Sweatman v. Commercial Union Insurance

United States Court of Appeals,

Fifth Circuit.

No. 94-40474

(Summary Calendar).

Cynthia SWEATMAN, Plaintiff-Appellant,

v.

COMMERCIAL UNION INSURANCE CO., et al., Defendants-Appellees.

Dec. 9, 1994.

Appeal from the United States District Court for the Western

District of Louisiana.

Before SMITH, EMILIO M. GARZA and PARKER, Circuit Judges.

EMILIO M. GARZA, Circuit Judge:

After Metropolitan Life Insurance Company ("MetLife") denied

Cynthia Sweatman's claim for disability benefits, Sweatman brought

an action under ERISA, 29 U.S.C. § 1132(a)(1)(B) (1988), seeking

district court review of MetLife's determination. The court upheld

MetLife's decision, and Sweatman appeals. We AFFIRM.

I

Cynthia Sweatman worked for Commercial Union Insurance Co.

("Commercial Union") for nineteen years as a claims adjuster, a job

that required her to climb ladders, inspect roofs, and crawl under

houses. When Sweatman stopped working for Commercial Union, she

timely submitted a statement of claim for benefits under Commercial

Union's Long Term Disability Plan ("the Plan"). Sweatman claimed

that her medical condition (listed as rheumatoid arthritis and/or

1

fibrositis) rendered her unable to perform any of her job duties.1

Under the terms of the Plan, Sweatman was eligible for

long-term disability benefits if she was totally disabled. The

Plan defines "total disability" as follows:

"Total Disability" means that during the first 24 months of

disability you are unable because of sickness or accident to

perform the duties of your own occupation for any employer.

Thereafter, "total disability" means the inability to perform

any occupation for which you are fitted by training,

education, or experience.

Record on Appeal, vol. 1, at 48. As claims administrator for the

Plan,2 MetLife sought to determine whether Sweatman was in fact

"totally disabled." Shirley Darvasi, a claim reviewer employed by

MetLife, attempted to gather Sweatman's medical records from her

various physicians. At first, this task proved difficult. Dr.

Burda, the physician who completed the Attending Physician

Statement accompanying Sweatman's disability claim, did not

promptly produce Sweatman's complete medical records.

To expedite its review of Sweatman's claim, MetLife sent the

records it had received to Underwriting Medical Actuarial

Consultants, Inc. ("UMAC"). Dr. Peter Blendonhy, a board certified

physiatrist retained by UMAC, reviewed Sweatman's medical records

and concluded that they did "not support limitations on work or

physical activity." After UMAC's peer review board, the

1

Pending determination of her disability claim, Sweatman

received a percentage of her salary under Commercial Union's

"salary continuation plan," which provided for such payments "in

the event of an illness or accident resulting in [the] inability

to work."

2

In addition to acting as claims administrator, MetLife

insured the plan.

2

"Physician's Roundtable," reviewed and concurred with Dr.

Blendonhy's opinion, UMAC sent MetLife a report summarizing its

findings. The report pointed to numerous deficiencies in

Sweatman's medical records and noted that the diagnosis of

rheumatoid arthritis had not been established according to the

American Rheumatism Association's criteria.

Even after receiving UMAC's report, MetLife continued its

efforts to obtain Sweatman's complete medical records. After

repeatedly contacting the physicians listed on Sweatman's

disability claim, MetLife was able to gather additional records.

Because these records had not been considered by UMAC in its first

review, MetLife forwarded the additional records to UMAC for a

second review. Dr. Dwyer, an orthopedic surgeon, reviewed the

complete records and concluded that they did not support the

physical limitations that Sweatman claimed. After its Physician's

Roundtable reviewed and concurred with Dr. Dwyer's opinion, UMAC

issued a second report summarizing its findings. Specifically,

UMAC found that Sweatman's lab work refuted a diagnosis of

rheumatoid arthritis. UMAC also concluded that "the diagnosis of

fibromyositis or fibromyalgia, if accepted, is certainly not

substantiated to the degree that would disable Sweatman."

MetLife also hired Equifax Services ("Equifax") to investigate

Sweatman's claim. An investigator working for Equifax interviewed

Sweatman's neighbors and a local merchant who operated a business

across the street from that of Sweatman's husband. None of these

sources knew of Sweatman's disability. The neighbors reported that

3

Sweatman was taking care of her husband, who was confined to a

wheelchair after suffering a stroke, on a full-time basis. The

investigator also interviewed Sweatman and reported that she "moved

about with no apparent restrictions or obvious signs of

impairments."

Based on Sweatman's medical records, the two UMAC reports, the

Equifax claim investigation, and its own employment-related

information, Darvasi recommended in writing to her supervisor Allen

Carson, a MetLife unit claims manager, that Sweatman's disability

claim be denied. Carson reviewed the claim file and agreed that

Sweatman was not totally disabled within the meaning of the Plan.

MetLife then informed Sweatman by letter of the denial and

explained its reasons for denying her claim. MetLife also

explained that Sweatman could request reconsideration of her claim.

When Sweatman requested review of the denial, MetLife

forwarded her file to Laura Sullivan, a "procedure analyst" at

MetLife who had not been involved in the prior decision to deny

Sweatman's claim. Sullivan reviewed the file and upheld the

original determination. Consequently, MetLife informed Sweatman by

letter of its decision to uphold the earlier denial.

Sweatman filed suit under ERISA, 29 U.S.C. § 1132(a)(1)(B)

seeking district court review of MetLife's disability

determination.3 After a bench trial submitted on pleadings,

3

29 U.S.C. § 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."

4

depositions, and the administrative record, the court held that

MetLife did not abuse its discretion when it denied Sweatman's

claim and entered judgment against Sweatman. Sweatman now appeals,

alleging: (1) that the district court erroneously applied an abuse

of discretion standard of review to MetLife's determination; and

(2) that even if "abuse of discretion" was the proper standard,

MetLife abused its discretion in determining that Sweatman was not

"totally disabled."

II

A

Sweatman argues that the district court erroneously applied

an abuse of discretion standard of review to MetLife's denial of

her claim. In the Fifth Circuit, the proper standard for district

court review of a plan administrator's benefit determination is

governed by the Supreme Court's decision in Firestone Tire and

Rubber Co. v. Bruch, 489 U.S. 101, 109 S.Ct. 948, 103 L.Ed.2d 80

(1989), and our decision in Pierre v. Connecticut General Life

Insurance Co., 932 F.2d 1552 (5th Cir.), cert. denied, --- U.S. ---

-, 112 S.Ct. 453, 116 L.Ed.2d 470 (1991). In Bruch, the Court held

that "a denial of benefits challenged under § 1132(a)(1)(B) is to

be reviewed under a de novo standard unless the benefit plan gives

the plan administrator or fiduciary discretionary authority to

determine eligibility for benefits or to construe the terms of the

plan." 489 U.S. at 115, 109 S.Ct. at 956-57. In Pierre, we held

"that for factual determinations under ERISA plans, the abuse of

discretion standard of review is the appropriate standard." 932

5

F.2d at 1562.4 Consequently, district courts in the Fifth Circuit

review under an abuse of discretion standard a plan administrator's

factual determinations and determinations made pursuant to a plan

that gives the administrator discretionary authority to determine

eligibility or interpret the terms of the plan.

Sweatman concedes that MetLife's determination that she was

not disabled was "more factual in nature than interpretive in

nature," and therefore is ordinarily subject to abuse of discretion

review by the district court under Pierre. However, she argues

that two special circumstances in her case warrant heightened

scrutiny of MetLife's decision.

1

First, she argues that because she was deprived of the "full

and fair review" of her claim required by ERISA, 29 U.S.C. §

1133(2) (1988), the district court should have reviewed MetLife's

decision de novo. We do not reach this issue5 because in this case

MetLife conducted a "full and fair review" of Sweatman's claim.

Section 1133(2) provides that "every employee benefit plan

shall ... afford a reasonable opportunity to any participant whose

4

We recently reaffirmed this standard in Southern Farm

Bureau Life Insurance Co. v. Moore, 993 F.2d 98, 101 (5th

Cir.1993).

5

Sweatman cites no authority for the proposition that

noncompliance with § 1133(2) would warrant heightened scrutiny of

MetLife's disability determination. In Weaver v. Phoenix Home

Life Mutual Insurance Co., 990 F.2d 154 (4th Cir.1993), the

Fourth Circuit held that a plan administrator's noncompliance

with § 1133(1) was evidence of abuse of discretion, but the court

did not apply a heightened standard of review. See id. at 158-

59.

6

claim for benefits has been denied for a full and fair review by

the appropriate named fiduciary of the decision denying the

claim."6 Other circuits have explained that "full and fair review

means "knowing what evidence the decision-maker relied upon, having

an opportunity to address the accuracy and reliability of the

evidence, and having the decision-maker consider the evidence

presented by both parties prior to reaching and rendering his

decision.' " Sage v. Automation, Inc. Pension Plan & Trust, 845

F.2d 885, 893-94 (10th Cir.1988) (quoting Grossmuller v.

International Union Local 813, 715 F.2d 853, 858 n. 5 (3d

Cir.1983)).

Sweatman argues that MetLife's review of her claim was

inadequate because "the word "review' contemplates an examination

and evaluation of the file by someone other than the various people

who initially denied the claim." This argument is both legally and

factually inaccurate. The word "review" does not connote

examination by a second party. Instead, "review" means "to view,

6

The Department of Labor's regulations further elaborate on

the "full and fair review" requirement of 29 U.S.C. § 1133(2):

Every plan shall establish and maintain a procedure by

which a claimant or his duly authorized representative

has a reasonable opportunity to appeal a denied claim

to an appropriate named fiduciary or to a person

designated by such fiduciary, and under which a full

and fair review of the claim and its denial may be

obtained. Every such procedure shall include but not

be limited to provisions that a claimant or his duly

authorized representative may: (i) Request a review

upon written application to the plan; (ii) Review

pertinent documents; and (iii) Submit issues and

comments in writing.

29 C.F.R. § 2560.503-1(g) (1993).

7

look at, or look over again." The Random House College Dictionary

1130 (Rev. ed. 1980); see also Black's Law Dictionary 1320 (6th

ed. 1990) ("Review. To re-examine judicially or administratively.

A reconsideration; second view or examination; revision;

consideration for purposes of correction."). We have found no case

law supporting Sweatman's interpretation of "review" as it appears

in § 1133(2). To the contrary, courts have held that a plan

administrator's reconsideration of its prior decision satisfies §

1133(2). See, e.g., Brown v. Retirement Comm., 797 F.2d 521, 534-

35 (7th Cir.1986) (committee's review of its own decision

"satisfied the section 1133 requirement of a full and fair review

by the appropriate named fiduciary"), cert. denied, 479 U.S. 1094,

107 S.Ct. 1311, 94 L.Ed.2d 165 (1987); see also Davidson v.

Prudential Ins. Co., 953 F.2d 1093, 1096 (8th Cir.1992)

(Prudential's reconsideration of permanent disability claim three

times was "full and fair review").

Furthermore, even if § 1133(2) required review by a second

decision-maker, MetLife's procedure did involve such review. As

Sweatman acknowledges in her brief, Laura Sullivan, who was not

involved in the original disability determination, reviewed

Sweatman's file and the recommendations of Shirley Darvasi, "the

original claim reviewer." We cannot agree that a second review of

the recommendations of an "original reviewer" does not amount to a

"review" as contemplated by § 1133(2).7

7

Sweatman also argues that Sullivan could not have

adequately reviewed Sweatman's claim because "Paragraph 6 of her

affidavit states that, "based upon my ERISA review of MetLife's

8

Sweatman has not pointed to any other procedural deficiency in

MetLife's review of her claim. Therefore, we hold that the

district court properly declined Sweatman's request that it review

MetLife's decision with heightened scrutiny on the grounds that

MetLife failed to comply with § 1133(2).

2

Sweatman also argues that MetLife's inherent conflict of

interest as plan administrator and benefit insurer warranted

heightened scrutiny by the district court. We have previously

held, however, that a conflict of interest does not change the

standard of review. Salley v. DuPont de Nemours & Co., 966 F.2d

1011, 1014 (5th Cir.1992). Instead, the district court should

weigh any potential conflict of interest in its determination of

whether the plan administrator abused its discretion. Id.;

Haubold v. Intermedics, Inc., 11 F.3d 1333, 1337 (5th Cir.1994).8

denial decision, MetLife again determined that Ms. Sweatman was

not totally disabled from performing her job and, therefore,

upheld the decision to deny benefits.' " This statement is

inaccurate, according to Sweatman, because Drs. Dwyer and

Blendonhy "did not base their decisions upon any conclusion that

she wasn't disabled but, in fact, denied the claim because they

did not believe there were sufficient records of medical findings

to support the disability opinion offered by plaintiff's treating

physicians." This argument assumes that UMAC played a greater

role than it actually did in MetLife's disability determination

process. MetLife asked Drs. Dwyer and Blendonhy to review

Sweatman's medical records to ascertain whether the documents

supported Sweatman's claimed physical limitations. With the

benefit of these opinions, MetLife, the plan administrator, made

the ultimate determination that Sweatman was not totally

disabled. See infra part II.B.2.

8

See also Duhon v. Texaco, Inc., 15 F.3d 1302, 1306 (5th

Cir.1994) (plan administrator's possible conflict of interest did

not change abuse of discretion standard of review); Callahan v.

Rouge Steel Co., 941 F.2d 456, 459 (6th Cir.1991) (conflict of

9

In this case, the district court properly reviewed MetLife's

decision under the abuse of discretion standard, weighing MetLife's

conflict of interest as a factor in that review.

B

Sweatman argues in the alternative that even if the court

applied the proper standard of review, it erroneously concluded

that MetLife did not abuse its discretion. Both parties cast our

standard of review on appeal as whether the district court's

"finding" was erroneous. However, Sweatman attacks not the

district court's findings of fact, but rather the district court's

holding that the plan administrator's denial of benefits was not an

abuse of discretion. The posture of this case requires us to

clarify the proper standard of review on appeal from a district

court's review of a denial of benefits under § 1132(a)(1)(B).

1

The Supreme Court's holding in Bruch that "a denial of

benefits challenged under § 1132(a)(1)(B) is to be reviewed under

a de novo standard unless the benefit plan gives the plan

administrator or fiduciary discretionary authority to determine

interest is a factor to be considered in determining whether plan

administrator abused its discretion); Brown v. Blue Cross & Blue

Shield, 898 F.2d 1556, 1563 (11th Cir.1990) (arbitrary and

capricious standard applies to case in which administrator is

insurer, but application of the standard is shaped by the

circumstances of the inherent conflict of interest), cert.

denied, 498 U.S. 1040, 111 S.Ct. 712, 112 L.Ed.2d 701 (1991).

Contra Bogue v. Ampex Corp., 976 F.2d 1319, 1325 (9th Cir.1992)

("This court has confirmed that less deference applies when the

administrator's decision involves a "serious conflict' between

the administrator and the employee."), cert. denied, --- U.S. ---

-, 113 S.Ct. 1847, 123 L.Ed.2d 471 (1993).

10

eligibility for benefits or to construe the terms of the plan," 489

U.S. at 115, 109 S.Ct. at 956-57, describes the district court's

standard of review—not that of the Court of Appeals.9 Plaintiffs

who file suit under § 1132(a)(1)(B) to challenge denials of

benefits do so in district court, and the district court reviews

the plan administrator's decision. Then, if a party appeals the

district court's judgment, we review its decision. On appeal, our

standard of review for district court decisions reviewing plan

administrators' eligibility determinations is guided by the

principles that typically guide our standard of review. Namely, we

review questions of law de novo and set aside factual

determinations only if clearly erroneous. Odom v. Frank, 3 F.3d

839, 843 (5th Cir.1993). Consistent with these principles, we

review a district court's determination of whether a plan

administrator abused its discretion—a mixed question of law and

fact—de novo.10 Our review of the district court's holding will

then require us to apply Bruch and Pierre to determine what

9

Similarly, our holding in Pierre "that for factual

determinations under ERISA plans, the abuse of discretion

standard of review is the appropriate standard," 932 F.2d at

1562, also describes the district court's standard of review.

10

Cf. Phillips v. Alaska Hotel & Restaurant Employees

Pension Fund, 944 F.2d 509, 515 (9th Cir.1991) (question whether

pension plan trustees acted arbitrarily and capriciously is mixed

question of law and fact; ultimate conclusions are reviewed de

novo while underlying facts are reviewed for clear error), cert.

denied, --- U.S. ----, 112 S.Ct. 1942, 118 L.Ed.2d 548 (1992);

Brown v. Blue Cross & Blue Shield, 898 F.2d 1556, 1559 (11th

Cir.1990) (clarifying that district court's holding on question

of whether plan administrator's determination was arbitrary and

capricious is a matter of law subject to de novo review), cert.

denied, 498 U.S. 1040, 111 S.Ct. 712, 112 L.Ed.2d 701 (1991).

11

standard of review applies to the plan administrator's decision.

See Sandoval v. Aetna Life and Casualty Ins. Co., 967 F.2d 377, 380

(10th Cir.1992) ("The district court's holding that the

administrator's decision was not arbitrary and capricious is a

legal conclusion. Hence, our review of the district court's

decision, although not the underlying administrator's decision, is

plenary.").

Previous cases in this circuit have applied the proper

standard of review for potentially conflicting reasons. In some

cases, we have applied the Bruch and Pierre tests to determine our

standard of review of the plan administrator's decision. For

example, in Vasseur v. Halliburton Co., 950 F.2d 1002 (5th

Cir.1992), we explained that "[b]ecause the applicable plan gives

the plan administrator discretion to construe plan terms, the

arbitrary and capricious standard applies," id. at 1006, and held

that "[t]he plan administrator's decision ... was not arbitrary and

capricious." Id. at 1007.11 While these cases properly review the

district court's decision de novo, they only implicitly recognize

the fact that as a court of appeals we review the district court's

decision and not the plan administrator's determination directly.12

11

Accord Salley v. E.I. DuPont de Nemours & Co., 966 F.2d

1011, 1014 (5th Cir.1992); Batchelor v. IBEW, Local 861 Pension

and Retirement Fund, 877 F.2d 441, 442-43 (5th Cir.1989).

12

The one case in which we did recognize the fact that on

appeal we review a district court's decision reviewing a plan

administrator's determination is Cathey v. Dow Chemical Co.

Medical Care Program, 907 F.2d 554 (5th Cir.1990), cert. denied,

498 U.S. 1087, 111 S.Ct. 964, 112 L.Ed.2d 1051 (1991). There we

explained: "Accordingly, the New Plan cannot be read as granting

discretion expressly, and thus we will review de novo the

12

Other decisions have applied the Bruch standard to determine

our standard of review of the district court 's decision. In

Schultz v. Metropolitan Life Ins. Co., 872 F.2d 676 (5th Cir.1989),

we explained our standard as follows: "Neither party has pointed

to any provision in the Plan which gives the administrator

discretionary authority to determine benefit eligibility or to

construe the plan terms. Accordingly, the district court's review

of the administrator's denial of the Schultz claim will be tested

here based on a de novo standard." Id. at 678; accord Wise v. El

Paso Natural Gas Co., 986 F.2d 929 (5th Cir.1993) (citing Schultz,

872 F.2d at 678), cert. denied, --- U.S. ----, 114 S.Ct. 196, 126

L.Ed.2d 154 (1993). These cases also apply the proper standard—de

novo review of the district court's decision—but they imply that if

a plan does give the plan administrator discretion, then we would

review the district court's decision under an abuse of discretion

standard. However, this implication is inconsistent with the

general rule in this circuit that we review mixed questions of law

and fact de novo. E.g., United States v. Faubion, 19 F.3d 226, 228

(5th Cir.1994).

Finally, some cases have suggested that all actions brought

under 29 U.S.C. § 1132(a)(1)(B) are reviewed de novo on appeal.

See, e.g., Godwin v. Sun Life Assur. Co., 980 F.2d 323, 329 (5th

Cir.1992) ("Because this is an action brought under 29 U.S.C. §

fiduciary's denial of Cathey's nursing claims here. Having the

benefit of prior judicial review, however, we will not upset the

district court's factual determinations unless they are clearly

erroneous." Id. at 560.

13

1132(a)(1)(B), we review de novo the district court's decision.")

(citing Bruch, 489 U.S. at 115, 109 S.Ct. at 956); Jones v. Sonat,

Inc. Employee Benefit Plan Admin. Comm., 997 F.2d 113, 115 (5th

Cir.1993) (same) (citing Goodwin, 980 F.2d at 329). Again, while

these cases reach the proper result—de novo review of the district

court's decision upholding or overruling the plan administrator's

decision—they are potentially misleading because our standard of

review does not derive from § 1132(a)(1)(B).13 Furthermore, we

apply the "clearly erroneous" standard to a district court's

findings of fact in an action under § 1132(a)(1)(B). Cathey, 907

F.2d at 560.

In sum, while none of our cases have applied an incorrect

standard of review to a district court's decision in a §

1132(a)(1)(B) case, their conflicting explanations of the

applicable standard of review warrant clarification. The Supreme

Court's decision in Bruch and our decision in Pierre determine the

proper standard of review in a § 1132(a)(1)(B) action for review of

a plan administrator's determination of benefits. On appeal from

a district court's judgment in a § 1132(a)(1)(B) case, our

traditional standards of review apply, and we review de novo the

district court's holding on the question of whether the plan

administrator abused its discretion or properly denied a claim for

13

As we explained in Wise v. El Paso Natural Gas Co., 986

F.2d 929 (5th Cir.1993), "[a]lthough it is a "comprehensive and

reticulated statute,' ... ERISA fails to set out the applicable

standard of review for actions under § 1132(a)(1)(B) challenging

benefit eligibility determinations." Id. at 933 (quoting Nachman

Corp. v. PBGC, 446 U.S. 359, 361, 100 S.Ct. 1723, 1726, 64

L.Ed.2d 354 (1980)).

14

benefits. However, we will set aside the district court's factual

findings underlying its review of the plan administrator's

determination only if clearly erroneous.

2

The parties in this case agree that Sweatman asked the

district court to review MetLife's factual determination that she

was not permanently disabled. The district court held that MetLife

did not abuse its discretion, a holding we review de novo. See

supra part II.B.1. Consequently, under Pierre, we must determine

whether MetLife's decision amounted to an abuse of its discretion.

932 F.2d at 1562. "In applying the abuse of discretion standard,

we analyze whether the plan administrator acted arbitrarily or

capriciously." Salley v. E.I. DuPont de Nemours & Co., 966 F.2d

1011, 1014 (5th Cir.1992).

Sweatman essentially argues that MetLife made the wrong

decision because it attached insufficient weight to her doctors'

opinions and too much weight to the results of its own

investigation, which Sweatman alleges was deficient. MetLife

considered all of the medical records Sweatman submitted in support

of her disability claim, contracted independent medical consultants

to evaluate those records and determine whether they supported her

physical limitations,14 hired an investigator to interview and

14

Sweatman argues that because Drs. Blendonhy and Dwyer

review twenty to thirty files per month for UMAC, they are

"financially dependent upon UMAC [which, Sweatman argues, is in

turn financially dependent on MetLife] and ... by no means

"independent' or "impartial.' " This argument lacks merit.

First, UMAC's doctors are independent consultants because MetLife

hires UMAC on a contractual basis. Second, even assuming the

15

investigate Sweatman, and reviewed the entire administrative record

twice.

The record generated by these evaluations contains ample

evidence to support MetLife's finding that Sweatman was not

permanently disabled. Specifically, the UMAC reports explained

that Sweatman's own medical records did not support a diagnosis of

rheumatoid arthritis. UMAC's second report found that "the

diagnosis of fibromyositis or fibromyalgia, if accepted, is

certainly not substantiated to the degree that would disable

Sweatman." After reviewing the record and considering MetLife's

issue were relevant, Sweatman points to no evidence in the record

that proves that Drs. Dwyer and Blendonhy are "financially

dependent" on UMAC or that UMAC depends on MetLife. The number

of files they review per month proves nothing about their

financial status. Finally, we note that the only way for MetLife

to satisfy Sweatman's standard for impartiality would be to seek

physicians willing to volunteer their time to review the medical

files of disability claimants.

Sweatman also argues that Dr. Blendonhy's opinion is

worthless because he did not review all of Sweatman's

medical records. It is true that Dr. Blendonhy examined

only those records that Sweatman had submitted to MetLife at

the time of his review. However, when Sweatman submitted

additional records, some of which filled gaps identified by

Dr. Blendonhy, MetLife resubmitted the complete records for

UMAC's consideration. Sweatman does not dispute that Dr.

Dwyer based his opinion on all of the records Sweatman

submitted to MetLife. Consequently, even if Dr. Blendonhy's

opinion were based on an insufficient record, Dr. Dwyer's

opinion and MetLife's ultimate benefit determination were

based on Sweatman's complete medical records.

Sweatman also contends that UMAC's "Physician's

Roundtable" has no evidentiary value whatsoever, and in fact

"is nothing more than a bucket of whitewash which is

legitimated by the professional degrees of those that

participate." However, Sweatman's characterization of

UMAC's peer review process does not change the fact that

UMAC's report contains ample evidence supporting MetLife's

determination.

16

dual role as plan administrator and insurer, we agree with the

district court that MetLife's disability determination was not an

abuse of discretion. See Donato v. Metropolitan Life Ins. Co., 19

F.3d 375, 380 (7th Cir.1994) (MetLife's denial of benefits was not

arbitrary and capricious when its "decision simply came down to a

permissible choice between the position of UMAC, MetLife's

independent medical consultant, and the position of [the claimant's

physicians].").

Citing our decision in Salley, Sweatman argues that MetLife

abused its discretion because it failed to obtain necessary

information and selectively relied on only part of her treating

physicians' diagnoses. In Salley, the plaintiff, a teenager with

a history of emotional disabilities, drug abuse, and depression,

had been admitted to a hospital three times for psychiatric care.

966 F.2d at 1012. After she had been hospitalized for almost a

month during her third admission, Salley's treating psychiatrist,

Dr. Blundell, found that her condition had improved dramatically.

Id. at 1013. However, he concluded she should remain as an

inpatient until a suitable environment could be found to avoid a

regression to her previous behavior. Id. DuPont ultimately

terminated Salley's inpatient hospitalization benefits based on a

determination by Preferred Health Care ("Preferred") that continued

hospitalization was not medically necessary. Id. Preferred's case

manager Ron Schlegel and its psychiatrist Dr. Ahluwalia had spoken

with Dr. Blundell about Salley's improved condition, examined the

medical records of Salley's first admission, and concluded that

17

continued hospitalization was not medically necessary. Id. We

held that:

[A]lthough DuPont followed the prescribed procedures, it

abused its discretion in relying upon the Schlegel and Dr.

Ahluwalia recommendation to terminate [Salley's] benefits.

Because they chose to follow Dr. Blundell's diagnosis,

Schlegel and Dr. Ahluwalia were required, absent independent

inquiry, to follow all his advice, not just part of it. If

they decided to deviate from his diagnosis, they were required

to investigate further the medical necessity of in-patient

hospitalization. Whether this investigation included an

examination of [Salley] or an analysis of hospital records

depended on the particulars of each case. At the very least,

however, administrators relying on hospital records obviously

must review the most recent records. The case administrator

and the physician conceded at trial that they did not do so.

Id. at 1015-16 (emphasis added). In this case, MetLife

investigated Sweatman's condition and analyzed all of her hospital

records. When Sweatman submitted additional records after Dr.

Blendonhy's review, MetLife sought another opinion from UMAC

regarding whether her records supported the physical limitations

found by her treating physicians. Furthermore, MetLife did not

rely on Sweatman's physicians' diagnoses only to ignore their

advised treatment. Rather, MetLife denied Sweatman's claim for

disability benefits based on the opinions of Drs. Dwyer and

Blendonhy disagreeing with those of Sweatman's physicians.

Finally, we note that Salley involved a determination of "medical

necessity" and not a claim for disability benefits.

Sweatman also argues that because she received a percentage

of her salary under Commercial Union's "salary continuation plan,"

she is entitled to a presumption of total disability, and that

MetLife did not rebut this presumption with evidence of a change in

her condition. Sweatman cites no authority for such a rule, and we

18

see no need to create one in this case. Furthermore, there is no

evidence in the record that payments under the salary continuation

plan depend on a finding of total disability. The parties

stipulated at trial that a beneficiary is entitled to such benefits

"in the event of an illness or accident resulting in [the]

inability to work." However, the terms of the salary continuation

plan are not contained in the record, and the Long Term Disability

Plan makes no reference to such benefits.

The remainder of Sweatman's arguments simply overstate UMAC's

role in MetLife's disability determination. Sweatman argues that

MetLife abused its discretion because Drs. Blendonhy and Dwyer were

not asked whether Sweatman was "totally disabled" but rather only

whether her medical records supported the physical limitations she

claimed. Sweatman also argues that Drs. Dwyer and Blendonhy were

not qualified to determine whether she was "totally disabled"

within the meaning of the Plan because they were not familiar with

what her occupation entailed. Both of these arguments are beside

the point because MetLife, not Drs. Dwyer and Blendonhy, was

responsible for the ultimate determination of whether Sweatman was

"totally disabled." MetLife consulted the UMAC physicians only on

the question of whether Sweatman's own records supported the

physical limitations that she claimed.15 In fact, had MetLife

15

Sweatman also argues that Drs. Dwyer and Blendonhy were

not qualified to render their opinions because they do not

practice in Louisiana where Sweatman was diagnosed and do not

specialize in the same areas as her primary treating physicians.

These arguments similarly assume too great a role for UMAC's

physicians. Drs. Blendonhy and Dwyer were asked to determine

only whether the contents of Sweatman's medical records supported

19

delegated its decision to grant or deny disability benefits to

UMAC, it might have run afoul of its fiduciary duty under the Plan.

Cf. Salley, 966 F.2d at 1014 ("As long as a company maintains the

ultimate decision on denial of benefits, it can be beneficial for

it to have experienced agents assist in the determination.").

In sum, in light of the ample evidence supporting MetLife's

"total disability" determination, and recognizing MetLife's dual

role as claims administrator and insurer, we hold that the district

court properly upheld MetLife's denial of Sweatman's claim.

III

For the foregoing reasons, we AFFIRM.

her claimed physical limitations. Sweatman fails to show that

Drs. Blendonhy and Dwyer were not qualified to make this limited

determination.

20