Jurasin v. GHS Property & Casualty Insurance

463 F. App'x 289
CourtCourt of Appeals for the Fifth Circuit
DecidedFebruary 28, 2012
Docket11-50500
StatusUnpublished
Cited by4 cases

This text of 463 F. App'x 289 (Jurasin v. GHS Property & Casualty Insurance) is published on Counsel Stack Legal Research, covering Court of Appeals for the Fifth Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Jurasin v. GHS Property & Casualty Insurance, 463 F. App'x 289 (5th Cir. 2012).

Opinion

PER CURIAM: *

John Jurasin seeks long-term disability benefits for a neck condition he claims resulted from an accident during work. His employer provides an Occupational Injury Benefit plan subject to the Employee Retirement Income Security Act (ERISA). The plan is administered by Caprock Claims Management and funded with an insurance policy issued by GHS Property & Casualty. Caprock informed Jurasin his neck condition was not compensable. A review board also denied his claim. Ju-rasin brought suit, but the district court granted summary judgment to the defendants. We AFFIRM.

BACKGROUND

On January 21, 2008, while removing a tarp from his tractor-trailer, John Jurasin slipped on some mud. Although he avoided a fall by grasping a rail, he claimed to have heard a “pop.” Shortly thereafter, he sought treatment for pain to his “right back and right abdominal wall.” After some improvement, Jurasin returned to work with light-duty restrictions. By February 1, he resumed unrestricted assignments after having completed physical therapy.

Jurasin complained of renewed lower thoracic back pain that March and was referred to a pain management specialist. He received a cortisone shot due to a knot in his back. Complications ensued. Jura-sin developed an abscess which required surgery. After a hospital stay, he received home health care. In July, an orthopedic surgeon, Dr. Dar, suggested conditioning and rehabilitation, known as work hardening, and he sent Jurasin to another pain manager. Dr. Dar reviewed MRI films and made what he termed an “incidental finding” that Jurasin’s C6-7 cervical disc in the neck was herniated; Dar further noted that Jurasin was not experiencing neck discomfort.

An independent medical examination on August 21 found that Jurasin’s C6-7 herniation was not compressing his spinal cord and that his cervical spine’s range of motion was unrestricted. Several other doctors specializing in orthopedics and neurology expressed the opinion that his neck condition was chronic and preexisting, not traceable to Jurasin’s injury at work. On November 18, 2008, Caprock informed Ju-rasin that it had determined, after consideration by a Medical Review Officer, that his cervical condition was not compensable. Coverage was limited to the injury to his thoracic and lumbar spine. For the com-pensable injuries, the plan ultimately paid *291 over $32,000 in medical expenses and $17,000 in disability benefits.

On February 4, 2009, Jurasin was examined by Dr. Garza-Vale. This doctor found the neck injury was preexisting but that Jurasin’s accident had aggravated the injury. His findings were submitted to Caprock. After reviewing the medical evidence, including the submission from Dr. Garza-Vale, Caprock again informed Jura-sin, on March 20, 2009, that the only com-pensable injury was to his back. Ten days later, Dr. Garza-Vale again examined Ju-rasin; a letter reiterating his view more emphatically was furnished to the GHS appeals board. The appeals board denied Jurasin’s claim on April 17, 2009.

Pursuant to ERISA’s civil enforcement provision, Jurasin filed suit challenging the denial of benefits for his cervical condition. See 29 U.S.C. § 1132(a)(1)(B). The court granted summary judgment for the plan defendants, Caprock and GHS. Jurasin timely appealed. In addition to contesting the coverage decision, Jurasin claims that the district court erred in striking parts of his own affidavit, as well as one from Dr. Garza-Vale.

DISCUSSION

We review the grant of summary judgment de novo and apply the same standard as the district court. Schexnayder v. Hartford Life and Accident Ins. Co., 600 F.3d 465, 468 (5th Cir.2010). When, as here, the administrator of an ERISA plan has discretion to determine eligibility and interpret plan terms, the plan’s denial is reviewed for an abuse of discretion. Id. “A plan administrator abuses its discretion where the decision is not based on evidence, even if disputable, that clearly supports the basis for its denial.” Id. (quotation marks and citation omitted). We are not “to engage in full review of the motivations behind every plan administrator’s discretionary decisions.” Crosby v. La. Health Serv. and Indem. Co., 647 F.3d 258, 264 (5th Cir.2011) (quotation marks and citation omitted). Our review is to “assure that the administrator’s decision fall[s] somewhere on a continuum of reasonableness — even if on the low end.” Corry v. Liberty Life Assurance Co. of Boston, 499 F.3d 389, 398 (5th Cir.2007) (quotation marks and citation omitted).

We employ a two-step inquiry as to ERISA plan decisions. We first decide if the determination by the plan administrator was legally correct, and if it is, there is no abuse of discretion. Holland v. Int’l Paper Co. Ret. Plan, 576 F.3d 240, 246 n. 2 (5th Cir.2009). If the determination is not legally correct, we then determine whether the administrator’s decision was an abuse of discretion. Id. Because Jurasin does not assert any improper plan interpretation, we exercise our discretion to bypass the first step here. Id.

I. Conflict of Interest

Jurasin alleges two sources of conflict that “should have tilted the [district] court’s review toward a less-than-deferential standard.” Though Jurasin refers to some of our earlier caselaw about a sliding scale of review, this Court no longer employs that method. Holland, 576 F.3d at 247-248 & n. 3 (discussing Metro. Life Ins. Co. v. Glenn, 554 U.S. 105, 128 S.Ct. 2343, 171 L.Ed.2d 299 (2008)). It is fair to say that “conflicts are but one factor among many,” and the “specific facts of the conflict will dictate its importance.” Id. at 247-48.

Both his arguments relate to a conflict of interest rooted in Caprock’s dual role as the evaluator and the payor. See, e.g., Holland, 576 F.3d at 248 n. 3. We are required to take into account this dual role in reviewing a benefit determination. Metro. Life, 554 U.S. at 115, 128 S.Ct. 2343. Jurasin claims bias stemming from the fact that the Medical Review Officer on *292 whom Caprock relied for its November 2008 denial, Dr. Cunningham, was employed by Blue Cross and Blue Shield of Oklahoma, a division of the funding insurance company GHS. Jurasin’s suggestion that Cunningham provided a dishonest medical assessment merely due to an attenuated employment relationship with GHS is too theoretical and speculative for us to entertain. See Davis v. Unum Life Ins. Co. of Am.,

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