Federal Circuits, First Circuit (May 27, 1998)
Docket number: 97-2190
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US Code - Title 29: Labor - 29 USC 1133 - Sec. 1133. Claims procedure
US Code - Title 29: Labor - 29 USC 1002 - Sec. 1002. Definitions
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James B. Krasnoo, with whom Richard Briansky and Law Offices of James B. Krasnoo, were on brief, for appellant.
William J. Klemick, with whom John J. Myers, Treazure R. Johnson, and Eckert Seamans Cherin & Mellott, LLC, were on brief, for appellees.Before LYNCH, Circuit Judge, COFFIN and BOWNES, Senior Circuit Judges.BOWNES, Senior Circuit Judge.In this appeal under the Employee Retirement Income Security Act of 1974, as amended, 29 U.S.C.A. §§ 1001--1461 (West Supp.1998)("ERISA"), appellant Michael F. Terry challenges the termination of his long-term disability benefits. The district court granted summary judgment to the defendants. We affirm.I.As required under the summary judgment standard, we recite the following undisputed facts in the light most favorable to the non-movant Terry, drawing all reasonable inferences in his favor. August v. Offices Unlimited, Inc., 981 F.2d 576, 580 (1st Cir.1992).Terry began working at Bayer Corporation ("Bayer") in 1982 as a computer software test auditor.1 At some point during the course of the next several years, Terry was moved to a new position, involving the tracking of rejected computer materials, and reporting his findings to the Bayer engineering and purchasing departments.On or about January 5, 1987, as he exited his apartment building on the way to work, Terry slipped on ice and fell down nine steps, injuring his knee. He continued on to work that day, but on arrival was sent to the hospital by Bayer's nurse. Over the course of the next several weeks, Terry was cared for by both his primary care physician, Dr. Walter H. Jacobs, and an orthopedic surgeon, Dr. George Ousler. Dr. Ousler determined at the time that Terry most likely had suffered a "medial lateral collateral ligament injury strain or an internal derangement of the knee." While Dr. Ousler's treatment plan was originally conservative, in March, 1987, Terry underwent arthroscopic surgery in an attempt to remedy persistent soreness and slight swelling. Pain management and physical therapy ensued for the next several months.Terry returned to work in August 1987. He was promoted in 1988 to a position maintaining desk-top computers. In January 1990, as a result of budget cuts, Bayer transferred Terry to the position of test technician. This position involved the assembly and testing of computer boards, and involved considerably more physical activity than his previous positions; Terry was now required to move containers of computer boards around the workplace. After having been in his new position for approximately one month, Terry's knee buckled and he fell to the ground. This incident occurred outside of the workplace.As a result of this second injury, Terry did not return to work at Bayer. A second arthroscopic surgery was soon performed, and torn cartilage and bone chips were removed from his knee.Terry's primary care physician, Dr. Jacobs, states that Terry suffers from a degenerative knee condition which results in bone-on-bone contact. As a result of the condition, Terry is in almost constant pain, and is unable to stand, sit, or otherwise maintain a single stationary position for any extended period of time. Dr. Jacobs treats Terry's pain with a variety of anti-inflammatories and painkillers.In July, 1990, Bayer approved Terry's application for long-term disability benefits. The Summary Plan Description ("SPD") states that long-term disability benefits are provided under the Bayer Long-Term Disability Plan ("Plan") when a beneficiary is "unable to work at any job for which [they] are qualified by education, training, or experience."As Plan Administrator, Bayer retained Northwestern National Life Insurance Company ("Northwestern") to process and manage claims made under the Plan.2 As part of that service, Northwestern assigned Anne Tacl to Terry's case to serve as rehabilitation case manager. Tacl's job was to monitor Terry's medical condition in order to make sure that he continued to meet the Plan's definition of total disability. Tacl was also charged with attempting to rehabilitate Terry, with the goal of returning Terry to full-time employment. These responsibilities were consistent with Plan provisions. Because Tacl was based in Minnesota, Tacl hired Sandy Lowery to provide local rehabilitation services to Terry.In April, 1991, Tacl received a report from a Dr. Zarins, an orthopedic surgeon whom Terry had consulted prior to the active involvement of Northwestern. That report opined that Terry's accounts of pain did not correspond to the pathology observed in his knee. Dr. Zarins stated that Terry could return to part-time work with certain significant restrictions. Northwestern, however, was unable to locate an appropriate job for Terry at Bayer. Dr. Zarins saw Terry again one year later, in April 1992, and again determined that Terry could perform sedentary work on a part-time basis. Dr. Jacobs, for his part, however, continued to insist that Terry was completely disabled.In November of 1992, Tacl, as authorized by the Plan, scheduled an independent medical evaluation ("IME") in an attempt to resolve the conflicts in medical opinion. The IME was performed by Dr. Thomas King, who determined that Terry's pain was "out of proportion to all physical findings," but wanted to rule out "reflex sympathetic dystrophy" ("RSD").3 Terry was referred to another specialist, who determined that Terry was not suffering from RSD.On the basis of these medical evaluations, Tacl decided that Terry should participate in a work-hardening rehabilitation program, with the goal of returning Terry to full-time employment. Terry was informed, pursuant to a Plan provision, that if he failed to attend a rehabilitation program, his benefits would be terminated. Terry was given a choice among three institutions, and he opted to attend Farnum Industrial Rehabilitation ("Farnum"). Dr. Jacobs eventually signed off on the referral to Farnum, but did not think the program would be helpful to Terry.Dr. Robert Haile, the Medical Director at Farnum, examined Terry upon his entry to the program. Haile opined at the time that,[Terry's] degree of disability ... appears to be out of proportion to the degree of findings in his knee. I believe the patient has developed chronic pain syndrome, which refers primarily to the whole person effect of a chronic painful injury. It involves in addition to local persistent pain the psychosocial effects of chronic pain. I think the patient would be a good candidate for Work Hardening.Dr. Haile did not doubt that Terry's pain was genuine. Although Terry's Farnum experience started out well enough, in the end Terry had completed fourteen rehabilitation sessions and canceled thirteen. Terry states that the cancellations were due primarily to complaints of severe pain, caused by the effort required to attend and participate in the rehabilitation program.At about the same time as he was participating in the Farnum program, Terry was referred by Tacl to Deborah Veatch, a local vocational rehabilitation consultant. Although Terry was initially receptive to Veatch's services, his interest and participation in her services quickly waned. Veatch eventually communicated to Tacl that "[b]ased on Mr. Terry's obvious lack of follow through with treatment and vocational activities, ... Mr. Terry is most likely not an appropriate candidate for vocational rehabilitation services." Veatch did conclude, however, that Terry possessed transferable skills in the computer field.On January 20, 1994, Terry was discharged from the Farnum program. The Program Director, Cheryl Baldwin, reported in the discharge summary: "Mr. Terry is capable of working full time, although the amount of standing needs to be limited. He is able to sit for two to four hours with intermittent stretch breaks. Mr. Terry is currently at Sedentary-Light duty work capacity. He has full, unlimited use of his upper body." Tacl thereafter requested that Dr. Haile complete a Physical Capacities Evaluation. Dr. Haile did so, and released Terry to full-time work with restrictions on continuous time in a sitting or standing position, as well as lifting, bending, and crawling.Terry received a letter dated February 24, 1994 from Tacl indicating that she was recommending that his benefits be terminated. The letter stated that "[b]ecause you have been released to work with restrictions, you no longer meet the [Plan's] definition of total disability." Shortly thereafter, Terry received a termination letter dated March 3, 1994. The letter stated that, "[d]isability is defined as your complete inability to work in any job for which you[ ] are reasonably fitted by education, training, or experience. Based on a review of the medical and vocational information in your file you are no longer totally disabled from performing 'any occupation.' " Terry was advised of certain of his appeal rights, and benefits were terminated retroactively to February 25, 1994. Terry's benefit checks were not continued during the pendency of his appeals.Shortly after Terry's termination, Tacl received a letter from Dr. Haile. Dr. Haile apparently sent the letter after receiving a phone call from Dr. Jacobs. The Haile letter stated that Haile had only been a consultant in a work-hardening program, and if Tacl required a formal "work release," that release would have to come from Dr. Jacobs.Terry requested an appeal from Northwestern's decision. The "Northwestern ERISA Committee" was convened, reviewed his entire file, and upheld the benefits termination. Terry was advised of this by letter dated March 25, 1994. That letter stated that "[a]lthough Dr. Jacobs provided us with a detailed historical account of your problems with knee pain, he did not provide us with objective evidence to support your total disability from all occupations, as your LTD plan requires." Terry was informed in the letter that further requests for appeal should be directed to Bayer.On June 1, 1994, Terry--now represented by counsel--sent a letter to Tacl demanding reinstatement of benefits. Tacl informed Terry that Bayer would handle any further appeal, and notified Bayer of the receipt of the latest request from Terry. By letter dated July 18, 1994, Bayer's Benefits Manager Joyce Fleischer notified Terry of the steps he needed to take in order to perfect an appeal before the Bayer Benefit Administration Committee ("Benefit Committee"). Included in that letter was the requirement that Terry file his appeal within sixty days. A copy of the relevant appeal procedure from the SPD was appended to Fleischer's letter.It was not until August 15, 1995--over one year later--that Terry formally requested an appeal before the Benefit Committee. Additional materials were forwarded to Bayer,4 and Bayer scheduled a meeting of the Committee to decide the appeal. Before the meeting, Bayer requested that Northwestern's ERISA Committee also review the additional materials forwarded by Terry. The Northwestern Committee did so, and again affirmed its decision to terminate benefits. The Bayer Benefit Committee met on December 6, 1995, reviewed Terry's file, and voted to uphold the termination of benefits.Terry was advised of the decision by a letter from Bayer's employee benefits counsel dated December 21, 1995, stating the Benefit Committee's reasons for upholding the termination. First, the Benefit Committee determined that Terry's appeal was untimely, because it was not filed within the sixty-day time period provided for in the Plan and communicated to Terry in the letter from Fleischer. The Committee went on "[a]s a courtesy to [Terry]", to reach the merits of Terry's appeal. The Benefit Committee detailed the following.To assist the Bayer Corporation in making its determination, our agent, [Northwestern], has been extensively involved in evaluating Mr. Terry's medical condition as well as his ability to return to work. With the approval of Dr. Jacobs, Mr. Terry was put in a "work hardening" program--which is an approved rehabilitation program under the terms of the Plan. During the nine week period of the program, he attended fourteen sessions, canceled thirteen sessions and did not complete the program. On February 1, 1994, at the end of the program, he was released to full-time, sedentary work by Dr. Haile. Dr. Haile was the Medical Director and Physiatrist specializing in assessment of functional capacities in the work hardening program. Based on Dr. Haile's release, as well as Mr. Terry's failure to participate to any meaningful extent in the work hardening program, the Committee would uphold the termination of Mr. Terry's benefits under the Plan even if his appeal was timely filed.It is also important to note that the Committee considered the information you supplied from Dr. Jacobs, Dr. Taylor, the Social Security Administration and Paul Blatchford but, as it is permitted to do under the terms of the Plan, concluded that the opinions of Dr. Haile and Debbie Veatch, a vocational expert, were more credible because those opinions are based on the objective medical testing performed during the work hardening program and Mr. Terry's medical status as of February 1, 1994.Dr. Jacobs is not a specialist but rather a generalist who has consistently prescribed narcotic medications to treat the pain associated with Mr. Terry's condition but has not been directly involved in any rehabilitative course of action for Mr. Terry's condition. Although Dr. Taylor is a specialist, his report does not include any information regarding objective testing performed on Mr. Terry in determining his physical capabilities. Also, the information provided by Dr. Taylor is based on his medical condition as of July 10, 1995--approximately seventeen months after his February 1, 1994 release. Similarly, Mr. Blatchford's report is based on Mr. Terry's medical condition as of October 20, 1995--approximately 20 months after his February 1, 1994 release--and is based on subjective medical complaints rather than objective testing.Terry filed suit under ERISA in Superior Court, Essex County, Massachusetts, in February, 1996, alleging that the benefits termination contravenes the Plan language. The Bayer Plan removed to federal court, see Metropolitan Life Ins. Co. v. Taylor, 481 U.S. 58, 63-67, 107 S.Ct. 1542, 95 L.Ed.2d 55 (1987), and in due course moved for summary judgment. The district court, by margin order, granted summary judgment in defendants' favor on all claims, finding no abuse of discretion in the benefits termination.5 This appeal followed.Our standard of review over the district court's decision on summary judgment is de novo. See Vartanian v. Monsanto Co., 131 F.3d 264, 266 (1st Cir.1997). We are directed to grant summary judgment where "the pleadings, depositions, answers to interrogatories, and admissions on file, together with the affidavits, if any, show that there is no genuine issue as to any material fact and that the moving party is entitled to a judgment as a matter of law." Fed.R.Civ.P. 56(c). The Supreme Court has stated that summary judgment is appropriate "against a party who fails to make a showing sufficient to establish the existence of an element essential to that party's case, and on which that party will bear the burden of proof at trial." Celotex Corp. v. Catrett, 477 U.S. 317, 322, 106 S.Ct. 2548, 91 L.Ed.2d 265 (1986). Here, Terry bears the burden of making "a showing sufficient to establish" a violation of ERISA, namely, that the benefit termination was unreasonable.II.ERISA is a "comprehensive and reticulated statute," Nachman Corp. v. Pension Benefit Guar. Corp., 446 U.S. 359, 361, 100 S.Ct. 1723, 64 L.Ed.2d 354 (1980), which governs the rights and responsibilities of parties in relation to employee pension and welfare plans, see generally New York State Conference of Blue Cross & Blue Shield Plans v. Travelers Ins. Co., 514 U.S. 645, 650-51, 115 S.Ct. 1671, 131 L.Ed.2d 695 (1995). This federal statute includes a cause of action for plan participants, and other beneficiaries, "to recover benefits due to him [or her] under the terms of his [or her] plan." 29 U.S.C.A. § 1132(a)(1)(B). It is under this statutory provision that claims, such as this one, challenging denials and termination of employer-sponsored disability benefits are brought.Although Terry presents his arguments on appeal in a variety of arrangements, his positions can be effectively stated as follows. First, Terry posits that this court should review the decision of Northwestern, as opposed to that of the Bayer Benefit Committee, in making the determination whether the disability benefits were wrongfully terminated. Next, Terry argues that, regardless of which decision we review, that review should not be conducted pursuant to the abuse of discretion standard adopted by the district court, but instead should be conducted de novo; in other words, Terry asks us to undertake an independent review of the record and decide whether Terry is "disabled" within the meaning of the Bayer Plan. Finally, Terry urges us to determine that, regardless of the standard applied, and regardless of the decision we review, the benefits termination violated ERISA because (1) Terry received defective notice of termination, and (2) he was, and is, totally disabled within the meaning of the Plan. We address each position in turn.A.As we have stated, Bayer contracted with a third party, Northwestern, to provide administrative assistance to the Benefit Committee. The agreement between Bayer and Northwestern, entitled "Administrative Services Only Agreement" ("ASO Agreement"), stipulated that Northwestern was to, among other things, "[i]nvestigate and process claims ... [, e]valuate claims for potential rehabilitation ... [, and u]pon receipt of the Plan Sponsor's final decision on claims appeals, make payment or issue a denial notice in accordance with the Plan Sponsor's decision." ASO Agreement § 1(B)(1). The ASO Agreement specifically disclaimed any responsibility on Northwestern's part as a Plan Administrator. Id. § 5(A). The existence of this contractual arrangement between Northwestern and the Benefit Committee was authorized by the Benefit Committee's governing guidelines. Miles, Inc. (Bayer) Administrative Procedures for the Benefit Administration Committee Art. VII, § 2 ("Admin.Proc.").Terry's argument that we should review the decision of Northwestern, and ignore the later decision by the Benefit Committee, is stated in his brief as follows: "The Plan vests discretionary authority with Bayer Corporation, the Plan's fiduciary. Northwestern, however, not Bayer Corp., made the initial decision to terminate Mr. Terry's benefits. Bayer delegated only its administrative duties to Northwestern, but expressly reserved and thereby intentionally withheld any fiduciary authority from Northwestern." Appellant Br. at 22. Terry argues that, because the Plan itself did not grant Northwestern any discretionary authority to interpret the meaning of the plan, Northwestern's "initial decision" must be considered afresh under Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115, 109 S.Ct. 948, 103 L.Ed.2d 80 (1989).In Firestone, the Supreme Court ended the debate over the proper standard of review that courts should employ when examining the out-of-court decisions of plan administrators to deny benefits. The Court stated 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 administrator or fiduciary discretionary authority to determine eligibility for benefits or to construe the terms of the plan." Id. Thus, Terry argues that because the Plan does not grant the decision-maker the necessary authority to resolve disputes, determinations made by that decision-maker are reviewed de novo.In making his argument, however, Terry ignores the fact that the decision of Northwestern was but one step in the process. It was not the final and binding termination decision. In Terry's own words, it was the "initial decision." We must focus, as in the usual case, on the determinations of the final decision-maker, which was the Bayer Benefit Committee."ERISA contemplates actions against an employee benefit plan and the plan's fiduciaries. With narrow exception, however, ERISA does not authorize actions against nonfiduciaries of an ERISA plan." Santana v. Deluxe Corp., 920 F.Supp. 249, 253 (D.Mass.1996). See Mertens v. Hewitt Assocs., 508 U.S. 248, 262-63, 113 S.Ct. 2063, 124 L.Ed.2d 161 (1993); Reich v. Rowe, 20 F.3d 25, 29 (1st Cir.1994) (nonfiduciary liability limited to those "who commit violations of ERISA or who are engaged in an 'act or practice' proscribed by the statute"). Courts have determined that when the plan administrator retains discretion to decide disputes, a third party service provider, such as Northwestern, is not a fiduciary of the plan, and thus not amenable to a suit under § 1132(a)(1)(B). See, e.g., HealthSouth Rehab. Hosp. v. American Nat'l Red Cross, 101 F.3d 1005, 1008-09 (4th Cir.1996), cert. denied, --- U.S. ----, 117 S.Ct. 2432, 138 L.Ed.2d 194 (1997); Harris Trust & Sav. Bank v. Provident Life & Accident Ins. Co., 57 F.3d 608, 613-14 (7th Cir.1995); Kyle Rys., Inc. v. Pacific Admin. Servs., Inc., 990 F.2d 513, 516 (9th Cir.1993); Baker v. Big Star Div. of The Grand Union Co., 893 F.2d 288, 289-90 (11th Cir.1989). An interpretive bulletin issued by the Department of Labor bears this out, stating that an entity which merely processes claims "is not a fiduciary because such person does not have discretionary authority or discretionary control respecting management of the plan." 29 C.F.R. § 2509.75-8, D-2 (1997). Thus, "[t]he proper party defendant in an action concerning ERISA benefits is the party that controls administration of the plan." Garren v. John Hancock Mut. Life Ins. Co., 114 F.3d 186, 187 (11th Cir.1997).Similarly, as we recognized in Rowe, 20 F.3d at 32, ERISA itself significantly limits the liability of service providers in actions under the statute. The Rowe panel refused to exercise its power to fashion a common law remedy to generally extend "the threat of liability over the heads of those who only lend professional services to a plan without exercising any control over, or transacting with, plan assets." Id. Such liability was withheld in Rowe in recognition of, inter alia, the fact that it would likely "deter such [service providers] from helping fiduciaries navigate the intricate financial and legal thicket of ERISA." Id.; see also Buckley Dement Inc. v. Travelers Plan Admins. of Ill., Inc., 39 F.3d 784, 790 (7th Cir.1994)(approving of Rowe reasoning).Terry is correct when he points out that this line of cases is concerned with service provider liability, and as such does not necessarily foreclose the construct he suggests--to review the decision of Northwestern but hold the Plan liable. Nevertheless, we find the precedent compelling. We do not think it supportable or reasonable for a court, when conducting this form of inquiry, to examine an intermediate step in the internal review process de novo. After all, we have determined that a prerequisite to obtaining judicial review under § 1132(a)(1)(B) is that the claimant have exhausted the internal administrative remedies available to him. Drinkwater v. Metropolitan Life Ins. Co., 846 F.2d 821, 825-26 (1st Cir.1988). Thus, if Terry had approached the district court after having received the termination letter from Northwestern, but prior to his appeal to Bayer, his case would likely have been dismissed for failure to exhaust the internal ERISA remedies. See, e.g., Tarr v. State Mut. Life Assur. Co. of Am., 913 F.Supp. 40, 43-45 (D.Mass.1996)(relying on Drinkwater ). It seems an odd proposition to now ignore the results of those mandated internal administrative remedies, and focus de novo review on the intermediate step taken by Northwestern. We reject Terry's argument that we review Northwestern's decision de novo.Terry argues that the fact that his benefits were terminated by Northwestern (subject to appeal to Bayer) means that Northwestern, not Bayer, was the real decision-maker. The balance of the record, however, convinces us otherwise. The record amply demonstrates that Bayer and the Committee retained--by written instrument--the discretion to decide disputed claims. There is nothing to suggest that Northwestern was doing anything other than applying the terms of the Plan as written to Terry's particular situation. Although it may have been imprudent for Northwestern to terminate Terry's benefit checks as soon as it made the initial decision, Terry has not demonstrated that he would not have been entitled to a back payment of his disability benefits if his appeal at Bayer were successful. Indeed, the ASO Agreement specifically requires Northwestern to adhere to the determinations of the Benefit Committee. Therefore, although we recognize the impression generated by Northwestern's immediate termination, the remainder of the record simply does not support the position Terry presses. Bayer's Benefit Committee was the entity with the power to make, and is the entity that actually made, the final decision to terminate Terry's benefits. It is therefore the decision of the Benefit Committee which we shall review.B.We next turn to the proper standard of review to apply in examining the out-of-court decision of the Benefit Committee. Two issues need to be addressed in formulating the proper standard of review. First we determine whether the Plan expressly grants discretionary authority to the plan administrator to determine a claimant's eligibility. Firestone, 489 U.S. at 115, 109 S.Ct. 948. Second, we decide whether the administrator has properly delegated that discretionary authority to the Benefit Committee. Rodriguez-Abreu v. Chase Manhattan Bank, N.A., 986 F.2d 580, 584 (1st Cir.1993). We address each point in turn.As we have previously outlined in part A, supra, the Supreme Court has determined 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 administrator or fiduciary discretionary authority to determine eligibility for benefits or to construe the terms of the plan." Firestone, 489 U.S. at 115, 109 S.Ct. 948; see also Varity Corp. v. Howe,Try vLex for FREE for 3 days
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