holding that when an insurer’s benefits denial rests on evidence generated by conflicted physicians, courts must view the insurer’s rationale “with some skepticism”
How later courts described this case
- holding that when an insurer’s benefits denial rests on evidence generated by conflicted physicians, courts must view the insurer’s rationale “with some skepticism”
- holding that denial of coverage based on a selective review is arbitrary and capricious
- determining that insurer’s decision to terminate benefits was arbitrary and capricious because it relied on medical reviewer whose decision was based on a “selective review of the administrative record”
- noting that below and I assume for purposes of this case, where the non-retired plaintiffs are seeking a judgment to clarify future benefits, that exhaustion was not required under § 1132(a)(1)(B). 19 No. 09-3513 Szoke v. United Parcel Serv. of Am., Inc. federal courts are limited to reviewing the administrative record as it existed when the plan administrator made its final decision
Written by the judges who cited it.
The opinion
SILER, Circuit Judge, dissenting.
I respectfully dissent because I think under the highly deferential arbitrary and capricious standard, the district court did not err in upholding the denial of benefits.
Certainly, as the majority observes, Dr. Feagin was on Unum’s payroll, so that fact must be considered. Nevertheless, he is a qualified board-certified internist physician who concluded that Dr. Watson’s opinions were “rather unorthodox” because Dr. Watson opined that Moon would have higher blood pressure in the sitting position than in the supine position. Dr. Feag-in also decided that Moon could work based upon Dr. O’Brien’s blood pressure tests revealing that Moon’s pressure was higher in the supine position and Dr. O’Brien’s observation that “with proper and effective antihypertensive medication, I suspect her blood pressure is indeed controllable and should not alone be considered disabling.” Dr. Feagin further found that Moon had no “evidence of significant hypertensive end organ damage.” He admitted Moon could not perform medium to heavy work, but he concluded she could do sedentary or light work.
As Black & Decker Disability Plan v. Nord, 538 U.S. 822, 829-33 , 123 S.Ct. 1965 , 155 L.Ed.2d 1034 (2003), holds that the opinion of the treating physician is not to be given deference over that of other physicians, I would find that the decision not to award long-term benefits by Unum was not arbitrary and capricious, because it was based on Dr. Feagin’s conclusions. Were we to view the matter under a de novo standard, I might very well decide otherwise.