Diana K. Hightshue v. Aig Life Insurance Company

135 F.3d 1144, 28 Employee Benefits Cas. (BNA) 1273, 1998 U.S. App. LEXIS 1478, 1998 WL 40280
CourtCourt of Appeals for the Seventh Circuit
DecidedFebruary 4, 1998
Docket96-3646
StatusPublished
Cited by73 cases

This text of 135 F.3d 1144 (Diana K. Hightshue v. Aig Life Insurance Company) is published on Counsel Stack Legal Research, covering Court of Appeals for the Seventh Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Diana K. Hightshue v. Aig Life Insurance Company, 135 F.3d 1144, 28 Employee Benefits Cas. (BNA) 1273, 1998 U.S. App. LEXIS 1478, 1998 WL 40280 (7th Cir. 1998).

Opinion

MANION, Circuit Judge.

On three separate occasions, Diana Hi-ghtshue was exposed to an industrial odorizer while working at DowBrands. On each occasion, she was taken to the emergency room and treated for breathing difficulties. After the third exposure, she resigned. Eight months later, she sought ERISA disability payments for being permanently and totally disabled. AIG Life Insurance Co. (AIG), the ERISA claims administrator, denied her claim. Hightshue sued in federal district court, seeking to overturn the administrator’s decision, but the district court granted summary judgment to AIG. We affirm.

I. Facts

Diana K. Hightshue worked as a customer service representative and then as an accounts payable assistant for DowBrands, a subsidiary of the Dow Chemical Company, between August 1990 and January 1993. From 1984 until joining DowBrands, Hi-ghtshue held various advertising and retail sales positions. In August 1991, Hightshue enrolled in the Dow Chemical Company’s Voluntary Group Accident Plan (VGA plan). The VGA plan is an ERISA plan, funded by payroll deductions from plan participants. By the terms of the plan, DowBrands is the plan administrator, responsible for soliciting participants, providing information about the plan, and collecting premiums. The plan also designates AIG, an insurance company, as the claims administrator. AIG determines the necessary premiums, and pays or denies claims.

On June 9, 1992, mercaptan gas leaked from a holding tank located in Hightshue’s vicinity at DowBrands. Mercaptan is an odorizer, added to natural gas to alert people to a possible gas leak by giving natural gas a distinct, “rotten-egg” smell. Hightshue was taken to a local emergency room and treated for breathing difficulties, loss of voice, and disorientation. She did not return to work for two weeks. During those two weeks, Hightshue was treated frequently for breathing difficulties and pain in her chest. Even after returning to work, she experienced hoarseness, coughing, wheezing, shortness of breath, and nocturnal breathing difficulty, though the symptoms became less severe.

On September 23, 1992, Hightshue was again exposed to mercaptan, and she sought immediate medical treatment. She suffered the same symptoms, and also found even light physical exertion difficult to do. She also found she had problems engaging in conversation because she “was not processing information accurately or rapidly and would even forget the subject under discussion in mid-conversation or even mid-sentence.” After the September incident, Hi-ghtshue did not return to work for two months. When she returned to work on November 30, 1992, Dow moved her to accounting (in a different budding).

On January 19, 1993, it happened again— Hightshue was again exposed to mercaptan. But this time was more severe. Her symptoms continue unabated. On January 29, 1993, shortly after the third incident, she resigned from DowBrands.

On October 25, 1993, Hightshue sought Total Disability or Permanent Total Disability Benefits under the VGA Plan. AIG collected medical records from various treating physicians and had Hightshue complete a questionnaire regarding her claim of disabilities. It then reviewed the file, and subsequently forwarded it to an independent company, NorthAmerican Medical Evaluations, Inc. NorthAmerican retained Dr. Jack Kaufman to review the file and make a recommendation regarding Hightshue’s claim of disability. Dr. Kaufman is a board certified internist, and has frequently reviewed disability cases for the Social Security Administration. A substantial portion of his medical *1147 practice involves the evaluation and treatment of allergies.

After reviewing the file on Hightshue, but without examining her, Dr. Kaufman concluded that Hightshue was not disabled. He found that no tests revealed any disabling condition, and that her symptoms were generally characterized as mild. He therefore concluded that Hightshue was not disabled from working.

AIG subsequently submitted Hightshue’s medical file and Dr. Kaufman’s report to Genex Services, Inc., another independent agency, who assigned employee Carolyn Pa-vol to assess Hightshue’s employability. Ms. Pavol hold:, a master’s degree in Counseling and Human Services and a bachelor’s degree in psychology. She is also a Licensed Professional Counselor and a Certified Insurance Rehabilitation Specialist. Since 1992, Ms. Pavol has worked as a vocational rehabilitation consultant for Genex. Ms. Pavol reviewed the entire file, and concluded that there were jobs which Hightshue eould physically perform and which were suitable for Hightshue’s educational background and experience. Consequently, she concluded Hi-ghtshue was not permanently and totally disabled.

AIG reviewed the conclusions of Dr. Kaufman and Ms. Pavol, and decided to deny the claim. AIG sent a letter to Hightshue, through her attorney, explaining its decision and informing her of the opportunity to seek further review with the AIG hierarchy. Instead of appealing internally, Hightshue filed this action in federal court. After discovery, the parties filed cross motions for summary judgment. The district court granted summary judgment to AIG, and Hightshue appeals.

II. Analysis

A. Standard of Review

We review the district court’s grant of summary judgment on ERISA claims de novo, Klosterman v. Western General Management, Inc., 32 F.Sd 1119, 1122 (7th Cir. 1994). If the employer’s ERISA plan gives discretion to its administrator to pay or deny claims, we review the administrator’s benefit entitlement decision under the arbitrary and capricious standard. Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 110-11, 109 S.Ct. 948, 954-55, 103 L.Ed.2d 80 (1989); Brehmer v. Inland Steel Industries Pension Plan, 114 F.3d 656, 660 (7th Cir.1997).

In this case, the Plan states that the “Claims Administrator shall be entitled to use its discretion in good faith in reviewing claims submitted under this Plan, and its decisions shall be upheld absent any arbitrary and capricious action on the part of the Claims Administrator.” While this language certainly suggests a deferential standard of review, Hightshue argues that the plan does not expressly give AIG the discretion to interpret plan terms, and thus our review must be de novo. However, as explained by the Supreme Court in Firestone, either a grant of discretion to pay claims or a grant of discretion to construe plan terms is sufficient to trigger a deferential standard of review. Firestone, 489 U.S. at 115, 109 S.Ct. at 956 (“The validity of a claim to benefits under an ERISA plan is likely to turn on the interpretation of terms in the plan at issue.”). Because the Plan gives AIG, as claims administrator, the discretion to pay or deny claims, we will review its decision under the- arbitrary and capricious standard, and will reverse only if it is clearly unreasonable. Brehmer,

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Bluebook (online)
135 F.3d 1144, 28 Employee Benefits Cas. (BNA) 1273, 1998 U.S. App. LEXIS 1478, 1998 WL 40280, Counsel Stack Legal Research, https://law.counselstack.com/opinion/diana-k-hightshue-v-aig-life-insurance-company-ca7-1998.