Pfifer v. Sedgwick Claims Management Services Inc.

UNITED STATES DISTRICT COURT September 30, 2019

SOUTHERN DISTRICT OF TEXAS David J. Bradley, Clerk

HOUSTON DIVISION

ALLISON PFIFER, §

§

Plaintiff, §

VS. § CIVIL ACTION NO. 4:18-CV-1296

§

SEDGWICK CLAIMS MANAGEMENT §

SERVICES INC., §

§

Defendant. §

MEMORANDUM OPINION AND ORDER

I. INTRODUCTION

The plaintiff, Allison Pfifer (“Pfifer” or “the plaintiff”), commenced the instant action

against the defendant, Sedgwick Claims Management Services, Inc. (“Sedgwick”), pursuant

to the Employee Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C. § 1132

(a)(1)(B),1 alleging that Sedgwick, the Claims Administrator, wrongfully denied her claims

for short-term disability (“STD”) benefits pursuant to the 3M Short Term Disability Plan and

long-term disability (“LTD”) benefits pursuant to the 3M Long Term Disability Plan. Both

plans are sponsored by 3M Company (“3M”) and governed by ERISA. The plaintiff seeks

compensation for denied benefits, interest and attorneys’ fees and costs.

Pending before the Court are Sedgwick’s motion for summary judgment and

memorandum of law in support thereof (Dkt. No. 21), the plaintiff’s response in opposition

to Sedgwick’s motion for summary judgment (Dkt. No. 24), Sedgwick’s reply (Dkt. No. 25),

the plaintiff’s cross-motion for summary judgment (Dkt. No. 22) and Sedgwick’s response in

1 ERISA § 1132(a)(1)(B) provides that “[a] civil action may be brought by a participant or beneficiary to recover

benefits due to him under the terms of his plan, to enforce his rights under the terms of the plan, or to clarify his

rights to future benefits under the terms of the plan.” 29 U.S.C. § 1132(a)(1)(B).

opposition to the plaintiff’s cross-motion for summary judgment (Dkt. No. 23). After having

carefully considered the motions, responses, reply, the record and the applicable law, the

Court determines that Sedgwick’s motion for summary judgment should be GRANTED; and

the plaintiff’s cross-motion for summary judgment should be DENIED.

II. FACTUAL BACKGROUND

The plaintiff, Pfifer, is a 64-year old female who worked as a “Lead Proposal Writer2”

for 3M. During the relevant time, the plaintiff participated in a 3M-sponsored Short Term

Disability Plan (“STD Plan”) and Long Term Disability Plan (“LTD Plan”) for eligible

employees, effective January 1, 2016. Pursuant to the specific terms of the STD Plan and the

LTD Plan, 3M’s Director, Total Rewards Program Management, is designated as the Plan

Administrator with the authority to delegate “its full and final discretionary power and

authority with respect to benefit determinations to the Claims Administrator.” (Dkt. No. 21,

App. 3 at 3M00001479; App. 4 at 3M00001446.). Sedgwick is identified as the Claims

Administrator with the discretionary authority to interpret the Plans’ terms and decide

questions of eligibility for coverage. (Id. at 3M00001482, 3M00001449).

An employee participant’s eligibility for benefits under the STD Plan is determined as

follows:

Eligibility for Benefits

You are eligible to receive [STD] benefits under the Plan only if the Claims

Administrator determines that:

 You are eligible and covered under the Plan;

2 The plaintiff’s position as a “Lead Proposal Writer” is classified as a sedentary, skilled position pursuant to the

Dictionary of Occupational Titles.

 You meet the Plan’s definition of Disabled (including providing

Objective Medical Evidence of your disability, when requested by

the Claims Administrator);

 Your disability is not one excluded from coverage under the Plan;

and

 You satisfy all other eligibility requirements under the Plan.

To be eligible for STD benefits, you must provide sufficient Objective

Medical Evidence of your disability. The Claims Administrator determines

whether you have provided sufficient Objective Medical Evidence of your

disability and may require more than one examination. You may be required

to provide the Claims Administrator with continuing proof of your disability

and prove that you are under the regular care of a physician. You must

provide this proof at your own expense and within the timeframe required by

the Claims Administrator. Failure to comply with the Claims Administrator’s

requests may impact your eligibility for and payment of benefits.

(Id. at 3M00001461.). The term “disabled” is defined under the STD Plan as follows:

Disabled Defined

You are considered Disabled for purposes of the Plan only if the Claims

Administrator determines that due to an illness, injury, pregnancy or other

medical condition you are unable to perform the material duties of:

 Your regular and customary occupation at 3M; or

 Any other appropriate job offered by 3M.

In addition, you must be under the regular and continuous care of a licensed

Health Care Provider, unless such treatment is not medically necessary given

the nature of your disability.

. . .

The Claims Administrator determines whether or not you are Disabled on the

basis of Objective Medical Evidence and any other relevant evidence.

Please Note: Social Security’s decision is not considered when determining

your eligibility for STD benefits. Therefore, if the Social Security

Administration approves you for disability benefits, it doesn’t mean you are

eligible for 3M STD benefits.

(Id.).

An employee participant’s eligibility for benefits under the LTD Plan is determined as

follows:

Eligibility for Benefits

You are eligible to receive [LTD] benefits under the Plan only if the Claims

Administrator determines that:

 You are eligible and covered under the Plan;

 You meet the Plan’s definition of Disabled (including providing

Objective Medical Evidence of your disability, when requested by

the Claims Administrator);

 Your disability is not one excluded from coverage under the Plan;

 You have exhausted your 3M STD benefits; and

 You satisfy all other eligibility requirements under the Plan.

To be eligible for LTD benefits, you must provide sufficient Objective

Medical Evidence of your disability. The Claims Administrator determines

whether you have provided sufficient Objective Medical Evidence of your

disability and may require more than one examination. You may be required

to provide the Claims Administrator with continuing proof of your disability

and prove that you are under the regular care of a physician. You must

provide this proof at your own expense and within the timeframe required by

the Claims Administrator. Failure to comply with the Claims Administrator’s

requests may impact your eligibility for and payment of benefits.

(Id. at 3M00001428.). The term “disabled” is defined under the LTD Plan as follows:

Disabled Defined

You are considered Disabled for purposes of the [LTD] Plan only if the

Claims Administrator determines the following:

 During the First 18 Months of LTD Benefit Payments: Due to an

illness, injury, pregnancy or other medical condition you are unable to

perform the material duties of:

 Your regular and customary occupation at 3M; or

 Any other appropriate job offered by 3M.

In addition, you must be under the regular and continuous care of a

licensed Health Care Provider, unless such treatment is not medically

necessary given the nature of your disability.

 After the First 18 Months of LTD Benefit Payments:

 You are totally Disabled;

 You are unable to perform the material duties of any occupation

or employment for which you are, or may become, reasonably

qualified by training, education or experience; and

 You are unable to earn 70% or more of your Planned Total Cash

Compensation (as defined under the “Planned Total Cash

Compensation Defined” topic under this section) while working

in any occupation or employment.

In addition, you must be under the regular and continuous care of a

licensed Health Care Provider, unless such treatment is not medically

necessary given the nature of your disability.

Please Note: Social Security’s decision is not considered when determining

your eligibility for LTD benefits. Therefore, if the Social Security

Administration approves you for disability benefits, it doesn’t mean you are

eligible for 3M LTD benefits.

(Id.).

On May 11, 2016, the plaintiff ceased actively working for 3M due to severe pain in

her right knee, including “swelling, stiffness, a decreased range of motion, changed gait and

multiple falls.” (Dkt. No. 1 at ¶ 24.). The plaintiff alleges that she became “disabled” on

May 11, 2016 and, as such, filed a claim for STD benefits through 3M’s STD Plan

administered by Sedgwick. Pursuant to a letter dated May 12, 2016, Sedgwick sent the

plaintiff necessary forms to be executed and returned to it by May 27, 2016, as support for

her claim of disability. The letter further advised the plaintiff as follows: “Failure to meet

the eligibility requirements for Short Term Disability Benefits or failure to timely

submit the required forms will result in delay or denial of benefits.” (Dkt. No. 21, App.

1 at 3M0000234).

On May 27, 2016, personnel from one of the plaintiff’s treating physicians’ offices

contacted Sedgwick and left a message indicating that it would not be able to complete the

necessary forms on time. By letter dated May 31, 2016, Sedgwick denied the plaintiff’s

claim for STD benefits, informing her that “due to the failure or refusal to submit objective

medical evidence, there is insufficient information to support that you are unable to perform

the material duties of your regular and customary occupation at 3M, or any other appropriate

job offered by 3M, due to an illness, injury, pregnancy, or other medical condition.” (Id. at

3M0000140 - 42). Sedgwick’s letter further informed the plaintiff of her right to seek review

of its decision, submit additional evidence or obtain a reasonable accommodation. (Id.).

On June 3, 2016, the plaintiff filed a request for an appeal of Sedgwick’s decision to

deny her claim for STD benefits. As support for her appeal, she included office notes from

Dr. Xinmin Tang, her treating physician, dated May 24, May 31, June 2 and June 3, 2016,

along with a radiology report from Dr. Jonathan Squires dated May 28, 2016. (Id. at

3M0000119 - 27). An Attending Provider Statement executed by Dr. Tang was also

encompassed amongst the medical documentation submitted by the plaintiff in support of her

appeal. (Id.). In the Attending Provider Statement, Dr. Tang opined that on May 24, 2016--

two weeks after the plaintiff ceased working—she reported severe right knee pain and could

not “walk, stand, squat, sit [without] elevations” or do “anything that involves [her right]

knee.” (Id. at 3M0000119 - 20).

Sedgwick referred the plaintiff’s medical records to Dr. John Evans, a board-certified

orthopedic surgeon, for an Independent Physician Assessment (“IPA”). (Id. at 3M0000177 -

80). Dr. Evans, after reviewing the medical records provided by the plaintiff and contacting

two of her treating physicians, Dr. Tang and Dr. Sang Choi, opined that the limited medical

records provided by the plaintiff did not support her inability to perform her regular and

customary occupation. (Id. at 3M0000116). Dr. Evans memorialized his findings in a report

dated June 16, 2016, which noted that the plaintiff did not have any restrictions that would

prevent her from performing her regular and customary occupation at 3M. (Id.). He further

noted that her sedentary position was not a physically demanding job. (Id.).

On June 22, 2016, Sedgwick notified the plaintiff that its denial of her claim for STD

benefits would be upheld. It further advised the plaintiff of the contractual limitations period

governing her right to initiate a civil action with respect to her claim for STD benefits under

the STD Plan. On September 7, 2016, the plaintiff’s employment with 3M was terminated.

On March 16, 2017, the plaintiff, by way of a letter from her attorney, sought to

obtain LTD benefits, claiming a disability due to her right knee. On April 6, 2017, Sedgwick

denied the plaintiff’s claim for LTD benefits, asserting that the plaintiff was ineligible for

such benefits due to her failure to exhaust STD benefits as required by the LTD Plan. On

October 3, 2017, the plaintiff sought to appeal Sedgwick’s denial of her LTD claim. On

October 10, 2017, Sedgwick issued a letter to the plaintiff advising her that its decision to

deny her claim for LTD benefits would be upheld and further reiterating that the plaintiff was

not entitled to LTD benefits due to her failure to exhaust STD benefits. The letter further

informed the plaintiff of the contractual limitations period governing her right to commence

any lawsuit for LTD benefits under the LTD Plan.

On April 25, 2018, the plaintiff commenced the instant action against Sedgwick

seeking to challenge its denial of her claims for STD and LTD benefits. Both Sedgwick and

the plaintiff now move for a summary judgment.

III. STANDARDS OF REVIEW

A. Standard of Review for Summary Judgment

Rule 56 of the Federal Rules of Civil Procedure authorizes summary judgment against

a party who fails to make a sufficient showing of the existence of an element essential to the

party’s case and on which that party bears the burden at trial. See Celotex Corp. v. Catrett,

477 U.S. 317, 322 (1986); Little v. Liquid Air Corp., 37 F.3d 1069, 1075 (5th Cir. 1994) (en

banc). The movant bears the initial burden of “informing the district court of the basis for its

motion” and identifying those portions of the record “which it believes demonstrate the

absence of a genuine issue of material fact.” Celotex, 477 U.S. at 323; see also Martinez v.

Schlumber, Ltd., 338 F.3d 407, 411 (5th Cir. 2003). Summary judgment is appropriate

where the pleadings, the discovery and disclosure materials on file, and any affidavits show

“that there is no genuine dispute as to any material fact and the movant is entitled to

judgment as a matter of law.” Fed. R. Civ. P. 56(a).

If the movant meets its burden, the burden then shifts to the nonmovant to “go beyond

the pleadings and designate specific facts showing that there is a genuine issue for trial.”

Stults v. Conoco, Inc., 76 F.3d 651, 656 (5th Cir. 1996) (citing Tubacex, Inc. v. M/V Risan,

45 F.3d 951, 954 (5th Cir. 1995); Little, 37 F.3d at 1075). “To meet this burden, the

nonmovant must ‘identify specific evidence in the record and articulate the ‘precise manner’

in which that evidence support[s] [its] claim[s].’” Stults, 76 F.3d at 656 (citing Forsyth v.

Barr, 19 F.3d 1527, 1537 (5th Cir.), cert. denied, 513 U.S. 871, 115 S. Ct. 195, 130 L. Ed.2d

127 (1994)). It may not satisfy its burden “with some metaphysical doubt as to the material

facts, by conclusory allegations, by unsubstantiated assertions, or by only a scintilla of

evidence.” Little, 37 F.3d at 1075 (internal quotation marks and citations omitted). Instead,

it “must set forth specific facts showing the existence of a ‘genuine’ issue concerning every

essential component of its case.” Am. Eagle Airlines, Inc. v. Air Line Pilots Ass’n, Intern.,

343 F.3d 401, 405 (5th Cir. 2003) (citing Morris v. Covan World Wide Moving, Inc., 144

F.3d 377, 380 (5th Cir. 1998)). Thus, “[t]he appropriate inquiry [on summary judgment] is

‘whether the evidence presents a sufficient disagreement to require submission to a jury or

whether it is so one-sided that one party must prevail as a matter of law.’” Septimus v. Univ.

of Hous., 399 F.3d 601, 609 (5th Cir. 2005) (quoting Anderson v. Liberty Lobby, Inc., 477

U.S. 242, 251 – 52 (1986)).

B. Standard of Review Under ERISA

The United States Supreme Court has generally held that the denial of a right to

benefits under an ERISA plan is reviewed under a de novo standard. See Firestone Tire and

Rubber Co. v. Bruch, 489 U.S. 101, 115, 109 S. Ct. 948, 103 L. Ed.2d 80 (1989); see also

Baker v. Metro. Life Ins. Co., 364 F.3d 624, 629 (5th Cir. 2004). However, where the benefit

plan expressly confers the “discretionary authority to determine eligibility for benefits or to

construe the terms of the plan” on the plan administrator or fiduciary, the applicable standard

of review is abuse of discretion. Firestone, 489 U.S. at 115, 109 S. Ct. 948; Baker, 364 F.3d

at 629; see also Gellerman v. Jefferson Pilot Fin. Ins. Co., 376 F. Supp.2d 724, 731 (S.D.

Tex. 2005) (citing Meditrust Fin. Servs. Corp. v. Sterling Chems., Inc., 168 F.3d 211, 213

(5th Cir. 1999)). The Plans at issue here vests Sedgwick, as the Claims Administrator, with

discretionary authority to determine a participant’s eligibility for benefits and thus, the

standard of review applicable is the abuse of discretion standard. (See Dkt. No. 21, App. 3 at

3M00001482; App. 4 at 3M00001449.). The relevant provision contained in both the STD

Plan and the LTD Plan confers authority as follows:

The Plan Administrator delegates its full and final discretionary power and

authority with respect to benefit determinations to the Claims Administrator.

This power and authority includes, without limitation:

 Determining all factual and legal questions;

 Interpreting any ambiguous or unclear terms in the Plan and the

underlying documents,

 Determining the amount of benefits, if any, to which an individual is

entitled to under the Plan;

 Prescribing forms to be used and procedures to be followed in applying

for benefits and appealing any adverse benefit decision under the Plan;

and

 Deciding all claims for benefits, adverse benefit determinations and

appeals.

The Claims Administrator has discretionary authority to grant or deny benefits

under the Plan. Benefits under the Plan shall only be paid if the Claims

Administrator decides, in its discretion, that an individual is entitled to them.

With respect to benefit determinations, all determinations, interpretations,

rules and decisions of the Claims Administrator shall be final, conclusive and

binding as to all parties. This delegation of authority shall not, however, apply

to determinations pertaining to eligibility to participate in the Plan, which shall

remain with the Plan Administrator. With respect to its delegated authority,

the Claims Administrator is a named fiduciary under the Plan.

(Dkt. No. 21, App. 3 at 3M00001479; App. 4 at 3M00001446.).

A plan administrator or fiduciary’s factual determinations under an ERISA plan are

also reviewed pursuant to an abuse of discretion standard. See Vercher v. Alexander &

Alexander, Inc., 379 F.3d 222, 226 (5th Cir. 2004); see also Pierre v. Conn. Gen. Life Ins.

Co., 932 F.2d 1552, 1562 (5th Cir. 1991) (reasoning “for factual determinations under

ERISA plans, the abuse of discretion standard of review is the appropriate standard.”).

“Under the abuse of discretion standard, ‘[i]f the plan fiduciary’s decision is supported by

substantial evidence and is not arbitrary and capricious, it must prevail.’” Corry v. Liberty

Life Assur. Co. of Boston, 499 F.3d 389, 397 - 98 (5th Cir. 2007) (quoting Ellis v. Liberty

Life Assurance Co. of Boston, 394 F.3d 262, 273 (5th Cir. 2004)). “Substantial evidence is

‘more than a scintilla, less than a preponderance, and is such relevant evidence as a

reasonable mind might accept as adequate to support a conclusion.’” Id. “A decision is

arbitrary when made ‘without a rational connection between the known facts and the

decision or between the found facts and the evidence.’” Lain v. UNUM Life Ins. Co. of

Am., 279 F.3d 337, 342 (5th Cir. 2002) (quoting Bellaire Gen. Hosp. v. Blue Cross Blue

Shield of Mich., 97 F.3d 822, 828 (5th Cir. 1996)). A plan administrator or fiduciary’s

“decision to deny benefits must be ‘based on evidence, even if disputable, that clearly

supports the basis for its denial.’” Lain, 279 F.3d at 342 (quoting Vega v. Nat’'l Life Ins.

Servs., Inc., 188 F.3d 287, 299 (5th Cir. 1999)).

Ordinarily, when resolving factual controversies, the court’s review is confined “to

the evidence before the plan administrator.” Vega, 188 F.3d at 299 (internal citations

omitted); see also Wilbur v. ARCO Chem. Co., 974 F.2d 631, 639 (5th Cir. 1992). It is not

confined to the administrative record, however, when determining whether an administrator

abused his discretion in interpreting the plan’s terms and making a benefit determination.

Wilbur, 974 F.2d at 639.

The Fifth Circuit usually employs a two-step analysis when determining whether an

administrator has abused its discretion in construing the plan’s terms. James v. La. Laborers

Health and Welfare Fund, 29 F.3d 1029, 1032 - 33 (5th Cir. 1994). First, the court must

determine whether the plan administrator’s interpretation was the legally correct

interpretation. Id. Second, if the plan administrator’s interpretation was not the legally

correct interpretation, then the court must consider whether the administrator’s interpretation

amounts to an abuse of discretion. Id. But, “if the administrator’s interpretation and

application of the Plan is legally correct, then [the] inquiry ends because obviously no abuse

of discretion has occurred.” Baker, 364 F.3d at 629 – 30 (citing Spacek v. Maritime Ass’n,

134 F.3d 283, 292 (5th Cir. 1998)).

Further, when, as the plaintiff suggests, the role of the administrator presents a

conflict of interest because it evaluates claims for benefits and pays benefits, the Court must

consider this conflict as a factor in determining whether there has been an abuse of

discretion. Firestone, 489 U.S. at 115, 109 S. Ct. 948 (citations omitted) (holding “if a

benefit plan gives discretion to an administrator or fiduciary who is operating under a

conflict of interest, that conflict must be weighed as a ‘facto[r] in determining whether there

is an abuse of discretion.’”). The United States Supreme Court in Metro. Life Ins. Co. v.

Glenn, resolved any debate relative to its finding in Firestone by holding that the conflict of

interest created by a plan administrator’s dual role is “but one factor among many that a

reviewing judge must take into account.” Glenn, 554 U.S. 105, 116 - 117, 128 S. Ct. 2343,

2351, 171 L. Ed.2d 299 (2008). That is to say, “when judges review the lawfulness of

benefit denials, they will often take account of several different considerations of which a

conflict of interest is one.” Id Nevertheless, such a conflict does not necessitate that a court

“create special burden-of-proof rules, or other special procedural or evidentiary rules”

focused on the party with the apparent conflict of interest when other rules or standards are

applicable. Id.

IV. ANALYSIS AND DISCUSSION

A. The Contractual Limitations Periods Governing the Plaintiff’s Claims for

Benefits

As a threshold matter, Sedgwick moves for a summary judgment on the plaintiff’s

claims to recover STD and LTD benefits, arguing that the plaintiff’s claims for benefits fail

because they are time-barred by the applicable contractual limitations periods contained in

the STD and LTD Plans. The plaintiff, in opposition, maintains that her lawsuit should be

deemed timely because equitable tolling is warranted under the circumstances, given

Sedgwick’s procedural unreasonableness. (See Dkt. No. 24 at 2).

ERISA does not provide any specific statute of limitations for initiating a claim for

judicial review, but “a participant and a plan may agree by contract to a particular limitations

period . . . as long as the period is reasonable.” Encompass Office Sols., Inc. v. Louisiana

Health Serv. & Indem. Co., 919 F.3d 266, 281 (5th Cir. 2019) (citing Heimeshoff v. Hartford

Life & Accident Ins. Co., 571 U.S. 99, 105 - 06, 134 S. Ct. 604, 187 L. Ed.2d 529 (2013)).

Such agreements “should be enforced unless the limitations period is unreasonably short or

foreclosed by ERISA.” Heimeshoff, 571 U.S. at 115, 134 S. Ct. at 616. Neither of those

restraints is applicable here.

In this case, both the STD Plan and the LTD Plan impose a six-month limitations

period from the time the administrative claims and appeal procedures are completed to file

any action for benefits under the Plans. (See Dkt. No. 21, App. 3 at 3M00001470; App. 4 at

3M00001437.). Specifically, the applicable limitations provision contained in both the STD

Plan and the LTD Plan provides as follows:

Time Limitation for Commencing a Lawsuit

You must commence any lawsuit for benefits under this Plan within

(whichever is earlier):

 Two years after the date you exhausted your STD benefits or

otherwise could have applied for LTD benefits; or

 Six months after the claims and appeal procedures are

completed.

(Id.).

This Court finds the aforementioned contractual limitations period reasonable and,

thus, enforceable. See Dye v. Assocs. First Capital Long–Term Disability Plan, No. 06–

41569, 243 Fed. App’x 808, 809 - 10 (5th Cir. June 14, 2007) (finding a 120–day period was

reasonable); RedOak Hosp., LLC v. GAP Inc., No. CV H-16-1303, 2017 WL 2936316, at *3

(S.D. Tex. July 10, 2017) (finding 90-day period for claimant to file suit reasonable); Rusch

v. United Health Grp. Inc., No. 2:12-CV-00128, 2013 WL 3753947, at *4 (S.D. Tex. July 15,

2013) (finding a 180-day period for filing lawsuit reasonable).

It is undisputed that Sedgwick notified the plaintiff of its final denial of her appeal for

STD benefits on June 22, 2016. It is also undisputed that Sedgwick notified the plaintiff of

its final denial of her appeal for LTD benefits on October 11, 2017. Pursuant to the

contractual limitations periods contained in both the STD Plan and the LTD Plan, the

plaintiff had until December 22, 2016 and April 11, 2018, respectively, to commence a

lawsuit challenging the denial of her claims for STD and LTD benefits under the respective

Plans. Nevertheless, the plaintiff did not file the instant action until April 25, 2018, well

after the six-month limitations period had expired. Having found no evidence of

extraordinary circumstances in the record to warrant the application of equitable tolling or

equitable estoppel with respect to the applicable contractual limitations periods as the

plaintiff suggests, the plaintiff’s claims are time-barred.

B. Whether the Administrator Abused Its Discretion in Denying the

Plaintiffs’ Claims for Benefits

Even assuming the plaintiff’s lawsuit was filed within the applicable contractual

limitations periods, the plaintiff has failed to demonstrate that Sedgwick abused its discretion

in denying her claims for benefits. “The law requires only that substantial evidence support a

plan fiduciary’s decisions, including those to deny or to terminate benefits, not that

substantial evidence (or, for that matter, even a preponderance) exists to support the

employee’s claim of disability.” Corry, 499 F.3d at 402 (internal citations omitted).

“Substantial evidence is ‘more than a scintilla, less than a preponderance, and is such

relevant evidence as a reasonable mind might accept as adequate to support a conclusion.’ ”

Ellis, 394 F.3d at 273 (quoting Deters v. Sec’y of Health, Educ. & Welfare, 789 F.2d 1181,

1185 (5th Cir. 1986)). Stated another way, as long as an administrator’s decision is not

arbitrary and capricious and is supported by substantial evidence, it must remain undisturbed,

even if the plaintiff’s disability is supported by a preponderance of the evidence. Id.

Here, Sedgewick has established that its decision to deny the plaintiff’s claim for

benefits was based on substantial evidence. Sedgewick reasonably relied on the opinion of

Dr. Evans, an independent consulting physician, who concluded that, based on the plaintiff’s

limited medical file, no objective evidence existed to support the plaintiff’s alleged

incapacity to perform the material duties of her regular and customary occupation at 3M.

The plaintiff maintains that it was unreasonable for Sedgewick to rely on Dr. Evans’ opinion,

especially in light of Dr. Evans’ obvious bias and the Attending Provider Statement provided

by her own treating physician. This Court does not agree.

Indeed, it is undisputed that Dr. Evans evaluated all of the medical evidence

submitted by the plaintiff and even contacted two of her own treating physicians to make

further inquiry as to the scope of their assessment of the plaintiff’s disability and, thereafter,

provided a definitive opinion on the plaintiff’s functional capabilities. Based on the

plaintiff's medical records and Dr. Evan’s opinion, Sedgwick upheld its decision to deny the

plaintiffs claim for STD benefits.

The Supreme Court has held that “[nJothing in the [ERISA] Act... suggests that plan

administrators must accord special deference to the opinions of [a claimant’s] treating

physicians. Nor does the Act impose a heightened burden of explanation on administrators

when they reject a treating physician’s opinion.” Black & Decker Disability Plan v. Nord,

538 U.S. 822, 831, 123 S. Ct. 1965, 1970, 155 L. Ed.2d 1034 (2003). Moreover, the Fifth

Circuit has held that an administrator does not abuse its discretion when it relies on the

conflicting medical opinion of a consulting physician, even when the consulting physician

never physically examined the claimant and has only reviewed a claimant’s medical records.

See Gooden v. Provident Life, 250 F.3d 329, 335 n. 9 (Sth Cir. 2001); Meditrust, 168 F.3d at

213. Against this background, this Court cannot say that Sedgwick’s decision to deny the

plaintiffs claim for STD benefits was arbitrary or capricious. Nor can it say that Sedgwick’s

decision to deny the plaintiffs claim for LTD benefits was incorrect, as it remains

undisputed that the plaintiff failed to exhaust her STD benefits.

V. CONCLUSION

Based on the foregoing analysis and discussion, Sedgwick’s motion for summary

judgment is GRANTED; the plaintiffs cross-motion for summary judgment is DENIED.

It is so ORDERED.

SIGNED on this 30" day of September, 2019.

KennethM.Hoyt

United States District Judge

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