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Defense Friendly ERISA LTD Decision – 5th Cir.

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  • Defense Friendly ERISA LTD Decision – 5th Cir.

    Defense Friendly ERISA LTD Decision – 5th Cir.

    Attached hereto is the Fifth Circuit case of Foster v. Principal Life Insurance Company. Plaintiff is an attorney seeking ERISA governed LTD benefits. The case is before the 5th Circuit on plaintiff’s appeal from the district court granting judgment to defendant. Plaintiff filed for LTD benefits asserting that she could no longer perform her occupation as a healthcare attorney due to intractable migraines. On appeal, plaintiff focuses on two arguments to demonstrate that defendant abused its discretion: First, that defendant did not consider her actual job duties as an attorney when determining whether or not she could work; and, second, that the nature of her disability is such that it cannot be verified via clinical or objective evidence. The court affirmed the district court’s decision.
    Foster’s first argument on appeal is that Principal abused its discretion when terminating her LTD benefits because it failed to analyze her disabling condition in light of her actual job duties as an attorney. The policy Principal issued to Sullivan states that a member will be considered “[d]isabled” if, “because of sickness, injury, or pregnancy,” “[t]he Member cannot perform one or more of the Substantial and Material Duties of his or her Own Occupation . . . .” (emphasis added). Foster contends that the doctors on whose reports Principal relied were never asked to evaluate her disability in light of her specific duties as a healthcare attorney, and that, instead, they evaluated her disability only in light of the less specific standard of whether she could perform “full-time sedentary work.” Consequently, these doctors did not provide any meaningful analysis of whether Foster’s intractable migraines would prevent her from performing the specific duties of a healthcare attorney—e.g., “meeting deadlines, handling stress, unpredictability of absences, . . . prolonged computer use, prolonged light exposure, [and the] intellectual challenges of handling complex situations.” Relying on those doctors’ opinions, argues Foster, constituted an abuse of discretion because Principal could not have rationally determined from them that Foster was, in fact, unable to “perform one or more of the material and substantial duties of . . . her Own Occupation,” as the policy demands.

    . . .

    We evaluate Foster’s argument in view of the light burden that Principal bears: Principal must support its decision only with “substantial evidence” and, if the decision “is not arbitrary and capricious, it must prevail.” Corry, 499 F.3d at 397–98 (quoting Ellis, 394 F.3d at 273) (emphasis added). Here, there is substantial evidence showing that at least one of the physicians—Dr. Chafetz—considered Foster’s disability in light of the specific duties required by her occupation as an attorney. Principal asked Foster for a description of her job duties and then provided to all reviewing physicians the documents she gave them. The reports Principal relied upon described not only “physical,” but also on the “non-exertional or cognitive” demands on Foster—such as her “ability to write, focus, and concentrate,” her “memory, cognition, and concentration,” and her ability to complete tasks such as “driving, shopping, and picking up her kids.” Most importantly, Dr. Chafetz was asked to (and did) assess a range of non-exertional, cognitive skills. He concluded that “according to [his] psychological findings, [Foster] would appear to have no limitations on more complex legal tasks if these did not involve much oversight and responsibility.” To be sure, Foster adduced evidence of her own suggesting that her headaches rendered her unable to perform as an attorney. But that does not entitle her to prevail under the substantial evidence standard. See, e.g., Ellis, 394 F.3d at 273 (even if an ERISA plaintiff “support[s] his claim with substantial evidence, or even with a preponderance,” he will not prevail for that reason). Accordingly, we find that Principal marshaled enough evidence to satisfy its burden, and Principal did not abuse its discretion on this ground.

    Foster’s second argument on appeal is that Principal wrongly denied benefits based on a lack of “objective or clinical evidence” of her migraines, when in fact migraines (like other conditions) are not susceptible to objective verification but must instead be verified by subjective evidence—which she claims the record shows without dispute. According to Foster, by requiring nonexistent evidence from Foster, Principal abused its discretion. Yet, as Principal correctly points out, Foster’s argument fails to make a critical distinction: Although the existence of a disability like migraines may not be denied based on impossible-to-obtain objective evidence, that is not true of one’s inability to work as a result of migraines.

    An administrator may rely on an absence of objective evidence of the latter (inability to work) as a basis for finding lack of disability and denying benefits. Indeed, one of the circuit opinions Foster cites—an unpublished Eleventh Circuit decision—makes precisely this distinction. See Creel v. Wachovia Corp., 2009 WL 179584, at *8–9 (11th Cir. Jan. 27, 2009) (unpublished) (explaining that, “[e]ven for subjective conditions like migraines, it is reasonable to expect objective medical evidence of an inability to work” (citing Boardman v. Prudential Ins. Co. of Am., 337 F.3d 9, 16 n.5 (1st Cir. 2003))). Our court has relied on this principle in a case involving a denial of a disability claim based on PTSD. In Anderson v. Cytec Industries, we held that a claims administrator “did not abuse its discretion by relying on the independent experts’ opinion that [the claimant] had not offered objective clinical proof showing the functional effect of his PTSD”—and this was true even when those experts “took into consideration [the claimant’s] subjective complaints and the conclusions of his doctors.” 619 F.3d 505, 513 (5th Cir. 2010). And we did not stop there:

    A plan administrator does not abuse its discretion by making a reasonable request for some objective verification of the functional limitations imposed by a medical or psychological condition, especially when the effects of that condition are not readily ascertainable from treatment and therapy notes—as in this case and analogous cases involving, for example, chronic fatigue syndrome. . . . Without some objective measurement of [the claimant’s] functional limitations, [the administrator] had no way to determine whether his concentration was impaired to the point that he could not perform his job[.]

    Id. at 514 (citing Williams v. Aetna Life Ins. Co., 509 F.3d 317, 322 (7th Cir. 2007); Boardman, 337 F.3d at 16–17 n.5).

    We need look no further than our decision in Anderson, and the authorities it relies on, to decide this issue. As the district court correctly determined, Principal relied on expert reports assessing—not whether Foster subjectively experienced migraines—but instead whether and to what extent those migraines “functionally” impaired Foster in her work.

    To the extent Foster criticizes Principal for relying on its experts rather than her treating physicians, our cases also reject this argument. Principal was required to base its decision on “substantial evidence,” and it is immaterial whether Foster herself adduced substantial evidence (or even a preponderance of evidence) to support her view of the severity of her impairment. See Corry, 499 F.3d at 397–98; Ellis, 394 F.3d at 273. Furthermore, we have recognized that a claims administrator is not required to accept the opinions of a claimant’s treating physicians regarding the severity of the claimant’s condition. See, e.g., Anderson, 619 F.3d at 513 (explaining “the experts here were not required to accept the opinion of [the claimant’s] treating physician that his symptoms rendered him incapable of performing his job”); Corry, 499 F.3d at 401 (“[T]he administrator, under the established standard of review that restricts the courts, was not obliged to accept the opinion of [the claimant’s] physicians. In this ‘battle of the experts’ the administrator is vested with discretion to choose one side over the other.”).

    At bottom, we see no abuse of discretion in Principal’s reliance on its own treating physicians’ reports detailing an absence of Foster’s functional impairments.4 Furthermore, although Principal has a “structural” conflict of interest in that it both evaluates and pays claims, see, e.g., Truitt, 729 F.3d at 508, we accord this factor little weight in view of the extensive investigation Principal undertook. We therefore conclude that Principal’s benefits denial was supported by substantial evidence.
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