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Failure to Accept Opinion of  Treating Physician Did Not Make Claim Decision <i>De Novo</i> Wrong

Failure to Accept Opinion of Treating Physician Did Not Make Claim Decision De Novo Wrong

Eads v. Liberty Life Assurance Co. of Boston, No. 4:13-CV-0238-HLM (N.D. Ga. Mar. 27, 2014)


ERISA and Life Insurance News
(May 30, 2014)

Eads was a sales representative for Charter Communications. He was a participant in Charter’s self-funded short term disability plan, which was governed by ERISA. Liberty Life was the claims administrator for the plan.

Eads submitted a claim for benefits, reporting that he was disabled due to anxiety. Liberty sought the opinion of a board-certified psychiatrist, who reviewed Eads’s medical records and spoke with his primary care physician, who had diagnosed agoraphobia with panic disorder. The reviewing psychiatrist opined that the disability claim “was unsupported for any time period,” because there were no abnormal findings on a mental status exam. The claim was denied.

During the administrative appeal, Liberty sought the opinion of a second board-certified psychiatrist, who reviewed additional medical records and spoke with Eads’s treating psychiatrist. The second psychiatrist opined that Eads was not impaired by a psychiatric condition and that he appeared to be over-reporting his anxiety symptoms.

Liberty upheld its decision, noting that the information received on appeal did not support the claim that Eads was unable to perform his job duties.

After suit was filed, Liberty moved for judgment on the administrative record under Fed.R.Civ.P. 52. The district court granted Liberty’s motion, ruling that its claim decision was neither de novo wrong nor unreasonable under the arbitrary and capricious standard of review.

The court applied the Eleventh Circuit’s series of steps for reviewing a denial of benefits in an ERISA case. Applying the first step, the court determined that Liberty “thoroughly reviewed Plaintiff’s claim, obtaining separate medical opinions from board certified psychiatrists finding that Plaintiff was not disabled, as defined by the Plan .... Under those circumstances, the Court cannot find that Defendant’s decision to deny Plaintiff’s claim for benefits was de novo wrong [i.e., the court disagrees with the administrator’s decision].”

The court said that Liberty’s decision could not be found to be de novo wrong “simply because Defendant failed to accept the opinions of Plaintiff’s treating physician concerning Plaintiff’s limitations, declined to give special weight to those opinions, or weighed the evidence in the record before it,” citing Blankenship v. Metropolitan Life Insurance Company, 644 F.3d 1350, 1356 (11th Cir. 2011) (“Plan administrators need not accord extra respect to the opinions of a claimant’s treating physicians.”).

The court also refused to consider an opinion and an office note from another treating psychiatrist, because those materials were not part of the administrative record. Moreover, the court said, those materials had little probative value because they related to Eads’s condition after Liberty’s final claim decision.

The court found “misplaced” Eads’s argument that Liberty had relied on inadmissible hearsay when reaching its claim decision, given that the court’s review was “limited only by what was available to the plan administrator, not by the Federal Rules of Evidence.”

Finally, the court determined that the same evidence showing that the claim decision was not de novo wrong constituted reasonable grounds for Liberty to deny the claim, and therefore its decision also was not arbitrary or capricious.

Click here to view the full May 2014 Edition of the ERISA and Life Insurance News.

Authors
H. Sanders Carter
T (404) 962-1015
F (404) 962-1220
Kenton J. Coppage
T (404) 962-1065
F (404) 962-1256
Dorothy H. Cornwell
T (404) 962-1096
F (404) 962-1246
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