NOT RECOMMENDED FOR PUBLICATION File Name: 23a0338n.06
Case No. 22-1960
UNITED STATES COURT OF APPEALS FOR THE SIXTH CIRCUIT
FILED Jul 24, 2023 JACQUELINE AVERY, ) DEBORAH S. HUNT, Clerk ) Plaintiff - Appellant, ) ) ON APPEAL FROM THE v. ) UNITED STATES DISTRICT ) COURT FOR THE EASTERN SEDGWICK CLAIMS MANAGEMENT ) DISTRICT OF MICHIGAN SERVICES, INC. and FCA US LLC LONG- ) TERM DISABILITY BENEFIT PLAN, ) ) OPINION Defendants - Appellees. )
Before: McKEAGUE, GRIFFIN, and MURPHY, Circuit Judges.
McKEAGUE, Circuit Judge. For roughly two years, Jacqueline Avery received long-
term disability benefits from her former employer, Chrysler Group LLC (Chrysler), through its
FCA US LLC Long Term Disability Benefit Plan (the Plan). The Plan’s third-party claims
administrator, Sedgwick Claims Management Services, Inc. (Sedgwick), later terminated those
benefits after concluding that Avery no longer qualified as “totally disabled” within the meaning
of the Plan. Avery brought this action under 29 U.S.C. § 1332(a)(1)(B) of the Employee
Retirement Income Security Act of 1974 (ERISA) to recover and reinstate her long-term disability
benefits. The district court granted judgment on the administrative record in favor of Sedgwick
and the Plan, and Avery now appeals. For the following reasons, we affirm. Case No. 22-1960, Avery v. Sedgwick Claims Mgmt. Servs., et al.
I
A. Factual Background
In 2006, Jacqueline Avery was on a camping trip when she fell and fractured her right
ankle. She largely recovered, but severe pain in her right leg spontaneously returned in 2011. At
the time, Avery worked for Chrysler as a finance specialist, and the persistent pain began to impede
her ability to work. In July 2011, Avery was diagnosed with “advance peripheral deyelinatibe and
axonal polyneuropathy [of the] lower legs,” and her last date worked was July 15, 2011. A.R. 195.
Avery initially applied for and received short-term disability benefits under Chrysler’s
Disability Absence Plan. But when her eligibility for short-term benefits expired, Avery converted
her claim into one for long-term benefits. To be eligible for long-term disability benefits, the Plan
states in ungrammatical fashion that a participant must “be ‘totally disabled’ because of disease or
injury so as during the first 24 months of disability to be unable to perform the duties of the
Participant’s occupation, and after the first 24 months of disability be unable to engage in regular
employment or occupation with the Corporation.” A.R. 1206.
Due to the nature of Avery’s condition, Sedgwick referred Avery’s claim to two board-
certified neurologists, Dr. Hermann Banks, M.D., and Dr. David Gaston, M.D., for independent
medical examinations. Dr. Banks opined that Avery suffered from “[r]ight lower extremity pain
with paresthesia and dysesthesia” and recommended that Avery not return to work. A.R. 793. Dr.
Gaston similarly identified “exquisite pain on motion of the right distal leg and foot,” and
diagnosed Avery with Complex Regional Pain Syndrome Type II. Relying on the results of these
medical examinations, among other medical records, Sedgwick approved Avery for long-term
disability benefits effective August 10, 2012, on the basis of “totally disabling condition(s) of
Right Lower Extremity Neuropathy & reflex sympathetic dystrophy lower extremity.” A.R. 1055.
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Pursuant to the terms of the Plan, Sedgwick also required Avery to apply for Social Security
Disability Insurance (SSDI) benefits. The Social Security Administration (SSA) awarded Avery
monthly SSDI benefits in the amount of $2,024, retroactive to January 2012. Sedgwick then
requested and received reimbursement for overpayment in the amount of $15,069.42.
Throughout 2013 and early 2014, Avery continuously furnished medical records from her
treating physicians to substantiate her disability, and Sedgwick repeatedly approved Avery’s long-
term disability benefits under the Plan. But in June 2014, Chrysler’s Special Investigations Unit
surveilled Avery and purportedly observed her driving—something she is medically restricted
from doing. Chrysler also suspected that Avery was running a business out of her home. This
prompted Chrysler to request an additional independent medical examination. Sedgwick scheduled
the requested medical exam with Dr. Joel Shavell, D.O., who is board certified in internal medicine
and rheumatology; he examined her on July 15, 2014. Dr. Shavell observed that Avery “walked in
quickly with a normal gait and had no problems getting undressed, and no problems getting in and
out of the room; no problems moving, and no problems functionally.” A.R. 977. Based on these
observations, Dr. Shavell concluded:
At this time, I do not see any evidence of a regional complex pain issue, and normally with these pain syndromes, they are so severe and difficult that patients hardly recover fully. They have some residual, such as walking with a limp, or inability to move a leg, as well as sensitivity to touch. These would be some of the findings that would be common and Ms. Avery exhibits none of them. . . .
Based on the fact that I do not find a regional complex pain issue, and because she does not have a venous issue, and based on the fact that when I examined her ankle she [can] bear weight on the ankle, on her heels and toes despite her weight, I do not find any physical evidence to substantiate at this point any disability whatsoever. It is my opinion that she can return to full duty work, as of today’s date.
A.R. 978–79.
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After receiving the results of the independent medical examination, Sedgwick notified
Avery via letter dated July 21, 2014, that she had been found able to work, and requested that she
report to her plant medical department for further evaluation. Sedgwick indicated that Avery’s
benefits “may be suspended effective July 21, 2014, pending the outcome of the ability to work
examination.” A.R. 974. On July 22, 2014, Avery reported to Chrysler’s medical department where
the plant medical doctor determined that Avery was able to return to work.
During the evaluation, a plant medical nurse provided Avery with a copy of Dr. Shavell’s
narrative report. Believing the report to be filled with “bold face lies,” Avery called Sedgwick to
complain. A.R. 944. A Sedgwick representative instructed Avery to formalize her complaints in
writing, which she did a few days later. On July 28, 2014, Avery sent a letter to Sedgwick “to
appeal [her] recent return to work decision” and “to challenge several statements” made by Dr.
Shavell. A.R. 964–66. On August 4, 2014, Sedgwick acknowledged receipt of Avery’s “request
for appeal” and indicated that her claim would be reviewed by Sedgwick’s Appeals Unit. A.R.
957. On August 8, 2014, Sedgwick called Avery to ask whether she intended to provide any
additional information or documentation. Avery responded that she did not. A.R. 949.
Internal documents indicate that Sedgwick’s July 21, 2014, letter was neither a formal nor
final denial letter, as it did not “outlin[e] the reason for denial or [detail] appeal rights. The letter
only request[ed] that the claimant RTW [return to work].” A.R. 458. Rather, Sedgwick did not
issue its formal benefits determination until roughly one month later, via letter dated August 20,
2014, wherein Sedgwick set forth the Plan’s eligibility criteria, articulated the reasons for its
benefits denial, and outlined the appeals procedures. Nonetheless, Sedgwick continued to treat
Avery’s July 28, 2014, letter as an appeal and reviewed Avery’s claim in the ordinary course.
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As part of this review process, Sedgwick referred Avery’s claim for an independent record
review (IRR) with Dr. David Hoenig, M.D., a specialist in neurology and pain medicine. Dr.
Hoenig reviewed Avery’s medical records and concluded that “[b]ased on the documentation
provided, and from a neurological perspective only, [Avery] is not disabled from performing any
work as of 07/22/14.” A.R. 663.
By letter dated September 12, 2014, Sedgwick formally denied Avery’s appeal. The letter
indicated that the decision was “the Claim Administrator’s final decision,” and that Avery had “the
right to bring a civil action under ERISA” and was “entitled to receive[], upon request and free of
charge, reasonable access to, and copies of, all documents, records, and other information relevant
to [her] claim for benefits.” A.R. 659.
Avery did not respond until more than eight months later, when her attorney sent a letter
to Sedgwick on May 18, 2015, demanding that “Ms. Avery’s benefits be immediately reinstated
with retroactive pay forthwith.” A.R. 654. Attached to this demand was a letter from Dr. Brengel,
Avery’s primary care doctor who specializes in family medicine, wherein Dr. Brengel disputed
Dr. Shavell’s findings and attempted to bolster Avery’s claimed disability. Specifically, Dr.
Brengel referenced “an EMG performed by K. Fram, M.D., in December of 2014,” and indicated
that “Dr. Fram believes that Ms. Avery has reflex sympathetic dystrophy in her right lower
extremity by history, chronic S1 radiculopathy bilaterally, severe peripheral polyneuropathy, and
bilateral tarsal tunnel syndrome.” A.R. 655. On this basis, Dr. Brengel concluded that Plaintiff
“remain[ed] disabled due to the difficulties with her right leg.” Id.
Despite having no obligation to do so, Sedgwick responded to the letter by initiating a “re-
review” of Avery’s claim. A.R. 651. As part of this voluntary re-review, Sedgwick offered Avery
an opportunity to submit additional medical information and documentation before July 28, 2015,
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but Avery never submitted additional records.1 Sedgwick also referred Avery’s claim to Dr. Mark
N. Friedman, D.O, a board-certified neurologist and specialist in internal medicine, for another
IRR. Dr. Friedman reviewed Avery’s medical records and concluded that Avery “is not disabled
from performing any work as of 07/22/14.” A.R. 601. Relying on Dr. Friedman’s report, Sedgwick
upheld its decision to terminate Avery’s long-term disability benefits. By letter dated September
30, 2015, Sedgwick informed Avery that she no longer satisfied the Plan’s eligibility requirements.
The letter also outlined her appeal rights. Avery did not appeal that decision.
B. Procedural Posture
Avery filed suit in the Eastern District of Michigan pursuant to Section 502(a)(1)(B) of
ERISA, 29 U.S.C. § 1132(a)(1)(B), to recover long-term disability benefits allegedly owed to her
under the terms of the Plan. The complaint appears premised on Sedgwick’s September 12, 2014,
denial, which Avery refers to as “the final decision on Ms. Avery’s claim.” R. 1, PID 11. It does
not reference Sedgwick’s voluntary re-review or the decision issued on September 30, 2015.
She also filed a “Statement of Procedural Challenge,” alleging various procedural errors
committed by Sedgwick and requesting that the court schedule a status conference to address
discovery. Defendants filed a “Motion to Strike Statement of Procedural Challenge,” which the
district court construed as a motion to review and reject Avery’s Statement. The district court
rejected Avery’s Statement, finding that no valid procedural challenge was presented justifying
further discovery.
Thereafter, the parties filed competing motions for judgment on the administrative record.
The district court denied Avery’s motion and granted judgment on the administrative record in
favor of Sedgwick and the Plan. This appeal followed.
1 Avery claims she never received this letter. See Appellant’s Br. at 21.
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II
“We review de novo the decision of a district court granting judgment in an ERISA
disability action based on an administrative record.” DeLisle v. Sun Life Assurance Co. of Can.,
558 F.3d 440, 444 (6th Cir. 2009) (internal quotation marks omitted). And when the insurance plan
administrator is vested with discretion to interpret the plan, we review the administrator’s decision
to deny benefits under the arbitrary and capricious standard. Helfman v. GE Grp. Life Assurance
Co., 573 F.3d 383, 392 (6th Cir. 2009). Here, neither party disputes that the Plan gives Sedgwick
this discretion. We therefore review Sedgwick’s decision to terminate Avery’s long-term disability
benefits under the arbitrary and capricious standard. See Firestone Tire & Rubber Co. v. Bruch,
489 U.S. 101, 115 (1989).2 Finally, we review de novo “the question of whether the procedure
employed by the fiduciary in denying the claim meets the requirements of Section 1133.” Kent v.
United of Omaha Life Ins. Co., 96 F.3d 803, 806 (6th Cir. 1996).
A. Sedgwick Satisfied ERISA Procedural Requirements
On appeal, Avery raises a series of procedural objections, broadly arguing that Sedgwick
violated ERISA claims procedures, and that in so doing, Sedgwick denied her claim a full and fair
review. Specifically, Avery alleges the following: (1) Sedgwick’s initial denial letter failed to
comply with ERISA requirements, (2) Sedgwick did not afford Avery a reasonable opportunity to
appeal, (3) Sedgwick did not provide Avery with an opportunity to supplement the administrative
record, (4) Dr. Shavell lacked the required training and experience, and (5) Sedgwick omitted
2 Relying on the Second Circuit’s opinion in Halo v. Yale Health Plan, 819 F.3d 42 (2d Cir. 2016), Avery argues that the de novo standard of review should apply to our review of the administrator’s decision to terminate benefits because Sedgwick allegedly failed to comply with the claims procedure regulation. Appellant’s Br. at 25. In Halo, the Second Circuit held that “a plan’s failure to comply with the Department of Labor’s claims-procedure regulation, 29 C.F.R. § 2560.503-1, will result in that claim being reviewed de novo in federal court, unless the plan has otherwise established procedures in full conformity with the regulation and can show that its failure to comply with the regulation in the processing of a particular claim was inadvertent and harmless.” 819 F.3d at 45. However, this circuit has yet to adopt such a rule, and we decline to do so here.
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relevant documents from the administrative record. Addressing each procedural objection in turn,
we conclude that Sedgwick substantially complied with ERISA claims procedures.
ERISA Procedural Requirements
We begin with a brief overview of the ERISA regulations that govern employee benefit
claims procedures. ERISA ensures that fiduciaries administer employee benefit plans “solely in
the interest of the participants and beneficiaries.” 29 U.S.C. §§ 1104(a)(1), 1001(b). Under ERISA,
the Secretary of Labor has the authority to enact regulations that govern the administration of
employee benefit claims. Id. §§ 1133, 1135. Section 1133 provides that every employee benefit
plan must:
(1) provide adequate notice in writing to any participant or beneficiary whose claim for benefits under the plan has been denied, setting forth the specific reasons for such denial, written in a manner calculated to be understood by the participant, and
(2) afford a reasonable opportunity to any participant whose claim for benefits has been denied for a full and fair review by the appropriate named fiduciary of the decision denying the claim.
Id. § 1133. We have held that the “essential purpose” of these requirements is twofold: “(1) to
notify the claimant of the specific reasons for a claim denial, and (2) to provide the claimant with
an opportunity to have that decision reviewed by the fiduciary.” Wenner v. Sun Life Assurance Co.
of Can., 482 F.3d 878, 882 (6th Cir. 2007) (emphasis and citation omitted).
In deciding whether a plan has satisfied the requirements of § 1133, we employ a
“substantial compliance” test. Id. Under this test, all communications between the claimant and
the administrator are considered. “If the communications between the administrator and participant
as a whole fulfill the twin purposes of § 1133, the administrator’s decision will be upheld even
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where the particular communication does not meet those requirements.” Id. (internal quotation
marks omitted).
Additional procedural safeguards are codified in 29 C.F.R. § 2560.503–1, titled “Claims
procedure.” Specifically, “in the context of an administrative appeal of an adverse benefits
determination, 29 C.F.R. § 2560.503–1(h)(2) outlines the essential procedural requirements for a
full and fair review.” Balmert v. Reliance Standard Life Ins. Co., 601 F.3d 497, 502 (6th Cir. 2010).
That provision provides, in part:
[T]he claims procedures of a plan will not be deemed to provide a claimant with a reasonable opportunity for a full and fair review of a claim and adverse benefit determination unless the claims procedures— . . .
(ii) Provide claimants the opportunity to submit written comments, documents, records, and other information relating to the claim for benefits;
(iii) Provide that a claimant shall be provided, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the claimant’s claim for benefits. . . .
(iv) Provide for a review that takes into account all comments, documents, records, and other information submitted by the claimant relating to the claim, without regard to whether such information was submitted or considered in the initial benefit determination.
29 C.F.R. § 2560.503–1(h)(2). Furthermore, “group health plans,” such as the Plan that is at issue
in this case, are required to comply with the following:
(i) Provide claimants at least 180 days following receipt of a notification of an adverse benefit determination within which to appeal the determination;
(ii) Provide for a review that does not afford deference to the initial adverse benefit determination and that is conducted by an appropriate named fiduciary of the plan who is neither the individual who made the adverse benefit determination that is the subject of the appeal, nor the subordinate of such individual; [and]
(iii) Provide that, in deciding an appeal of any adverse benefit determination that is based in whole or in part on a medical judgment, . . . the appropriate -9- Case No. 22-1960, Avery v. Sedgwick Claims Mgmt. Servs., et al.
named fiduciary shall consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment. . . .
Id. § 2560.503–1(h)(3)(i)–(iii).
Notice and an Opportunity to Appeal
Avery’s first procedural objection takes issue with Sedgwick’s July 21, 2014, letter. She
argues that the letter failed to “inform her that she could submit comments or other information,
that she could obtain documents relevant to her claim in order to prepare an appeal, and did not
describe any appeal procedures.” Appellant’s Br. at 31–32. In response, Sedgwick argues that its
letter was neither a formal benefit determination nor final claim denial. Rather, the letter merely
intended to advise Avery of the results of her independent medical examination and to instruct her
to report to her plant medical department for an ability-to-work determination. Sedgwick contends
that later communications—such as the August 20, 2014, letter terminating Avery’s benefits, the
September 12, 2014, letter denying Avery’s appeal, and the September 30, 2015, letter upholding
the benefits denial upon re-review—constitute benefits determinations, and that each complied
with ERISA.
We need not resolve whether Sedgwick’s July 21, 2014, letter was in fact a formal benefit
determination, because Sedgwick’s collective communications with Avery substantially complied
with ERISA’s procedural requirements. See Kent, 96 F.3d at 807 (holding that, despite technical
deficiencies in the insurer’s denial letters, “when viewed in light of the myriad of communications
between claimant, her counsel and the insurer, [the letters] were sufficient to meet the purposes of
Section 1133 in insuring that the claimant understood the reasons for the denial of the claim as
well as her rights to review of the decision”). Although Sedgwick’s July 21, 2014, letter
undoubtedly fell short of meeting the requirements articulated in § 2560.503–1(h), its August 20,
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2014, denial letter corrected any deficiencies. Avery was made aware of the reasons for
Sedgwick’s benefits denial (i.e., the results of Dr. Shavell’s independent medical examination) and
of her appeal rights. Collectively, therefore, Sedgwick’s communications with Avery satisfied the
dual purposes behind (and plain text of) Section 1133. See Wenner, 482 F.3d at 882; Putney v.
Med. Mut. of Ohio, 111 F. App’x 803, 807 (6th Cir. 2004) (finding that an administrator’s failure
to satisfy ERISA notice requirements was “neither significant nor outcome determinative” where
the “procedural failures did not prevent [the claimant] from gaining information necessary to
contest his denial of benefits”).
Avery’s argument that Sedgwick deprived her of an opportunity to appeal its adverse
benefit decision fails for similar reasons. First, on July 28, 2014, Avery “appealed” the results of
Dr. Shavell’s independent medical examination, albeit before receiving Sedgwick’s August 20,
2014, letter. Sedgwick ultimately treated Avery’s July 28, 2014, letter as a proper and timely
appeal, and it reviewed Avery’s claim as it would any other appeal. Thereafter, Sedgwick
effectively afforded Avery a second appeal by voluntarily re-reviewing her claim in 2015. And
finally, Sedgwick provided Avery with an opportunity to appeal its September 30, 2015, decision,
which upheld the termination of her long-term disability benefits upon re-review, but Avery chose
not to appeal that decision.
Given this posture, Avery cannot argue that she was denied a reasonable opportunity to
appeal Sedgwick’s decision. Put plainly, Avery did appeal the termination of her long-term
disability benefits—twice. And when afforded an additional opportunity to appeal Sedgwick’s
final benefits determination in 2015, Avery declined to do so. In sum, we simply cannot see how
Sedgwick’s procedures fell short of providing Avery’s claim a meaningful review.
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Opportunity to Supplement and Access the Record
Next, Avery contends that “Sedgwick did not provide [her] with an opportunity to submit
comments or documents in response to the initial benefit decision before issuing the final
decision,” in violation of 29 C.F.R. § 2560.503–1(h)(2)(ii). Reply Br. at 10. Again, we disagree.
Before issuing its initial benefits denial, Sedgwick contacted Avery to ask whether she
intended to provide any additional information, to which she responded “no.” A.R. 949. Likewise,
during its voluntary re-review, Sedgwick afforded Avery the opportunity to supplement the record
with any additional medical information or documentation, but Avery declined to do so. Most
important, however, is that Avery did submit comments in response to Dr. Shavell’s independent
medical examination, and those comments were considered throughout the appeals process. For
instance, Dr. Hoenig’s IRR report references Avery’s “appeal letters” dated July 28, 2014. And
Dr. Friedman’s IRR report notes that, “[o]n 07/28/14, the claimant wrote an appeal letter refuting
many of the physical examination findings, observations, and conclusions by Dr. Shavell.” A.R.
607. Nevertheless, the applicable regulations do not require plan administrators (or their
consultants) to reference a claimant’s comments with particularity. They merely require that plans
“[p]rovide claimants the opportunity to submit written comments.” 29 C.F.R. § 2560.503–1(h)(ii)
(emphasis added). And in this case, for the reasons already stated, Sedgwick and the Plan provided
Avery this opportunity.
Relatedly, Avery argues that Sedgwick failed to provide her “with reasonable access to all
of the information relevant to her claim for benefits,” in violation of 29 C.F.R. § 2560.503–
1(h)(2)(iii). Reply Br. at 10. We find no evidence in the record to support this assertion. While
claimants are entitled to reasonable access to records relevant to their claim, this access is provided
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“upon request.” 29 C.F.R. § 2560.503–1(h)(2)(iii). And there is no indication that Avery ever
requested access to records or that she was denied access following such request.
Dr. Shavell’s Training and Experience
Next, Avery argues that Dr. Shavell “did not have appropriate training and experience in
the field of neurology” necessary to evaluate her condition, in violation of 29 C.F.R. § 2560.503–
1(h)(3)(iii). Appellant’s Br. at 23. Again, Avery’s procedural challenge lacks merit. Although it is
true that Dr. Shavell is not a board-certified neurologist, his independent medical examination was
not the basis for Sedgwick’s final determination. Rather, Sedgwick relied on IRRs conducted by
two board-certified neurologists, Dr. Hoenig and Dr. Friedman, to terminate Avery’s long-term
disability benefits.
Furthermore, the requirement that a group health plan “consult with a health care
professional who has appropriate training and experience in the field of medicine involved in the
medical judgment,” applies only “in deciding an appeal of any adverse benefit determination.” 29
C.F.R. § 2560.503–1(h)(3)(iii). Because Dr. Shavell was not consulted in deciding an appeal, his
training and experience is procedurally irrelevant.
Documents Omitted from the Administrative Record
Finally, Avery argues that Sedgwick deliberately omitted relevant documents from the
administrative record. Specifically, she alleges that Sedgwick failed to include evidence of “actual
surveillance” and omitted documents related to her Social Security disability award. Appellant’s
Br. at 33–34. Again, Avery’s allegation lacks support.
Sedgwick included within the administrative record an email description of surveillance
that took place in April 2014. At the time, Chrysler’s Corporate Investigations department
observed Avery driving on several occasions and suspected that she may be running a business out
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of her home. An investigator communicated these observations and suspicions to Chrysler’s
Special Investigations Unit via email. But beyond this email description, which is already included
in the administrative record, there is no indication that any other documentation pertaining to
Chrysler’s surveillance—written, visual, or otherwise—even exists. Avery’s suggestion that
“actual surveillance” has been omitted from the administrative record is pure speculation.
And the same is true for Social Security Disability records. The administrative record
includes evidence of the following: the Plan’s requirement that Avery apply for Social Security
disability benefits, evidence of Avery’s application for Social Security disability benefits, the
Social Security Administration’s monthly SSDI benefit award of over $2,000, and Sedgwick’s
reimbursement in the amount of over $15,000 for overpayment. Avery speculates that, because
Sedgwick facilitated her Social Security application process, Sedgwick must possess additional
documents related to her Social Security disability award. But again, this is mere speculation.
Avery cannot identify any documents within Sedgwick’s possession that have been omitted from
the administrative record. If Avery wished to include additional Social Security documentation in
the administrative record, she should have requested said documents from the SSA directly and
supplemented the record when given the opportunity to do so.
B. Sedgwick’s Decision Was Not Arbitrary or Capricious
Having addressed Avery’s procedural objections—i.e., objections to how the benefits
decision was made—we turn to Avery’s contention that Sedgwick simply made the wrong
decision. As stated above, because the Plan grants Sedgwick the discretionary authority to
determine eligibility for benefits and to construe the Plan’s terms, we review Sedgwick’s decision
to terminate Avery’s long-term disability benefits under the arbitrary and capricious standard.
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McClain v. Eaton Corp. Disability Plan, 740 F.3d 1059, 1064 (6th Cir. 2014); see also Firestone,
489 U.S. at 115.
Arbitrary and capricious review “is the least demanding form of judicial review of
administrative action.” Williams v. Int’l Paper Co., 227 F.3d 706, 712 (6th Cir. 2000). Under this
extremely deferential standard, we need only decide “whether the plan administrator’s decision
was rational in light of the plan’s provisions.” Id. (internal quotation marks omitted). We will
uphold Sedgwick’s decision if “it is the result of a deliberate, principled reasoning process and if
it is supported by substantial evidence.” Baker v. United Mine Workers of Am. Health & Ret.
Funds, 929 F.2d 1140, 1144 (6th Cir. 1991). “[T]he ultimate issue in an ERISA denial of benefits
case is not whether discrete acts by the plan administrator are arbitrary and capricious but whether
its ultimate decision denying benefits was arbitrary and capricious.” Spangler v. Lockheed Martin
Energy Sys., Inc., 313 F.3d 356, 362 (6th Cir. 2002). The burden is on the claimant to show that
the administrator acted arbitrarily. Farhner v. United Transp. Union Discipline Income Prot.
Program, 645 F.3d 338, 343 (6th Cir. 2011).
With that being said, the arbitrary and capricious standard is not “without some teeth.”
McDonald v. W.-S. Life Ins. Co., 347 F.3d 161, 172 (6th Cir. 2003) (citation omitted). “[M]erely
because our review must be deferential does not mean our review must also be inconsequential.
While a benefits plan may vest discretion in the plan administrator, the federal courts do not sit in
review of the administrator’s decisions only for the purpose of rubber stamping those decisions.”
Moon v. Unum Provident Corp., 405 F.3d 373, 379 (6th Cir. 2005). Instead, “[s]everal lodestars
guide our decision: the quality and quantity of the medical evidence; the existence of any conflicts
of interest; whether the administrator considered any disability finding by the Social Security
Administration; and whether the administrator contracted with physicians to conduct a file review
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as opposed to a physical examination of the claimant.” Shaw v. AT&T Umbrella Ben. Plan No. 1,
795 F.3d 538, 547 (6th Cir. 2015) (internal quotation marks omitted). In conducting our review,
we may generally “consider only the evidence available to the administrator at the time the final
decision was made.” Id.
Avery alleges that Sedgwick’s benefits denial was arbitrary and capricious because
Sedgwick (1) ignored favorable evidence, (2) improperly relied on file reviews conducted by
physicians who were not provided adequate documentation, and (3) ignored the Social Security
Administration’s disability finding. We will address each substantive challenge in turn.
Sedgwick’s Review of the Evidence
First, Avery argues that Sedgwick “ignored and selectively reviewed” the evidence.
Appellant’s Br. at 41. Avery is correct that “administrators may not selectively review the
administrative record by picking out the opinions of the doctors that support their decisions while
ignoring the opinions of a participant’s treating doctors that do not.” Autran v. Proctor & Gamble
Health & Long-Term Disability Benefit Plan, 27 F.4th 405, 415 (6th Cir. 2022). Instead,
administrators must “consider all opinions on both sides of a disputed disability question.” Id.
But here, we find that the physicians whom Sedgwick consulted to evaluate Avery’s claim
engaged in a fulsome review of the record—including the medical evidence provided by Avery’s
treating physicians. Dr. Hoenig, for example, reviewed records from Avery’s primary care
physician, Dr. Brengel. Dr. Hoenig also reviewed the independent medical examination reports
from Dr. Banks and Dr. Gaston, both of whom had previously found Avery totally disabled. Dr.
Hoenig even attempted (to no avail) to contact Dr. Nounou, one of Avery’s treating physicians, to
discuss Avery’s history. Although a plan administrator need not “accord special deference to the
opinions of treating physicians,” Black & Decker Disability Plan v. Nord, 538 U.S. 822, 831
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(2003), the record reveals that Sedgwick took Avery’s doctors’ opinions seriously. Indeed, Dr.
Hoenig referred to their findings as “clinical[ly] significant.” A.R. 663. Relying on Dr. Hoenig’s
file review, among other medical records, Sedgwick concluded that the documentation provided
did not support Avery’s claimed disability.
A year later, upon re-review of Avery’s claim, Sedgwick consulted Dr. Friedman, who also
engaged in a comprehensive review of the record. Like Dr. Hoenig, Dr. Friedman reviewed
extensive medical records, including those provided by Avery’s treating physicians, as well as the
results of Dr. Banks’ and Dr. Gaston’s independent medical examinations. Dr. Friedman contacted
and spoke with a nurse in Dr. Nounou’s office. And Dr. Friedman even credited Avery’s subjective
reports of pain: “the claimant reports that she has ongoing symptoms related to complex regional
pain syndrome including walking with a limp and sensitivity to touch to the legs. She reported that
she was bedridden several days per week and had difficulties doing daily activities such as cooking,
cleaning, and shopping.” A.R. 600. Nonetheless, in reviewing Avery’s medical records, Dr.
Friedman concluded that, “[b]ased on the clinical evidence provided for review, the employee does
not require any restrictions on their work duties at any point during the dates of claimed disability
in order to return to work.” A.R. 601. Relying on Dr. Friedman’s report, Sedgwick upheld its
termination of Avery’s long-term disability benefits, citing “no sufficient clinical evidence to
support any restrictions and limitations.” A.R. 593.
In rejecting the opinion of a treating physician, a plan administrator need only offer
“reasons for adopting an alternative opinion” to survive arbitrary and capricious review. Shaw,
795 F.3d at 549. And “a lack of objective medical evidence upon which to base a treating
physician’s opinion has been held sufficient reason for an administrator’s choice not to credit [an]
opinion.” Gilewski v. Provident Life and Accident Ins. Co., 683 F. App’x 399, 406 (6th Cir. 2017).
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Here, Sedgwick rejected the opinions of Avery’s treating physicians based on the opinions of Dr.
Hoenig and Dr. Friedman, who concluded that the objective medical evidence in Avery’s file did
not support her claimed disability. And we can discern no selective review by the physicians who
reviewed Avery’s files. Indeed, their differences from earlier opinions can be explained by the
“extensive treatment” that Avery underwent in the interim—treatment that drastically reduced her
pain levels. A.R. 608. Accordingly, we find that Sedgwick engaged in a deliberate, principled
reasoning process when it decided to terminate Avery’s long-term disability benefits.
Sedgwick’s Reliance on Independent Record Reviews
Next, Avery argues that “Sedgwick’s reliance on record review consultants who were not
provided appropriate records . . . was also arbitrary and capricious.” Appellant’s Br. at 36. As an
initial matter, we note that Sedgwick’s decision to conduct IRRs—or “file reviews”—rather than
physical examinations is a factor that we must consider in determining whether Sedgwick acted
arbitrarily or capriciously, but that there is “nothing inherently objectionable about a file review
by a qualified physician in the context of a benefits determination.” Calvert v. Firstar Fin., Inc.,
409 F.3d 286, 296 (6th Cir. 2005). Instead, an administrator’s decision to conduct an IRR in lieu
of a physical examination is “just one more factor to consider in our overall assessment of whether
[the administrator] acted in an arbitrary and capricious fashion.” Id. at 295.
At different points in the review process, Sedgwick referred Avery’s claim to two
independent physician consultants, Dr. Hoenig and Dr. Friedman, for file reviews. Both doctors
reviewed Avery’s medical records, but neither physically examined her, before providing thorough
reports. In their IRRs, Dr. Hoenig and Dr. Friedman identified the medical records that they
reviewed and provided detailed accounts of Avery’s medical history. Both doctors also
acknowledged Avery’s prior limitations and credited her treating physicians’ observations.
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However, despite this favorable evidence, both Dr. Hoenig and Dr. Friedman identified contrary
evidence that cut against Avery’s claimed disability. For example, Dr. Hoenig noted that “[t]he
last neurological exam in the medical record is from February 6, 2013,” and that “after her spinal
cord stimulator (SCS), she has a normal neurological exam.” A.R. 663. And Dr. Friedman
observed that Dr. Nounou, one of Avery’s treating physicians, had not recommended any specific
restrictions after a July 2014 endovenous ablation procedure. Given this evidence, Dr. Hoenig and
Dr. Friedman concluded that Avery was not disabled from performing any work, and those
conclusions were reasonable.
Calvert is distinguishable. There we found that an insurance company acted arbitrarily and
capriciously when it based its benefits determination on a “clearly inadequate” file review, because
it, among other things, failed to identify the records reviewed, ignored favorable evidence, and
reached conclusions that squarely contradicted objective evidence. 409 F.3d at 296. But here, both
Dr. Hoenig and Dr. Friedman recited Avery’s medical history in detail, specifically noted
favorable evidence, and even credited Avery’s treating physicians. Furthermore, neither doctor
made any credibility findings. See Judge v. Metro. Life Ins. Co., 710 F.3d 651, 663 (6th Cir. 2013)
(“This court has found fault with file-only reviews in situations where the file reviewer concludes
that the claimant is not credible without having actually examined him or her”). The file reviews
at issue here were thus adequate.
As for Avery’s assertion that Dr. Hoenig and Dr. Friedman were not provided appropriate
records to review, Avery has not identified any post-termination medical records that exist, let
alone records that support her claimed disability. The closest thing to medical evidence made
available post-termination is Dr. Brengel’s April 2015 letter, which Dr. Friedman reviewed.
However, because Dr. Brengel’s letter “did not include any new examination findings or results of
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[EMG] testing,” Dr. Friedman concluded that his position remained unchanged. A.R. 592–93. In
sum, Sedgwick’s reliance on independent record reviews did not render its final benefits
determination arbitrary and capricious.
The Social Security Administration’s Disability Finding
Finally, Avery argues that Sedgwick’s decision was arbitrary and capricious because it did
not address the fact that Avery successfully applied for Social Security disability benefits. “[I]f the
plan administrator (1) encourages the applicant to apply for Social Security disability payments;
(2) financially benefits from the applicant’s receipt of Social Security; and then (3) fails to explain
why it is taking a position different from the SSA on the question of disability, the reviewing court
should weigh this in favor of a finding that the decision was arbitrary or capricious.” Bennett v.
Kemper Nat. Servs., 514 F.3d 547, 554 (6th Cir. 2008).
It is undisputed that Sedgwick required Avery to apply for Social Security benefits, and
that Sedgwick benefited financially from reimbursement payments. It is also undisputed that
Sedgwick neglected to reference Avery’s Social Security award in either its initial denial of
Avery’s appeal or in its final determination upon re-review. Nevertheless, Bennett merely instructs
“that a failure to take into account a Social Security disability award is to be weighed in favor of a
finding that the decision was arbitrary and capricious, not that such a decision is arbitrary and
capricious per se.” Morris v. Am. Elec. Power Long-Term Disability Plan, 399 F. App’x 978, 986
(6th Cir. 2010). And it is not necessary for a plan administrator to “expressly distinguish a
favorable SSA determination in denying disability benefits under the plan.” Leffew v. Ford Motor
Co., 258 F. App’x 772, 779 (6th Cir. 2007).
Although Sedgwick’s decision to terminate Avery’s benefits, despite the SSA’s earlier
disability finding, weighs “slightly in [Avery]’s favor when it comes to evaluating whether that
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decision was arbitrary and capricious,” Morris, 399 F. App’x at 986, it is not enough to convince
us that Sedgwick acted arbitrarily on the whole. For one, the SSA’s disability determination was
made two years prior to Sedgwick’s decision to terminate Avery’s benefits. See Cox v. Standard
Ins. Co., 585 F.3d 295, 303 (6th Cir. 2009). And at the time Sedgwick made its decision, it
possessed additional medical evidence that the SSA did not, including the results of Dr. Shavell’s
independent medical examination, the plant medical physician’s ability-to-work determination,
and IRRs from Dr. Hoenig and Dr. Friedman. See id.
Moreover, the fact that Avery qualified for Social Security disability benefits does not
necessarily mean that she should qualify for benefits under the Plan, because “a claim for benefits
under an ERISA plan often turns on the interpretation of plan terms that differ from SSA criteria.”
Whitaker v. Hartford Life and Acc. Ins. Co., 404 F.3d 947, 949 (6th Cir. 2005). For instance,
Sedgwick—unlike the SSA at the time of its decision—was not required to defer to the opinions
of Avery’s treating physicians. See O’Bryan v. Consol Energy Inc., 477 F. App’x 306, 308 (6th
Cir. 2012) (per curiam). We therefore conclude that Sedgwick’s failure to address the SSA’s
disability determination did not render Sedgwick’s decision arbitrary and capricious.
Sedgwick’s Decision Was Supported by Substantial Evidence
Sedgwick terminated Avery’s long-term disability benefits after deciding that she was no
longer “totally disabled” under the meaning of the Plan. The district court concluded that
substantial evidence supported Sedgwick’s decision. We agree.
In reviewing the quality and quantity of the evidence in the administrative record, we have
said that “substantial evidence” is “more than a mere scintilla.” McDonald, 347 F.3d at 171
(citation omitted). “It means such relevant evidence as a reasonable mind might accept as adequate
to support a conclusion.” Id. (citation omitted). “The fact that the evidence might also support a
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contrary conclusion is not sufficient to render the plan administrator’s determination arbitrary and
capricious.” Hurse v. Hartford Life & Accident Ins. Co., 77 F. App’x 310, 318 (6th Cir. 2003).
The administrative record in this case contained more than adequate evidence for Sedgwick
to conclude that Avery was no longer totally disabled under the terms of the Plan. First, Dr. Shavell
examined Avery in July 2014, and offered detailed observations that indicated “good range of
motion,” “no evidence of any loss of strength,” and a generally “normal exam.” A.R. 978. From
these findings, Dr. Shavell concluded, “I do not see any evidence of a regional complex pain issue.
. . . I do not find any physical evidence to substantiate at this point any disability whatsoever.”
A.R. 978–79. Next, Sedgwick required Avery to report to Chrysler’s plant medical department for
an ability-to-work determination. There, the plant medical physician observed, “[s]he is alert and
oriented. . . . Right and left lower legs – no stasis dermatitis. Normal dorsalis pedis pulse. No
pretibial edema. She walked without a limp.” A.R. 946. On that basis, the plant medical department
determined that Avery could return to work with no restrictions.
Sedgwick then referred Avery’s claim to Dr. Hoenig for a file review. Dr. Hoenig reviewed
Avery’s extensive medical records and concluded that after Avery’s “spinal cord stimulator (SCS),
she ha[d] a normal neurological exam” and was “not disabled from performing any work as of
07/22/14.” A.R. 663. Finally, Sedgwick initiated a voluntary re-review, referring Avery’s claim to
Dr. Friedman for another file review. Dr. Friedman reviewed Avery’s medical records and
concluded that there was “no sufficient clinical evidence to support any restrictions and
limitations.” A.R. 601.
To be sure, Avery’s treating physicians repeatedly diagnosed Avery with Complex
Regional Pain Syndrome and venous insufficiency. But even when “the evidence may be sufficient
to support a finding of disability, if there is a reasonable explanation for the administrator’s
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decision denying benefits in light of the plan’s provisions, then the decision is neither arbitrary nor
capricious.” Schwalm v. Guardian Life Ins. Co. of Am., 626 F.3d 299, 308 (6th Cir. 2010). And
here, no fewer than four physicians concluded that Avery is no longer totally disabled. If this did
not amount to “a reasonable explanation for the administrator’s decision,” it would be difficult to
say what would. In conclusion, we find that substantial evidence supported Sedgwick’s decision
to terminate Avery’s long-term disability benefits.
III
For the foregoing reasons, the district court’s judgment is affirmed.
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