefits based on the fact that the policy's limitation for headaches that were
primarily based on self-reported symptoms. The Huberts court found that UNUM's decision
was based on a rational interpretation of the plan and the medical evidence before it at the time
of its decision. Id. The court found that the plan at issue in Huberts provide a limited disability
benefit for disabilities "primarily based on self-reported symptoms." Id. The plan in Huberts
specifically listed "headaches" as an example of a self-reported symptom and Huberts based his
claim of disability on headaches. Id. Therefore, the Huberts court reasoned that while the ptosis
may have constituted some clinical confirmation of the existence of one of the types of
headaches complained of by Huberts, his disability, if any, was still "primarily based on selfreported symptoms." Id.
Similarly, in Rupert v. Prudential Insurance Co., 2006 WL 910405, at *11 (M.D. Pa.
Apr. 7, 2006), the court granted summary judgment to insurer based in part on the insurer's
reasonable application of a self-reported symptom limitation.
The plan at issue contained a
twenty-four month limitation on benefits for conditions based on self-reported symptoms.
Because the plaintiffs disability claim was based on self-reported symptomology, namely
headaches and depression, the court found the insurer's interpretation of its policy language and
its application of the limitation to the plaintiffs claim reasonable, concluding that the insurer
acted neither arbitrary nor capricious.
Akin to Huberts and Rupert, UNUM in this case reasonably interpreted the language of
the Plan when denying Ms. Hilton's claim.
When UNUM initially approved Ms. Hilton for
long-term benefits, it quoted the key Policy language including the self-reported symptoms
12
provisions under which the maximum benefit period for all disabilities based primarily on selfreported symptoms is twenty-four months. (AR at 534.) Pursuant to the Plan, "self-reported
symptoms" are defined as:
the manifestations of your condition which you tell your physician, that
are not verifiable using tests, procedures or clinical examinations
standardly accepted in the practice of medicine. Examples of self-reported
symptoms include but are not limited to headaches, pain, fatigue, stiffness,
soreness, ringing in ears, dizziness, numbness and loss of energy.
(AR at 120.) This plan language was provided to Ms. Hilton in writing once her long-term
benefits were approved.
Ms. Hilton was also advised that her migraine headaches were
considered self-reported symptoms and the maximum period of twenty-four months applies to
her claim.
(AR at 535.)
UNUM interprets headaches as self-reported symptoms because
headaches and other self-reported symptoms are not medically verifiable. (Def.'s Mem. Supp.
Def.'s Mot. Summ. J. at 25.) Additionally, UNUM's two board-certified physicians opined that
migraine headaches are not verifiable using tests, procedures or clinical examinations standardly
accepted in the practice of medicine. (AR at 2039.)
Thus, UNUM reasonably interpreted the
language of the Plan when denying Ms. Hilton's claim.
The Court rejects Ms. Hilton's argument that migraine headaches are objectively
verifiable and confirmed by neuroimaging, such that her condition does not fall within the "self-
reported symptoms" definition. (PL's Opp'n at 2, Doc. 57.) To support her position, Ms. Hilton
points to the MRI documenting white matter changes in the brain as the objective test used to
verify migraines and contends that white matter changes in the brain are common with migraine
patients. (Compl. f 22.) To the extent that Plaintiff argues that migraines are diagnosed through
medical testing, her argument misstates the issue presented.
The issue is not whether the
diagnosis of migraines is verifiable using tests and procedures, but rather whether the
13
manifestations themselves—the headaches—are verifiable using tests and procedures.
The
policy language defines self-reported symptoms as the manifestations (i.e, the headaches) of your
condition (migraine headaches) which are not verifiable using clinical tests or procedures. The
administrative record is entirely devoid of any evidence that headaches are verifiable using
medical testing. To the contrary, UNUM's medical team opined that no test currently exist to
verify the presence of headaches. The Policy language does not, as Plaintiff reads, apply the
limitation to diagnoses of which are objectively verifiable.
Moreover, the Court rejects Plaintiffs argument that white matter findings on a brain
MRI provide evidence of migraine headaches. (P's Mot. for S. J. at 35.) Plaintiff argues that her
diagnosis for migraines is verified by the presence of white matter lesions revealed in the MRIs.
Id. at 36. According to Dr. Re, the symptoms of migraine headaches cannot be verified by MRI.
(UNUM's MSJ at 16-17.)
In fact, adjunctive diagnostic testing is used to exclude other
diagnoses or secondary causes of headaches. (AR at 2039.) Both board-certified physicians
concluded that the presence of white matter on MRI is not diagnostic of migraines because 1246% of migraine patients had white matter on MRI. (P's SMF at f 18.)
The Court also rejects Plaintiffs argument that UNUM acted unreasonably in
determining that migraine headaches are distinct from "normal" or "regular" headaches, such
that UNUM unreasonably applied it to her claim. UNUM contends that migraine headaches are
undisputedly self-reported and not objectively verifiable according to their Plan language.
(Def.'s Mem. Supp. Def.'s Mot. Summ. J. at 25.)
UNUM's list of self-reported symptoms
includes a provision that says, "including but not limited to" which suggests that there could be
other self-reported symptoms that are not listed and that decision is based on UNUM's
discretion. Therefore, since two board-certified physicians found that migraine headaches are
14
not objectively verifiable and the Plan does not restrict the self-reported symptoms to only the
conditions listed, UNUM was reasonable in its denial of Plaintiff s long-term disabilities based
on a condition of migraine headaches.
Plan administrators are granted primary interpretive
authority over an ERISA plan, and based on Plaintiffs claim file, medical literature, and its own
understanding of the Policy terms, UNUM classified "migraine headaches" as part of the
category of "headaches" "in accordance with the documents and instruments governing the
plan," and UNUM exercised appropriate discretion to do so. Firestone Tire & Rubber Co., 489
U.S. at 109.
Therefore, UNUM, based on the evidence before it, acted reasonably at the time of its
decision in classifying headaches as self-reported. There is no evidence in the administrative
record that suggests that UNUM had any information to support the conclusion that migraine
headaches were distinct from headaches or that migraine headaches were objectively verifiable.
To the contrary, the evidence shows that UNUM engaged medical expert opinion in evaluating
Plaintiffs claim, the results of which did not conclusively support Plaintiffs position. Thus, the
Court is compelled to affirm UNUM's interpretation as reasonable absent any evidence to the
contrary.
B.
Whether the Decision-making Process was Reasoned and Principled
The Court also finds that UNUM's decision-making process was reasoned and principled
because it was based on a deliberate, principled reasoning process. "An administrator's decision
is reasonable if it is the result of a deliberate, principled reasoning process and if it is supported
by substantial evidence."
Evans, 514 F.3d at 322.
A principled reasoning process can be
determined by consideration of the complete record, reliance on independent medical
evaluations, and assessment of the claimant's vocational capacity amounted to a principled
15
reasoning process. Donnell v. Metropolitan Life Ins. Co., 165 F. App'x. 288, 295 (4th Cir.
2006). In Donnell, MetLife commissioned a physician not affiliated with Metlife to review the
medical evidence in Plaintiff Donnell's file.
Id. at 291.
The Donnell court found the benefits
decision principled and reasoned in their dispute because it included a genuine and thorough
consideration of all the evidence before it and it reviewed all medical evidence that Donnell
submitted, measured Donnell's vocational abilities, procured an independent evaluation of the
medical evidence, and considered all of the conditions that Donnell claimed contributed to her
disability. Id. at 295. Thus, a process is not principled and reasoned if the benefits decision was
based on interpretations of Plan terms that render text superfluous, or disregard plain meaning.
Id. Whether the decision process is based upon an independent medical review, the Court must
find the process to principled and reasonable. Id at 292.
Similarly here, Ms. Hilton argues that UNUM's decision-making process in denying her
appeal was not reasoned and principled. (PL's Opp'n at 38, Doc. 57.) Ms. Hilton contends that
UNUM did not give fair consideration to other procedures used and present in this record to
verify diagnosis of migraine.
Id.
The Court finds, however, that UNUM did not abuse its
discretion because its decision-making process was reasoned and principled based on the
guidelines set forth in Donnell.
UNUM's evaluation of Ms. Hilton's appeal included an
evaluation of Plaintiffs MRIs, headache calendars, and a variety of medical records from Ms.
Hilton's eleven different physicians. (AR at 1251-1491.) Additionally, UNUM assigned a Lead
Appeals Specialist to conduct a review of Ms. Hilton's appeal, which included reviewing the
medical records of Ms. Hilton's eleven different physician reports and a medical records review
from two board-certified internal medicine physicians in order to make the most principled
decision.
(AR 2029-31)
The reviewing physicians confirmed the self-reported nature of
16
migraine headaches. (AR at 2036-39.) One physician indicated that there are no specific lab or
X-ray studies that are diagnostic of migraine headaches. (AR at 2039.)
Huberts also informs the Court's decision here. UNUM's decision-making process was
reasoned and principled because upon review of Ms. Hilton's appeal of UNUM's decision,
UNUM carefully and thoroughly investigated Ms. Hilton's claim using both the information that
Ms. Hilton claimed contributed to her disability and the evaluations of two board-certified
physicians. (AR 2029-31.) UNUM followed the terms of the Plan and determined that Ms.
Hilton met her burden of establishing that the relevant limitation did not apply to her headaches.
(Def.'s Mot. Summ. J. at 22, Doc. 22.) The Huberts court found that UNUM was reasonable and
principled in their analysis and their decision-making process was not arbitrary and capricious as
a result of the fact that Ms. Hilton's file was reviewed by a registered nurse, Ms. Mininni, and
one of its board-certified physicians, Dr. Stewart Russell. Id. at 2. In fact, UNUM asked Dr.
Russell whether in regards to self-reported headaches, there are any conditions supported whose
manifestations (symptoms) are verifiable using tests, procedures or clinical examinations
standardly accepted in the practice of medicine. Id. at 3. Dr. Stewart replied and said, "No.
There is no support for an organic cause of his self-reported headaches." Id.
Here, UNUM's decision-making process was reasoned and principled because upon
review of Ms. Hilton's appeal of UNUM's decision, UNUM thoroughly investigated Ms.
Hilton's claim using both the information that Ms. Hilton claimed contributed to her disability
and the evaluations of two board-certified physicians.
(AR 2029-31.) UNUM followed the
terms of the plan and determined that Ms. Hilton met her burden of establishing that the relevant
limitation did not apply to her headaches. (Def.'s Mot. Summ. J. at 22, Doc. 22.) Cf Palm v.
Wausau Benefits, Inc., No, AMD 05-2170, 2007 WL 927617, at *4 (D. Md. Mar. 26, 2007)
17
(finding that a plan administrator did not abuse his or her discretion in determining that the
plaintiff was no longer "totally disabled" based upon medical evaluations and a vocational
analysis indicating that the plaintiff could perform a sedentary occupation on a part-time basis).
Thus, the Court holds that UNUM's decision-making process was not arbitrary and capricious
and based on a deliberate, principled reasoning process.
C.
Whether there was a Conflict ofInterest
The Court holds that UNUM did not act unreasonably in reviewing Plaintiffs claim due
to a known but unresolved conflict of interest.
A plan administrator's dual role of both
evaluating and paying benefits claims creates a conflict of interest. Metropolitan Life Ins. Co. v.
Glenn, 554 U.S. 105, 106 (2008). A conflict of interest exists where it is the employer itself that
both funds the plan and evaluates the claim, but a conflict also exists where the plan
administrator is an insurance company. Id.
The significance of the conflict of interest will
depend on the circumstances of each case. Id. at 107. In analyzing potential conflicts of interest
by plan administrators, courts review the plan's determination under the abuse-of-discretion
standard, and courts consider the conflict only as a factor, among several, in determining whether
the plan's determination was reasonable. Id. at 108. If the administrator or fiduciary having
discretion is operating under a conflict of interest, that conflict must be weighed as a factor in
determining whether there is an abuse of discretion. Firestone Tire & Rubber Co., 489 U.S. at
115.
As noted above, courts have determined that there is a conflict of interest that exists
where the plan administrator is an insurance company but the significance of the conflict of
interest will depend on the specific circumstances.
Glenn, 554 U.S. at 107.
In Glenn, the
plaintiff, Glenn, brought suit to appeal the denial of benefits by her plan administrator. The
18
Supreme Court gave the conflict of interest factor some weight, but focused more heavily on
other factors.
First, MetLife had encouraged Glenn to argue to the Social Security
Administration that she could not work, received the bulk of the benefits of her success in doing
so (being entitled to receive an offset from her retroactive Social Security award), and then
ignored the agency's finding in concluding that she could do sedentary work. Second, MetLife
emphasized one medical report favoring denial of benefits, deemphasized other reports
suggesting a contrary conclusion, and failed to provide its independent vocational and medical
experts with all of the relevant evidence.
Id. In Glenn, the court found the other factors
evidence of an arbitrary and capricious decision-making process and set aside the administrator's
decision. Id.
In this case, however, the Court finds that the circumstances outside of the conflict of
interest factor are not evidence of an arbitrary and capricious decision-making process.
In
viewing UNUM's appeals process in light of the circumstances, the Court finds that, although
UNUM had a conflict of interest, the circumstances lead to the conclusion that UNUM's
decision-making process was reasonable. Ms. Hilton argues that UNUM has a structural conflict
of interest because UNUM makes both the decisions on claims and pays the claims from its
general revenues. (Def.'s Opp'n at 27, Doc. 57.) Ms. Hilton contends that there is little doubt
that UNUM's conflict of interest played a role in the decision on Ms. Hilton's claim because
UNUM failed to apply the Plan terms to Hilton's claim and instead, UNUM's attorney directed
the conclusion of a purported physician reviewer. Id.
Plaintiff argues that in directing the
physician's review of Ms. Hilton's claim, UNUM's attorney does not refer to the language of the
Plan; she does not ask claims personnel to apply the language of the plan or to ascertain from
medical consultants whether there exist tests, procedures or clinical examinations standardly
19
accepted in medical practice that could verify diagnosis or manifestations of migraine. (PL's
Reply at 18.) Instead, plaintiff argues that UNUM's attorney's memorandum focuses entirely on
how to deny the claim and what is needed in the record to do so.
The Court does not find Plaintiffs contention persuasive. There is no evidence in the
record that UNUM's attorney directed the physician's review or that the physician did not
conduct any additional medical research before providing a recommendation for Ms. Hilton's
claim.
In fact, UNUM's attorney specifically asked Dr. Re if Plaintiffs symptoms can be
verified by diagnostics or medical data and whether Plaintiffs MRIs support her migraine
symptoms.
(AR at 2105.)
The Court finds UNUM's approach here to be reasoned and
principled and without a showing in the administrative record of bias toward Plaintiff in their
appeals process. Additionally, UNUM consulted with two board-certified physicians to address
Ms. Hilton's arguments and they also analyzed Ms. Hilton's medical literature in generating their
decision to Ms. Hilton's claim.
For these reasons, the Court holds that UNUM's decision-making process was not
arbitrary and capricious and, as such, UNUM did not abuse its discretion because of a conflict of
interest.
IV. CONCLUSION
For the foregoing reasons, the Court grants the Defendant's Motion for Summary
Judgment for four reasons. First, UNUM properly exercised its authority in terminating Ms.
Hilton's benefits based on its own interpretation of its clear policy language, which the Court
affords great deference and because of evidence that migraine headaches are not objectively
verifiable. Second, UNUM's process was reasoned and principle because upon review of Ms.
Hilton's appeal of UNUM's decision, UNUM thoroughly investigated Ms. Hilton's claim using
20
both the information that Ms. Hilton claimed contributed to her disability and the evaluations of
two board-certified physicians.
Additionally, UNUM followed the terms of the Plan and
determined that Ms. Hilton met her burden of establishing that the relevant limitation did not
apply to her headache. Lastly, UNUM's approach was reasoned and principled and without a
showing in the Administrative Record of bias toward Plaintiff in their appeals process.
Accordingly,
IT IS HEREBY ORDERED that Defendant's Motion for Summary Judgment (Doc. 21)
is GRANTED;
IT IS FURTHER ORDERED that Plaintiffs Cross-Motion for Summary Judgment
(Doc. 58) is DENIED.
IT IS SO ORDERED.
ENTERED this Z™1 day ofAugust, 2013.
Alexandria, Virginia
8/^2013
/s/
Gerald Bruce Lee
United States District Judge
21
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