“A plaintiff must make a showing of prejudicial procedural irregularity to warrant reversal [or remand] on the ground of denial of the right to full and fair review.”
How later courts described this case
- “A plaintiff must make a showing of prejudicial procedural irregularity to warrant reversal [or remand] on the ground of denial of the right to full and fair review.”
Written by the judges who cited it.
The opinion
UNITED STATES DISTRICT COURT
DISTRICT OF MAINE
BENJAMIN HUGHES, )
)
Plaintiff, )
)
v. ) Docket No. 2:22-cv-00098-NT
)
THE LINCOLN NATIONAL LIFE )
INSURANCE COMPANY, )
)
Defendant. )
ORDER ON CROSS-MOTIONS FOR JUDGMENT ON THE
ADMINISTRATIVE RECORD
Before me are the parties’ cross-motions for judgment on the administrative
record. For the reasons stated below, the Plaintiff’s Motion for Judgment on the
Administrative Record (ECF No. 25) is DENIED. The Defendant’s Motion for
Judgment on the Administrative Record (ECF No. 26) is GRANTED.
ADMINISTRATIVE RECORD1
I. The Plaintiff
The Plaintiff, Benjamin Hughes (“Hughes” or the “Plaintiff”), is a 43-year-
old man who resides in Biddeford, Maine. See Administrative R., at LIN000688,
LIN000694. Prior to the onset of health issues that form the basis of this action,
1 The following facts are drawn from the administrative record provided by the parties. See
Administrative R. (ECF No. 14). The administrative record was uploaded to the Electronic Filing
System (“ECF”) in four parts, though the record is numbered continuously using a “Bates numbering”
system. Part 1 (ECF No. 14-1) spans pages LIN000001—LIN000601; Part 2 (ECF No. 14-2) spans
pages LIN000602—LIN001159; Part 3 (ECF No. 14-3) spans pages LIN001160—LIN001797; and Part
4 (ECF No. 14-4) spans pages LIN001798—LIN002497. For simplicity’s sake, and following the lead
of the parties, citations in this Order will refer to the Bates number(s) of the page(s) cited and will
omit reference to the particular Part(s) in which the cited page(s) are located on ECF.
Hughes worked as a Principal Systems Engineer for Liberty Mutual Insurance
Company, which was subsequently purchased by the Defendant, Lincoln National
Life Insurance Company (“Lincoln” or the “Defendant”). See Administrative R., at
LIN001173, LIN001363. The Principal Systems Engineer position is a sedentary role
that entails mostly online work. See Administrative R., at LIN000699. During the
Covid-19 pandemic, the job became mostly remote. Administrative R., at LIN000699.
Hughes estimates that he generally worked from 6:00 a.m. to 6:00 p.m. each workday,
though he was “on-call 24/7 for anything that would come up.” Administrative R., at
LIN000699.
II. The Policy
The Plaintiff was enrolled in the Defendant’s group welfare benefit plan, which
includes a group disability policy (the “Policy”). Administrative R., at LIN002461–
LIN002497. Under the Policy, “Disabled” means that as of the last date worked and
continuously through the completion of a 180-day Elimination Period, the claimant
is “unable to perform the Material and Substantial Duties of his Own Occupation” as
a result of “Injury or Sickness.” See Administrative R., at LIN002467 (defining
“Disabled”), LIN002468 (defining “Elimination Period”), LIN002464 (Schedule of
Benefits defining “Elimination Period”).
“Material and Substantial Duties” are defined as “responsibilities that are
normally required to perform the Covered Person’s Own Occupation, or any other
occupation, and cannot be reasonably eliminated or modified.” Administrative R., at
LIN002469. The Policy defines “Own Occupation” as “the Covered Person’s
occupation that he was performing when his Disability or Partial Disability began.
For the purposes of determining Disability under this policy, Lincoln will consider
the Covered Person’s occupation as it is normally performed in the national economy.”
Administrative R., at LIN002469.
Lincoln will pay claims under the Policy when it “receives Proof that a Covered
Person is Disabled due to Injury or Sickness and requires the Regular Attendance of
a Physician” Administrative R., at LIN002477. The Policy requires proof of: “1.
Disability; 2. Regular Attendance of a Physician; and 3. Appropriate Available
Treatment.” Administrative R., at LIN002477. “The Proof must be given upon
Lincoln’s request and at the Covered Person’s expense.” Administrative R., at 2477.
The Policy states that a claimant has the burden of providing proof of his disability
throughout the duration of the disability benefit period; if the claimant fails to
provide proof of continued disability, his monthly benefits will be discontinued. See
Administrative R., at LIN002483.
III. The Plaintiff’s Health Problems
On January 8, 2021, the Plaintiff visited a gastroenterologist, Dr. Mark
Branda, reporting diarrhea, abdominal pain, and cramping. Administrative R., at
LIN001214. The Plaintiff told Dr. Branda that, “for many years[,] he has had episodes
of loose stools, urgency and abdominal pain and cramping in the morning,” and that
“[h]e often wakes up at 3–4 a.m. [w]ith gas and pain, [and] . . . then has stools which
eventually resolve[] his discomfort.” Administrative R., at LIN001215. Dr. Branda
ordered laboratory testing, recommended that the Plaintiff take a fiber supplement,
Metamucil, and gave the patient dicyclomine, a medication used to treat intestinal
problems. Administrative R., at LIN001214. He noted that “[d]epending on results
and clinical course, colonoscopy . . . could be considered.” Administrative R., at
LIN001214.
A little over two weeks later, on January 25, 2021, the Plaintiff had a
telehealth visit with Dr. Branda’s nurse practitioner, Jamie Hare. Administrative R.,
at LIN001217. Hughes told Hare that he “[c]ontinues to have pain[,] gas[,] and
bloating in the morning” and “[s]till some diarrhea,” which was accompanied by
“bouts of nausea” requiring the use of an anti-nausea medication, Zofran.
Administrative R., at LIN001218. Hughes reiterated that “he starts to feel better
later in the day after he has emptied his bowels.” Administrative R., at LIN001218.
Hughes told Hare that he had experienced a “partial benefit with dicyclomine and
Metamucil” but that, “[at] this point[,] this disrupted bowel pattern is having a
significant impact on his daily activities and is starting to affect his work schedule.”
Administrative R., at LIN001217. Hare ordered an endoscopy in addition to a
colonoscopy. Administrative R., at LIN001217–LIN001218.
IV. Short-Term Disability
The Plaintiff stopped working on February 26, 2021 and applied for short-term
disability benefits on March 8, 2021. Administrative R., at LIN002442, LIN002459.
In an email to a Lincoln claims examiner, Hughes stated that he was experiencing
the following symptoms, which were preventing him from performing his job duties:
urgent change in bowel movement; Diarrhea; nausea and vomiting
lasting periods of time each morning; severe abdominal pain interfering
with my ability to even focus on anything else; Inability to sleep due to
pain; debilitating “flare ups” that prevent daily functions, even my
ability to stand up; Intense Anxiety caused by symptoms, unknown
diagnosis, delay of medical care, and impact on my ability to function at
work.
Administrative R., at LIN002442. In evaluating Hughes’ claim, Lincoln requested
medical records from Dr. Branda and asked his office to complete a Restrictions Form.
Administrative R., at LIN002422. Hare completed the Restrictions Form on Dr.
Branda’s behalf, and wrote: “Patient has developed chronic diarrhea, waxing +
waning abd[ominal] pain[,] and intermittent nausea and vomiting. This results in
inability to perform daily tasks and creates unpredictability to work. Needs to have
endoscopic evaluation, however delayed due to Covid.” Administrative R., at
LIN002355. Hare added that Hughes could return to work on May 31, 2021, though
he could “tentatively . . . return sooner pending vaccine status.” Administrative R., at
LIN002355.
On April 9, 2021, Lincoln approved short-term disability benefits for Hughes
through April 25, 2021. Administrative R., at LIN002346. Hughes wrote back to
Lincoln requesting to extend his benefits “through the beginning of June at the
earliest” and told the claims examiner that Hare could provide more documentation
if needed. Administrative R., at LIN002341. On April 14, 2021, Hare faxed Lincoln a
letter “advis[ing] that Mr. Hughes is scheduled for endoscopic evaluation on 5/28/2021
and will be seen on 6/7/2021 for follow-up and re-evaluation in the office. He will be
unable to work until that date and we will make further determination about return
to work at that time.” Administrative R., at LIN001349. On April 26, 2021, Hare
submitted a letter on Hughes’ behalf, which stated:
As outlined in the 3/23/2021 restrictions form submitted to Lincoln
Financial, Mr. Hughes has been experiencing chronic diarrhea, waxing
and waning abdominal pain as well as bouts of nausea and vomiting
resulting in missed time from work.[ ] These have resulted in an
inability to maintain a consistent work schedule[ ] due to the
unpredictable and frequent nature of his symptoms and therefore [he]
has been out of work until he can complete[ ] his endoscopic evaluation.
This was delayed [due] to the COVID pandemic. He will undergo
evaluation on 5/28/2021 and will have an in office follow-up on 6/7/2021.
Administrative R., at LIN000357. On May 6, 2021, Lincoln approved the Plaintiff’s
short-term disability claim through June 20, 2021. Administrative R., at LIN001088.
On May 28, 2021, Hughes underwent an endoscopy and a colonoscopy.
Administrative R., at LIN001484, LIN001486. Dr. Branda reviewed the results of the
endoscopy and opined that there was “[m]ild erythematous gastropathy” but that it
was an “[o]therwise normal exam.” Administrative R., at LIN000420. As to the
colonoscopy results, Dr. Branda commented that there were “[s]mall internal
hemorrhoids” and “[m]ultiple diverticula . . . in the sigmoid colon.” Administrative R.,
at LIN000422. Dr. Branda noted a few areas that required biopsies, Administrative
R., at LIN000422, but later medical records note that the resulting “[l]aboratory
testing was unremarkable.” Administrative R., at LIN000060.
On July 30, 2021, Lincoln sent the Plaintiff a letter explaining that it closed
the Plaintiff’s claim because it “had not received the necessary documentation to
extend ongoing benefits beyond June 20, 2021.” Administrative R., at LIN001558. On
August 5, 2021, the Plaintiff sent in the requested documentation. See Administrative
R., at LIN001373–LIN001382, LIN001412. In a form submitted that day, Hughes
reported that he could only sit or stand for less than an hour at a time, and that he
could walk for twenty minutes at a time. Administrative R., at LIN001373. He stated
that he could drive for “2 hrs with breaks” and that he took a two-to-three hour nap
every afternoon. Administrative R., at LIN001373. Hughes wrote that he was able to
pursue his hobbies on only a “limited” basis, as his “hobbies are outdoors and often
no access to facilities.” Administrative R., at LIN001375. He also stated that his
“limited” exercise was to “walk when able.” Administrative R., at LIN001375. When
asked if he had “returned to any type of employment of activity that provide[d him]
money,” the Plaintiff responded that he had not, noting below that he was a
“[m]ember of LLC” that provided “[n]o income.” Administrative R., at LIN001378. On
August 5, 2021, after receiving Hughes’ documentation, Lincoln extended Hughes’
short-term disability benefits through August 29, 2021. Administrative R., at
LIN001084.
V. Initial Denial of Long-Term Disability
On August 6, 2021, as the Plaintiff’s short-term disability period was coming
to an end, Lincoln notified the Plaintiff that his Long-Term Disability (“LTD”) Claim
was under review and that it had “referred [his] file for a medical review and
assessment by a Board Certified Physician.” Administrative R., at LIN001252. Three
days later, on August 9, 2021, Lincoln requested an independent medical review from
MLS National Medical Evaluation Services, an independent medical review
company. Administrative R., at LIN000021. MLS then referred the Plaintiff’s file to
Dr. Brian Dooreck,2 who completed a report on August 17, 2021. Administrative R.,
at LIN001200—LIN001203.
2 The Plaintiff states that Dr. Dooreck “is an internal medicine doctor, not a gastroenterologist.”
Pl.’s Mot. for J. on the Administrative R. 9 (ECF No. 25). But the Plaintiff does not provide a citation
for this assertion, and in his report to Lincoln, Dr. Dooreck identified himself as “Board Certified:
American Board of Internal Medicine, Gastroenterology.” Administrative R., at LIN001203.
In his report, Dr. Dooreck summarized the Plaintiff’s symptoms and
colonoscopy results:
The claimant is noted with irritable bowel syndrome with diarrhea
associated with intermittent nausea and vomiting and wax and wean
[sic] abdominal pain, cramping and bloating. Symptoms were reported
since 12/2020. The claimant is also noted with a history
gastroesophageal reflux disease. Colonoscopy on 5/28/2021 noted
gastritis, hemorrhoids, diverticulosis with no colitis
Administrative R., at LIN001202. “Taking into consideration the entire clinical
picture,” Dr. Dooreck agreed that “there is a supported level of impairment that
translates into restrictions and limitations from 3/1/2021 to present and ongoing.”
Administrative R., at LIN001202. Dr. Dooreck, however, disagreed with the
Plaintiff’s assertion that he was unable to work. “While the claimant's condition is
unpredictable,” Dr. Dooreck wrote, “it does not preclude the claimant from working.
The claimant’s symptoms are intermittent and as such the following restrictions and
limitations would include having access to medical appointments, unrestricted
bathroom privileges with full access, and medications as needed and deemed
medically necessary and appropriate.” Administrative R., at LIN001202.
On August 18, 2021, the Lincoln claims specialist assigned to Hughes’ long-
term disability claim sent Dr. Dooreck’s report to Hare for her review and comment.
Administrative R., at LIN001149. Six days later, on August 24, Hare responded that
she “agee[d] with [Dr. Dooreck’s] overall assessment of symptoms and disruption in
daily activities,” but disagreed with Dr. Dooreck’s conclusion that Hughes could
return to work. Administrative R., at LIN001149. Hughes, Hare wrote, “still
experiences prolonged periods of disruption, days a time.” Administrative R., at
LIN001149. “Given the nature of [Hughes’] work,” which “require[d] prolonged
periods of time on [the] phone,” Hare recommended that Hughes be granted “an
additional 4 weeks of restriction/out of work to continue work-up and therapy
adjustments.” Administrative R., at LIN001149. Lincoln forwarded Hare’s comments
to Dr. Dooreck, who, in turn, completed an addendum stating that his “[r]eview of
[Hare’s comments] does not alter the prior assessment. There is no new objective
evidence to validate a change in determination.” Administrative R., at LIN001139.
Lincoln also requested a confidential investigative report into the Plaintiff’s
activities from Convent Bridge, an independent full-service investigations company.
Administrative R., at LIN000020. Convent Bridge scoured Hughes’ social media
accounts and found a photograph of him in knee-deep snow next to a shovel, posted
on February 6, 2021, and an accompanying comment posted by Hughes saying that
it was a “staged photo” and that he hadn’t done any of the shoveling himself.
Administrative R., at LIN001172. Convent Bridge also found a photograph of Hughes
fishing posted on July 16, 2021, and a photograph of him kayaking posted on August
8, 2021. Administrative R., at LIN001169–LIN001170. Convent Bridge also found
that Hughes was involved in a newly incorporated business called Virtually Onsite,
a property caretaking service. Administrative R., at LIN001181.
Finally, Lincoln commissioned an Occupational Analysis of the Plaintiff’s claim
by Nicole Hall, a Vocational Rehabilitation Counselor. Administrative R., at
LIN001141–LIN001142. Hall reviewed Hughes’ medical records, Dr. Dooreck’s
report, and other sources pertinent to evaluating Hughes’ occupational demands. See
Administrative R., at LIN001141. Hall concluded that Hughes’ occupation as a
Principal System Engineer
would allow one the opportunity to sustain comfort and autonomy in the
work setting with the ability to utilize the bathroom facilities as needed
as well as take medications as needed. The ability to attend medical
appointments may require a level of accommodation or agreement
between the employer and employee should such appointments require
time away from or off of work.
Administrative R., at LIN001142.
By letter dated August 31, 2021, Lincoln notified Hughes that it had
“determined you do not meet the definition of disability for your own occupation” and
thus no LTD benefits were payable. Administrative R., at LIN001112.
VI. The Appeal
The Plaintiff, through his attorney, Andrew Davis, appealed Lincoln’s
determination. See Administrative R., at LIN001056. Attorney Davis attempted to
send the appeal and accompanying documents on November 23, 2021, but Lincoln did
not receive the appeal until December 8, 2021. Administrative R., at LIN000388,
LIN001056.
In connection with the appeal, Hughes submitted medical records from Dr.
Branda’s office as well as a Vocational Analysis. See Administrative R., at
LIN000390. The medical records showed that Hughes had undergone a “capsule
endoscopy” and “was found to have a large intraluminal windsock
deformity/diverticulum” for which “[f]urther work up and testing . . . is ongoing” and
which “may require surgery.” Administrative R., at LIN000392. The medical records
submitted also showed, however, that at least a follow-up exam identified “no
intrinsic or extrinsic abnormality” and, “[i]n particular, a wind-sock deformity was
not visualized.” Administrative R., at LIN000799. The Plaintiff also provided the
record of a November 8, 2021 visit with Hare, the notes for which show only that Hare
gave the Plaintiff instructions regarding his medication and recommended he follow
up in five weeks. See Administrative R., at LIN000785.
The Plaintiff also commissioned a vocational analysis by two consultants at
Seacoast Rehabilitation—Charles Galarraga and Nicole Duchette. See
Administrative R., at LIN000688–LIN000689. In conducting the vocational analysis,
Galarraga and Duchette reviewed the Plaintiff’s medical file and conducted a survey
of employers “within a 50-mile geographical distribution of [Hughes’] address using
the medically opined restrictions and limitations of the claimant’s attending
providers as well as the insurance company medical providers.” Administrative R., at
LIN000688. The survey included the following questions:
• If a potential applicant, due to bouts of chronic disease, waxing
and waning abdominal pain including nausea, were to miss
several days of work due to the unpredictable and frequent
occurrence of these symptoms, would they be able to perform the
materials [sic] and substantial duties of this occupation?
• Would someone be able to attend medical appointments that
require time away from work greater than 2 or more days per
month while performing the duties of this occupation?
Administrative R., at LIN000707. All employers surveyed answered these questions
in the negative. See Administrative R., at LIN000688. The survey also asked
employers, “Would someone always be able to utilize the bathroom facilities as
needed while performing the duties of this occupation?” Administrative R., at
LIN000707. Surveyed employers answered this question in the affirmative, though
some qualified their response by stating, for example, “Yes, so long as it does not take
one off tasks and pace.” Administrative R., at LIN000708–LIN000716. Galarraga and
Duchette also conducted an occupational analysis based on the duties associated with
Hughes’ job and opined that:
a claimant such as Mr. Hughes who would be facing unpredictable
symptomology and medical scheduling would regularly be unable to
spend most of his time with conflict resolution, communicating with
others, and directing, controlling, or planning activities of others which
are time sensitive and/or immediate tasks, and could be unavailable if a
decision needed to be made by him.
Administrative R., at LIN000689. Overall, the Galarraga/Duchette analysis
concluded that “the claimant cannot perform the material and substantial duties of
his OWN Occupation.” Administrative R., at LIN000688.
On December 14, 2021, Lincoln requested a review of Hughes’ medical records
from Exam Coordinators Network (“ECN”), a different outside medical vendor than
the one used during the initial claim; ECN referred the Plaintiff’s file to Dr. Ravi
Ravinuthala, who identified himself as being “Board Certified [in] Gastroenterology.”
Administrative R., at LIN000017–LIN000018, LIN000215. Dr. Ravinuthala
submitted his report on December 30, 2021. Administrative R., at LIN000211. When
asked to “describe how any supported level of impairment translates into restrictions
and limitations,” Dr. Ravinuthala responded that Hughes’ “[c]linical condition is best
described by irritable bowel syndrome” and that, “[a]s the claimant has residual
diarrhea attributed to the diagnosis, it is reasonable to support a degree of
restrictions.” Administrative R., at LIN000214. “However,” Dr. Ravinuthala
continued, “there is no evidence of any measurable examination abnormality and/or
diagnostic finding that would translate into the need for physical restrictions or
limitations. Additionally, surveillance footage indicates the claimant has been
capable of performing activities including shoveling snow, wadding [sic] in a lake, and
fishing on a boat.” Administrative R., at LIN000214. Dr. Ravinuthala added that,
“The claimant would require access to a bathroom on a [sic] as needed basis based on
his symptoms of irritable bowel syndrome due to urgency and control of bowels. The
claimant would still be able to maintain full-time work capacity with bathroom
breaks being only as needed for IBS symptoms. Otherwise, the claimant has no
restrictions or limitations.” Administrative R., at LIN000214.
On December 28, 2021, the Plaintiff submitted additional medical records to
be included in the appeal review. Administrative R., at LIN000220. Lincoln
forwarded those additional records to Dr. Ravinuthala on January 3, 2022, and
requested an addendum. Administrative R., at 208. Dr. Ravinuthala returned the
addendum on January 12, 2022. Administrative R., at LIN000203. In the addendum,
Dr. Ravinuthala reiterated his initial conclusion that “[t]he claimant’s impairing
symptoms require access to a bathroom as needed for IBS symptoms,” but “[t]here is
no indication the claimant cannot sustain fulltime work activity.” Administrative R.,
at LIN000205.
On January 13, 2022, 36 days after Lincoln received the appeal, Lincoln sent
the Plaintiff Dr. Ravinuthala’s report and addendum, along with a cover letter setting
a deadline for the Plaintiff “to review and comment on new/additional evidence . . .
before a decision is rendered on Mr. Hughes’s appeal.” Administrative R., at
LIN000191. The letter further explained that due to “special circumstances,” Lincoln
was taking a 45-day extension to decide the Plaintiff’s appeal, and that its review
process would be “tolled while Lincoln is awaiting receipt of requested
documentation.” Administrative R., at LIN000191–LIN000192.
The Plaintiff responded on February 1, 2022. See Administrative R., at
LIN000077. In response to Dr. Ravinuthala’s review, Attorney Davis addressed the
investigative photos that showed the Plaintiff shoveling snow, fishing, and kayaking,
which Dr. Ravinuthala had taken into account in his medical review. See
Administrative R., at LIN000078. “Dr. Ravinuthala's assessment is not accurate,”
Attorney Davis wrote, because (1) Hughes merely posed with a shovel, but did not
actually shovel snow; and (2) the photo of Hughes on a boat could have been a “pre-
disability photo[ ].” Administrative R., at LIN000078.
The Plaintiff’s response also included a letter from Hare, in which she wrote
that she did not “feel that [Dr. Ravinuthala’s medical review] adequately capture[d]
the impact this condition [(IBS)] has on this patient’s day-to-day activities and impact
on work function.” Administrative R., at LIN000080. Hare noted that IBS “is an
understandably challenging diagnosis when it comes to disability because the
majority of the diagnosis and impact on functional status is based on primarily
subjective findings,” but “this does not mean the condition is any less impactful than”
other conditions diagnosable via objective findings. Administrative R., at
LIN000081–LIN000082.
Finally, the Plaintiff’s response included the results of a CT Scan dated
December 29, 2021. See Administrative R., at LIN000083. The CT Scan found “[n]o
acute abnormality of the abdomen or pelvis.” Administrative R., at LIN000084.
On February 10, 2022, Dr. Ravinuthala completed a second addendum in
response to the Plaintiff’s additional information. See Administrative R., at
LIN000064–LIN000065. Dr. Ravinuthala wrote that “the additional medical
information does not alter the prior claim determination.” Administrative R., at
LIN000065.
On February 8, 2022, Attorney Davis submitted an “updated gastroenterology
visit” note from Dr. Branda. Administrative R., at LIN000058. Dr. Branda’s note
reiterated Hughes’ diagnosis of IBS, though he noted that Hughes’ “symptoms are
currently marginally well controlled on a combination of” different medications.
Administrative R., at LIN000059. As to the “windsock” deformity, Dr. Branda noted
that various tests had failed to show an abnormality, and wrote that “[i]t is unlikely
that the abnormality seen in the duodenum is contributing to [Hughes’] current
symptoms.” Administrative R., at LIN000059.
Dr. Ravinuthala submitted a third addendum on February 18, 2022, reviewing
the February 8 note from Dr. Branda. See Administrative R., at LIN000049. Dr.
Ravinuthala concluded as follows:
The additional medical information does not alter the prior claim
determination. As of 02/08/2022, the claimant seemed to be stable on his
current medication regimen. The information did not provide any
indication that the claimant’s gastric issues had been affecting his
ability to function on a daily basis as it pertained to completing
activities[,] daily living or work-related duties.
Administrative R., at LIN000050.
On March 3, 2022, at the request of Lincoln, Jason Miller, a Board-Certified
Vocational Expert, submitted a vocational review of the prior occupational analyses
completed by Hall and Galarraga/Duchette in light of the restrictions and limitations
outlined by Dr. Ravinuthala. See Administrative R., at LIN000040. As to the
Galarraga/Duchette analysis, Miller noted that “much of the information obtained by
Mr. Galarraga and Ms. Duchette were a direct result of” leading questions that, for
example, took as a given that the “potential applicant . . . [would] miss several days
of work due to the unpredictable and frequent occurrence of [his] symptoms”—a
restriction/limitation that was not prescribed in Dr. Ravinuthala’s medical review.
Administrative R., at LIN000041. Miller did find it notable that, in the
Galarraga/Duchette analysis, “[a]ll employers answered in the affirmative” to the
question of whether an employee would “always be able to utilize the bathroom
facilities as needed while performing the duties of this occupation.” Administrative
R., at LIN000041. “This is important and the most crucial question asked,” Miller
explained, “because it is a direct comparison between the restriction posed by Dr.
Ravinuthala and the response by the employers . . . and all employers responded that
this is possible.” Administrative R., at LIN000041.
VII. Lincoln’s Decision on Appeal
On March 10, 2022, Lincoln upheld its determination that Hughes was “not
eligible for LTD benefits.” Administrative R., at LIN000035. In its decision, Lincoln
quoted Miller’s vocational review at length. See Administrative R., at LIN000032–
LIN000034. Lincoln then summarized the reasoning for its denial of Hughes’ LTD
benefits as follows:
We acknowledge Mr. Hughes’s claim of total impairment based on IBS.
We also acknowledge the Vocational Reviews from Charles Galarraga,
MS/Nicole Duchette, MS which state Mr. Hughes cannot perform the
material and substantial duties of his Own Occupation. However, the
diagnostic assessment to date has been essentially unremarkable. The
ova and parasites stool testing was negative. The calprotectin Fecal by
immunoassay was normal. The Helicobacter pylori screen was negative.
CT scan of the abdomen and pelvis demonstrated no colonic
abnormality. A colonoscopy and upper endoscopy noted hemorrhoids,
diverticulosis, and reflux. The small bowel series demonstrated a
normal gas pattern, soft tissue, and bony structures. There is no
diagnostic abnormality to account for the claimant’s continued
symptoms. There were no abnormalities on physical examination. In
addition, there is no evidence of excessive use of the bathroom, emergent
treatment, or hospitalizations. The evaluation by Dr. Ravinuthala
outlined restrictions and limitations of having access to a bathroom. As
outlined in the occupational analysis, the occupation would allow Mr.
Hughes the opportunity to sustain comfort and autonomy in the work
setting with the ability to utilize the bathroom facilities as needed.
Therefore, the restriction and limitation of having access to a bathroom
would not prevent Mr. Hughes from performing his own occupation.
The appeal review and analysis considered all the medical, vocational,
and claim documentation contained in Mr. Hughes’s LTD
administrative record, whether or not specifically referenced in the
document. Our role in reviewing the file is to determine whether Mr.
Hughes’s medical conditions and the medical documentation contained
in the file validates impairment resulting in restrictions and limitations,
which would preclude his from performing the duties of his Own
Occupation as defined by the Policy. After a complete evaluation of his
claim, including all information submitted with the appeal, all medical
reviews completed on the file, and taking into consideration the opinions
of his providers as set forth in their written record, we determined the
clinical evidence does not support Mr. Hughes was precluded from
performing his Own Occupation throughout and beyond the Policy’s
elimination period. As such, our review concludes Mr. Hughes is not
eligible for LTD Benefits.
Administrative R., at LIN000034–LIN000035.
On April 15, 2022, the Plaintiff filed suit in this Court, seeking to recover
disability benefits under the Policy pursuant to the Employee Retirement Income
Security Act (“ERISA”), 29 U.S.C. § 1132(a)(1)(B). Compl. ¶ 7 (ECF No. 1).
DISCUSSION
The parties each move for judgment on the administrative record. The Plaintiff
makes two arguments in support of his motion. First, the Plaintiff argues that Lincoln
deprived Hughes of a “full and fair review” as mandated by ERISA and its
implementing regulation, and therefore that the case should be remanded to Lincoln
for a full and fair review of Hughes’ claim. See Pl.’s Mot. for J. on the Administrative
R. (“Pl.’s Mot.”) 18 (ECF No. 25). Second, alternatively, the Plaintiff asserts that I
should review Lincoln’s appeal determination de novo and find that Lincoln’s denial
of LTD benefits to Hughes was incorrect. See Pl.’s Mot. 18. Lincoln opposes the
Plaintiff’s motion and argues that it is entitled to judgment on the administrative
record. See Def.’s Mot. for J. on the Administrative R. (“Def.’s Mot.”) (ECF No. 26).
Lincoln asserts that I should apply the deferential arbitrary and capricious standard
of review and uphold Lincoln’s denial of Hughes’ LTD benefits. See Def.’s Mot. 3.
Below I address each of these arguments.
I. Full and Fair Review
I turn first to the Plaintiff’s contention that Lincoln deprived Hughes of a “full
and fair review” as mandated by ERISA and its implementing regulation. See Pl.’s
Mot. 18. “ERISA is a comprehensive statute designed to promote the interests of
employees and their beneficiaries in employee benefit plans.” Merit Constr. All. v.
City of Quincy, 759 F.3d 122, 127–28 (1st Cir. 2014) (quoting Shaw v. Delta Air Lines,
Inc., 463 U.S. 85, 90 (1983)). “To accomplish this goal, section 503 of ERISA
[(“Section 503”)] establishes minimum procedural requirements that govern how an
ERISA plan processes claims for health and disability benefits.” Jette v. United of
Omaha Life Ins. Co., 18 F.4th 18, 26 (1st Cir. 2021) (citing 29 U.S.C. § 1133). Section
503 provides that “any participant whose claim for benefits has been denied” must be
afforded a “full and fair review . . . of the decision denying the claim,” in compliance
“with regulations of the Secretary [of Labor].” 29 U.S.C. § 1133.
“In accordance with the authority of [S]ection[ ] 503,” the Department of Labor
promulgated a “claims procedure” regulation. 29 C.F.R. § 2560.503-1. Subsection (h)
of the regulation (“Subsection (h)”), which governs the “[a]ppeal of adverse benefit
determinations,” requires that “[e]very employee benefit plan . . . establish and
maintain a procedure by which a claimant shall have a reasonable opportunity to
appeal an adverse benefit determination . . . , and under which there will be a full
and fair review of the claim and the adverse benefit determination.” 29 C.F.R.
§ 2560.503-1(h)(1). Subsection (h) further states that for a plan to satisfy the
requirement of providing a “full and fair review of a claim and adverse benefit
determination,” the claimant must “be provided, upon request and free of charge,
reasonable access to, and copies of, all documents, records, and other information
relevant to the claimant’s claim for benefits.”3 Id. § 2560.503-1(h)(2)(iii). In addition,
3 “A document, record, or other information [is] considered ‘relevant’ to a claimant’s claim if” it
was “relied upon in making the benefit determination,” or was “submitted, considered, or generated in
the course of making the benefit determination.” 29 C.F.R. § 2560.503-1(m)(8)(i)–(ii).
claimants must be provided “the opportunity to submit written comments,
documents, records, and other information relating to the claim for benefits.” Id. at
§ 2560.503-1(h)(2)(ii). These requirements of disclosure and opportunity for response
are equally applicable at the administrative appeal stage as they are at the initial
determination stage. See Jette, 18 F.4th at 29.
Here, the Plaintiff contends that Lincoln denied him a full and fair review
because it failed to provide him with a copy of, or an opportunity to respond to, the
vocational analysis developed by Miller, which was relevant to the Defendant’s
determination of the Plaintiff’s appeal. Pl.’s Mot. 20. For its part, the Defendant does
not seem to contest the fact that it failed to provide Miller’s analysis to Hughes prior
to denying his internal appeal.
As the Defendant points out, however, whether Lincoln failed to turn over
relevant records is not the end of the full-and-fair-review analysis. See Def.’s Mem. in
Opp’n to Pl.’s Mot. for J. on the Administrative R. (“Def.’s Opp’n”) 17 (ECF No. 32).
Under First Circuit precedent, “even if the claimant shows that procedural
irregularities have occurred in the course of a review, [the Court] typically require[s]
[the claimant] to show prejudice as well.” Lavery v. Restoration Hardware Long Term
Disability Benefits Plan, 937 F.3d 71, 82 (1st Cir. 2019) (quoting Stephanie C. v. Blue
Cross Blue Shield of Mass. HMO Blue, Inc., 813 F.3d 420, 425 (1st Cir. 2016)); see
also Warming v. Hartford Life & Accident Ins. Co., 663 F. Supp. 2d 10, 12 (D. Me.
2009) (“A plaintiff must make a showing of prejudicial procedural irregularity to
warrant reversal [or remand] on the ground of denial of the right to full and fair
review.”). To establish prejudice, “[a] claimant must show prejudice ‘in a relevant
sense’ and [show] that correct notice ‘would have made a difference.’ ” Hatfield v. Blue
Cross & Blue Shield of Mass., Inc., 162 F. Supp. 3d 24, 42 (D. Mass. 2016) (quoting
Recupero v. New Eng. Tel. & Tel. Co., 118 F.3d 820, 840 (1st Cir. 1997)). In other
words, “a claimant must ‘demonstrate a connection between’ the plan administrator’s
procedural failure and ‘[the claimant’s] inability to receive from the plan
administrator a full and fair review of [his] claim to benefits.’ ” Winters v. Liberty Life
Assurance Co. of Bos., No. 20-11937-MLW, 2022 WL 6170588, at *8 (D. Mass. Oct. 7,
2022) (quoting DiGregorio v. Hartford Comprehensive Emp. Benefit Serv. Co., 423
F.3d 6, 16 (1st Cir. 2005)).
In this case, the Plaintiff asserts that Lincoln’s procedural error in failing to
provide Miller’s review prejudiced Hughes because it “deprived [him] of the
opportunity to further develop the administrative record that is now before this
Court.” Pl.’s Mot. 20. But the Plaintiff has not identified or submitted to this Court
any evidence that he contends he would have provided to Lincoln to further develop
the administrative record if given the opportunity to respond to Miller’s analysis. The
Plaintiff had the opportunity to submit such evidence if it existed—as the First
Circuit has explained, “it may be appropriate for the court to consider ‘evidence
outside the administrative record’ in assessing a claim of ‘prejudicial procedural
irregularity in the ERISA administrative review procedure.’ ” DiGregorio, 423 F.3d
at 16 (quoting Orndorf v. Paul Revere Life Ins. Co., 404 F.3d 510, 520 (1st Cir. 2005)).
And this Court’s scheduling order, issued on June 15, 2022, explicitly provided the
parties an opportunity to “modify the Administrative Record and/or to conduct
discovery.” ERISA Scheduling Order 2 (ECF No. 9). The Plaintiff’s failure to proffer
any additional evidence he would have provided to Lincoln given the chance to
respond to Miller’s review seriously undercuts his argument that the procedural
irregularity was prejudicial. See Winters, 2022 WL 6170588, at *9 (finding that the
claimant had not made a showing of prejudice in part because he “has not identified
or submitted to this court any evidence that he contends he would have provided to”
the plan administrator to support his appeal had he had the opportunity to do so).
Additionally, the Plaintiff has not demonstrated a connection between
Lincoln’s failure to provide a copy of Miller’s report and Hughes’ inability to receive
a full and fair review. The Plaintiff argues that he was denied the opportunity to
discuss what he asserts are shortcomings in Miller’s review—namely that Miller
unfairly characterized the Galarraga/Duchette survey because he “ignored . . . the
significant dialogue between employers and [the surveyors] that placed critical
limitations on” what it meant to provide “needed access” to bathroom facilities while
performing the duties of the occupation. Reply to Def.’s Resp. to Pl.’s Mot. for J. on
the Administrative R. (“Pl.’s Reply”) 3 (ECF No. 35). Specifically, the Plaintiff
suggests that Miller failed to acknowledge that some employers surveyed by
Galarraga and Duchette qualified their affirmative answers to the question of
whether an employee would always be able to utilize bathroom facilities while
performing the duties of their occupation, saying, for example, that the employee
could utilize bathroom facilities but still “would need to be able to complete their job
duties sufficiently.” Pl.’s Reply 3. As a result of this “misconception” about the
Galarraga and Duchette survey, the Plaintiff asserts, “the parties are far from any
agreement on the level of interruption caused by Mr. Hughes’ condition.” Pl.’s Reply
3–4.
The problem for the Plaintiff is that the portion of the Miller report quoted in
the appeal denial explicitly acknowledges that some employers qualified their
answers to the restroom access question: “All employers answered in the affirmative
on this question. . . . While some indicated that [the employee] would need to remain
on task [to perform the duties of this occupation], others simply said yes.”
Administrative R., at LIN000033. Thus, Lincoln already considered the point that
the Plaintiff states that he would have made if he had the opportunity to comment
on Miller’s review. And, even after considering that point, Lincoln still concluded that
the Plaintiff was not entitled to LTD benefits.
Moreover, while the Plaintiff may be correct that the parties disagree about
the level of interruption caused by Hughes’ medical condition, that disagreement does
not stem from the Miller review. As explained in more detail below, the real sticking
point for Lincoln was the lack of medical evidence showing that Hughes was disabled.
For example, in its appeal decision, Lincoln acknowledged the central conclusion of
the Galarraga/Duchette analysis—that Hughes “cannot perform the material and
substantial duties of his Own Occupation.” Administrative R., at LIN000034. Yet
Lincoln ultimately did not give the Galarraga/Duchette findings much weight, not
because of Miller’s comments, but rather due to the lack of “clinical evidence” to
support Hughes’ disability claim. Administrative R., at LIN000034. Even if Hughes
had responded to what he viewed as Miller’s mischaracterization of the
Galarraga/Duchette analysis, that would not have ameliorated the lack of medical
evidence supporting his claim for LTD benefits.
Overall, the Plaintiff has not shown he was prejudiced by Lincoln’s failure to
disclose Miller’s review prior to rendering its appeal decision. The Plaintiff’s request
to remand the appeal decision is therefore denied.
II. Lincoln’s Administrative Appeal Decision
I turn now to the parties’ disagreement as to whether I should uphold Lincoln’s
decision to deny Hughes’ appeal. This disagreement entails two, interrelated issues.
The first issue is what standard of review to apply; the second issue is, applying the
appropriate standard, whether Lincoln’s appeal decision should be upheld. Below I
address each of these issues.
A. Standard of Review
The parties disagree about how much deference I should afford to Lincoln’s
administrative appeal decision. In general, “[t]he standard of review for a claim
brought [to recover benefits due under a plan] depends on the discretion afforded the
administrator of the plan.” Quirk v. Vill. Car Co., 1:19-cv-00217-JCN, 2020 WL
908111, at *4 (D. Me. Feb. 25, 2020). “The default rule favors de novo review: a
challenge to a denial of benefits is to be reviewed de novo ‘unless the benefit plan
gives the administrator or fiduciary discretionary authority to determine eligibility
for benefits or to construe the terms of the plan.’ ” Stephanie C., 813 F.3d at 427.
“When, as in this case,[4] a plan administrator has discretion to determine an
applicant’s eligibility for and entitlement to benefits, the administrator’s decision
must be upheld unless it is ‘arbitrary, capricious, or an abuse of discretion.’ ” Gannon
v. Metro. Life Ins. Co., 360 F.3d 211, 212–13 (1st Cir. 2004) (quoting Vlass v. Raytheon
Emps. Disability Tr., 244 F.3d 27, 29–30 (1st Cir. 2001)).
The Plaintiff asserts that, even if the Plan grants Lincoln discretionary
decisionmaking authority, which normally would trigger arbitrary and capricious
review, Lincoln lost its entitlement to judicial deference because it failed to strictly
adhere to ERISA’s claims procedure regulation by taking an unjustified and untimely
extension.5 See Pl.’s Mot. 21. Therefore, the Plaintiff argues, Lincoln’s decision should
4 The Policy states that “Lincoln shall possess the authority, in its sole discretion, to construe
the terms of this policy and to determine benefit eligibility hereunder.” Administrative R., at
LIN002491. To accord a plan administrator deferential judicial review, “a grant of discretionary
decisionmaking authority in an ERISA plan must be couched in terms that unambiguously indicate
that the claims administrator has discretion to construe the terms of the plan and determine whether
benefits are due in particular instances.” Stephanie C. v. Blue Cross Blue Shield of Mass. HMO Blue,
Inc., 813 F.3d 420, 428 (1st Cir. 2016). As the Plaintiff offers no argument to the contrary, I assume
that the Policy affords Lincoln discretion to construe the terms of the Policy and determine whether
benefits are due.
5 The Plaintiff cites a Second Circuit case, Halo v. Yale Health Plan, Director of Benefits &
Records Yale University, 819 F.3d 42 (2d Cir. 2016), for the contention that a procedural violation of
this type warrants de novo review. See Pl.’s Mot. for J. on the Administrative R. 18 (ECF No. 25). In
Halo, the Second Circuit held that “a plan’s failure to establish or follow the claims-procedure
regulation entitles the claimant to have his or her claim reviewed de novo in federal court.” Halo, 819
F.3d at 53. It appears that the First Circuit has never directly addressed Halo nor determined whether
a plan administrator’s failure to strictly adhere to ERISA’s claims procedure regulation automatically
triggers de novo review. I need not address these issues here because I find that Lincoln did not commit
a procedural violation in taking the extension.
The Plaintiff does not raise the possibility that Lincoln’s failure to provide Miller’s analysis—
a procedural irregularity—triggers de novo review. I note, however, that caselaw suggests that this
type of procedural irregularity, absent a showing of prejudice, would not entitle a claimant to de novo
review. See, e.g., Winters v. Liberty Life Assurance Co. of Bos., No. 20-11937-MLW, 2022 WL 6170588,
at *10 (D. Mass. Oct. 7, 2022) (“[The claimant’s] failure to prove prejudice is fatal to [his] contention
that Liberty’s failure to provide him all the information it received entitles him to de novo review of
its decision to deny his claim for benefits.”). Indeed, Halo itself states that de novo review is not
triggered, despite a procedural irregularity, if the plan “can show that its failure to comply with the
regulation in the processing of a particular claim was inadvertent and harmless.” Halo, 819 F.3d at
be reviewed de novo. See Pl.’s Mot. 23. The Defendant, on the other hand, argues that
Lincoln did strictly follow the claims-procedure regulation and therefore its decision
is still entitled to deferential review. See Def.’s Mot. 6–7.
Under the ERISA claims-procedure regulation, a plan administrator has 45
days to issue a benefit determination appeal decision. 29 C.F.R. § 2560.503-1(i)(1)(i),
(i)(3)(i). The 45-day clock to decide an appeal starts “at the time an appeal is filed,”
29 C.F.R. § 2560.503-1(i)(4), though the regulation clarifies that “receipt of the
claimant’s request for review” is what starts the clock. 29 C.F.R. § 2560.503-1(i)(1)(i)
(emphasis added). A plan administrator may take one 45-day extension during the
course of reviewing a claimant’s appeal if the “administrator determines that special
circumstances (such as the need to hold a hearing, if the plan’s procedures provide
for a hearing) require an extension of time for processing the claim.” 29 C.F.R. §
2560.503-1(i)(1)(i), (i)(3)(i). To obtain the extension, the plan administrator must
provide the claimant with written notice of the extension prior to the termination of
the initial 45-day period, and the notice must “indicate the special circumstances
requiring an extension of time.” 29 C.F.R. § 2560.503-1(i)(1)(i).
In this case, the Plaintiff asserts that Lincoln committed a procedural violation
because it (1) failed to request an extension within 45 days after receipt of Hughes’
appeal, and (2) did not establish the “special circumstances” necessary to take a 45-
day extension. Pl.’s Mot. 21–23. The Defendant retorts that (1) Lincoln did in fact
46. Here, as explained above, Lincoln’s failure to provide Hughes with the Miller analysis was not
prejudicial and thus does not entitle Hughes to de novo review.
request an extension within 45 days after receipt of Hughes’ appeal, and (2) the
extension request was justified by “special circumstances.” See Def.’s Mot. 6; Def.’s
Opp’n 12.
The facts here support the Defendant’s version of events. First, as to whether
Lincoln requested an extension within the 45-day time limit, the Plaintiff’s argument
relies on the incorrect assertion that the 45-day clock started ticking on November
23, 2021. See Pl.’s Mot. 22. In fact, it seems that the Plaintiff did attempt to fax notice
of his appeal to Lincoln on November 23, 2021, but Lincoln, apparently through no
fault of its own,6 did not actually receive the appeal documents until December 8,
2021. See Administrative R., at LIN001058 (time stamp at top of page dated
12/8/2021), LIN000388 (explaining that Attorney Davis was “resending the appeal . .
. today December 8, 2021”), LIN001056 (December 8, 2021 fax transmission sent on
behalf of Attorney Davis acknowledging that the appeal was resent because Lincoln
“had not yet received the info” faxed on November 23, 2021). Contrary to what the
Plaintiff asserts, then, Lincoln’s 45-day processing time began running on December
8, when it received Hughes’ appeal, not November 23, when Hughes initially
attempted to send the appeal. See 29 C.F.R. § 2560.503-1(i)(1)(i) (stating that “receipt
of the claimant’s request for review” is what starts the appeal-processing clock).
Lincoln then sent notice of the 45-day extension on January 13, 2022—36 days after
6 The Defendant raises the possibility that the November 23, 2021 fax was sent to the wrong
number, which explains why Lincoln did not receive the Plaintiff’s appeal notice until it was resent to
a different number on December 8, 2021. See Def.’s Mem. in Opp’n to Pl.’s Mot. for J. on the
Administrative R. 12 (ECF No. 32). This theory certainly seems plausible and it is supported by the
record. The Plaintiff does not respond to the Defendant’s assertion, nor does he offer an alternative
explanation for why Lincoln did not receive the appeal until two weeks after it was originally sent.
it received Hughes’ appeal, and well within the 45-day window in which Lincoln was
permitted to file notice of an extension. See Administrative R., at LIN000191.
Having found that Lincoln’s notice of an extension was timely, I turn to the
question of whether Lincoln’s extension was justified by a “special circumstance.”
The ERISA claims-procedure regulation does not precisely define “special
circumstance,” nor does it seem that the First Circuit has addressed the meaning of
the term. The Department of Labor has offered some clarification, explaining that
“the time periods for decisionmaking are generally maximum periods, not automatic
entitlements.” ERISA Rules and Regulations for Administration and Enforcement;
Claims Procedures, 65 Fed. Reg. 70,246, 70,250 (Nov. 21, 2000). According to the
Department, “it may be unreasonable” to seek an extension if the “claim presents no
difficulty whatsoever,” and “an extension may be imposed only for reasons beyond the
control of the plan.” Id. Some courts have held, for example, that a plan’s need to
obtain a medical records review does not qualify as a special circumstance because
“[i]n most, if not all, long term disability appeals, the insurer obtains a file review by
a medical consultant.” Satter v. Aetna Life Ins. Co., No. 3:16-cv-1342 (AWT), 2019 WL
2896410, at *6 (D. Conn. Mar. 20, 2019). Therefore, “[t]o find that the [need to obtain
an independent medical review] constituted a ‘special circumstance’ would mean that
virtually any request for an extension would be permissible, an outcome the
Department of Labor has expressly rejected.” Id. (quoting Salisbury v. Prudential Ins.
Co. of Am., 238 F. Supp. 3d 444, 450 (S.D.N.Y. 2017)); see also Fredrich v. Lincoln
Life & Annuity Co. of N.Y., 603 F. Supp. 3d 38, 47 (E.D.N.Y. 2022) (finding that
“Lincoln’s need to seek yet another medical opinion . . . does not suffice” as a special
circumstance).
Here, the Plaintiff asserts that Lincoln did not have a “special circumstance,”
but I am not convinced. After the Defendant received the Plaintiff’s appeal on
December 8, 2021, it promptly commissioned an independent medical review from a
second gastroenterologist, Dr. Ravinuthala. But after the record was sent to Dr.
Ravinuthala, the Plaintiff submitted additional medical records on December 28,
2021. Administrative R., at LIN000220. Dr. Ravinuthala issued his initial report on
December 30, 2021. On January 3, 2022, Lincoln asked Dr. Ravinuthala to consider
the Plaintiff’s additional medical information to determine whether it changed Dr.
Ravinuthala’s opinion. Administrative R., at LIN000208. And Dr. Ravinuthala
submitted an addendum to his report on January 12, 2022. Administrative R., at
LIN000203. Lincoln sent Dr. Ravinuthala’s report and addendum to the Plaintiff the
next day, on January 13, but at that point only ten days remained in the initial 45-
day period, which Lincoln perceived to be too little time to allow the Plaintiff to
respond and then to complete the appeal process. Administrative R., at LIN000191.
The Plaintiff contends that Lincoln’s claimed special circumstance was its
“need to complete a medical review,” Pl.’s Mot. 22, but the record shows that Lincoln
took the 45-day extension in order to consider Hughes’ additional evidence and to
“provide [Hughes] with an opportunity to review and comment on new/additional
evidence that has been received before a decision is rendered on Mr. Hughes’s
appeal.” Administrative R., at LIN000191. Further, the record shows that Lincoln
acted promptly and efficiently in seeking the addendum. In other words, the record
indicates that Lincoln needed an extension not because it had failed to promptly
commission an initial medical records review, but rather because it had received
additional materials from the Plaintiff and therefore, “due to matters beyond control
of the plan,” 29 C.F.R. § 2560.503-1(f)(3), lost time that would have allowed Hughes
adequate time to respond. Cf. 29 C.F.R. § 2560.503-1(h)(4)(ii) (explaining that “new
or additional rationale” must be provided “sufficiently in advance . . . to give the
claimant a reasonable opportunity to respond”). This was a special circumstance and
one that benefitted Hughes. Lincoln did not commit a procedural violation and its
appeal determination is thus entitled to deferential arbitrary and capricious review.
B. Reasonableness of Lincoln’s Decision
The final question is whether Lincoln’s appeal decision survives arbitrary and
capricious review. “Under that standard, the decision ‘must be upheld if there is any
reasonable basis for it.’ ” Morales-Alejandro v. Med. Card Sys., Inc., 486 F.3d 693, 698
(1st Cir. 2007) (quoting Madera v. Marsh USA, Inc., 426 F.3d 56, 64 (1st Cir.2005)).
“Stated in different terms, [the Court] will uphold an administrator’s decision ‘if the
decision was reasoned and supported by substantial evidence,’ meaning that the
evidence ‘is reasonably sufficient to support a conclusion and contrary evidence does
not make the decision unreasonable.’ ” Id. (quoting Denmark v. Liberty Life Assurance
Co. of Bos., 481 F.3d 16, 33 (1st Cir. 2007)). “The fact that the record reflects
contradictory evidence does not by itself mean the administrator’s decision is not
supported by substantial evidence.” Carter v. Aetna Life Ins. Co., No. 2:17-cv-00398-
JAW, 2019 WL 80434, at *13 (D. Me. Jan. 2, 2019). And “a plan administrator’s
discretionary decision is not unreasonable merely because a different, reasonable
interpretation could have been made.” Ferry v. Prudential Ins. Co. of Am., No. 2:10-
cv-211-GZS, 2011 WL 4828816, at *17 (D. Me. Oct. 10, 2011).
Under any standard of review, “[a] person claiming ERISA benefits bears the
burden of proving [his] entitlement to those benefits.”7 Id. at *10. And, “[u]nlike
typical motions for summary judgment, the court deciding a motion for judgment on
the administrative record under the arbitrary and capricious standard does not draw
inferences in favor of the nonmoving party. Instead, doubts are typically resolved in
favor of the plan administrator.” Winters, 2022 WL 6170588, at *11 (citations
omitted).
Here, the Plaintiff bore the burden of providing “Proof of continued Disability.”
Administrative R., at LIN002483. This required the Plaintiff to show (1) that he had
an “Injury or Sickness,” and (2) that the injury or sickness rendered him “unable to
perform the Material and Substantial Duties of his Own Occupation” as it is
“normally performed in the national economy.” Administrative R., at LIN002467,
LIN002469. The Plaintiff argues that he met his burden and that “[t]he
Administrative Record is replete [with] testing confirming irregularities concerning
Mr. Hughes[’] gastrointestinal systems.” Opp’n to Def.’s Mot. for J. on the
Administrative R. 9 (ECF No. 31).
7 The allocation of the burden of proof on the claimant is consistent with the language of the
Policy, which states that the claimant must “provide Proof of continued disability.” Administrative R.,
at LIN002483.
The issue for the Plaintiff is that simply showing gastrointestinal
“irregularities” was not enough; the Plaintiff also had to prove that those
irregularities made him unable to perform the material and substantial duties of his
own occupation. See Administrative R., at LIN002467 (defining “Disabled”). Lincoln
reasonably determined that the Plaintiff did not meet this burden.
In its appeal decision, Lincoln “acknowledge[d] Mr. Hughes’s claim of total
impairment based on IBS,” but ultimately concluded that “the clinical evidence does
not support [that] Mr. Hughes was precluded from performing his Own Occupation
throughout and beyond the Policy’s elimination period.”8 Administrative R., at
LIN000034–LIN000035. Lincoln acknowledged Hare’s opinion that Hughes’s
symptoms were significantly disruptive to his daily life and ability to work. See
Administrative R., at LIN000030. But two medical records reviews commissioned by
Lincoln found no objective evidence to support the assertion that Hughes could not
work with his condition. See Administrative R., at LIN000028; cf. Falk v. Life Ins. Co.
of N. Am./Cigna Grp. Ins., No. 12-cv-178-JL, 2013 WL 5348189, at *11 (D.N.H. Sept.
23, 2013) (declining to “place too much weight upon” the treating physician’s opinion
when the doctor’s opinion “appear[ed] to be based upon [the claimant’s] own
8 As Hare noted, IBS “is an understandably challenging diagnosis when it comes to disability
because the majority of the diagnosis and impact on functional status is based on primarily subjective
findings.” Administrative R., at LIN000081–LIN000082. Still, even with a difficult-to-diagnose
condition like IBS, “it is permissible to require objective support that a claimant is unable to work as
a result of [medical conditions that do not lend themselves to objective verification].” Derosiers v.
Hartford Life & Accident Co., 515 F.3d 87, 93 (1st Cir. 2008). Indeed, the Policy explains that “proof”
includes the provision of “objective medical evidence in support of a claim for benefits.” Administrative
R., at LIN002469. Lincoln therefore did not act arbitrarily or capriciously in basing its decision largely
on the absence of objective medical evidence.
subjective complaints”). Those two medical reviews instead determined that the only
limitation objectively supported by the Plaintiff’s medical records was the need to
have ready access to bathroom facilities. See Administrative R., at LIN000028–
LIN000029. And Lincoln ultimately determined, based on the vocational analysis it
obtained from Hall, that this limitation—bathroom breaks as needed—“would not
prevent Mr. Hughes from performing his own occupation.” Administrative R., at
LIN000035.
In sum, Lincoln had a reasonable basis, grounded in substantial record
evidence, to conclude that Hughes had not met his burden of showing that his
gastrointestinal ailments rendered him unable to perform his occupation. Hughes has
failed to show that Lincoln’s decision was arbitrary or capricious. I therefore uphold
Lincoln’s determination denying Hughes’ LTD benefits and grant Lincoln’s motion.
CONCLUSION
For the reasons stated above, the Court DENIES the Plaintiff’s Motion for
Judgment on the Administrative Record (ECF No. 25) and GRANTS the Defendant’s
Motion for Judgment on the Administrative Record (ECF No. 26).
SO ORDERED.
/s/ Nancy Torresen
United States District Judge
Dated this 17th day of August, 2023.