NOT RECOMMENDED FOR FULL-TEXT PUBLICATION File Name: 19a0551n.06
Case No. 18-6095
UNITED STATES COURT OF APPEALS FOR THE SIXTH CIRCUIT
FILED Oct 31, 2019 SUSAN CARD, aka Karen Card, ) DEBORAH S. HUNT, Clerk ) Plaintiff-Appellant, ) ) ON APPEAL FROM THE UNITED v. ) STATES DISTRICT COURT FOR ) THE EASTERN DISTRICT OF PRINCIPAL LIFE INSURANCE ) KENTUCKY COMPANY, ) Defendant-Appellee. )
____________________________________/
Before: COLE, Chief Judge; MERRITT and LARSEN, Circuit Judges.
MERRITT, Circuit Judge. This dispute arises over disability insurance policies held by
plaintiff Susan Card that were underwritten and administrated by defendant Principal Life
Insurance Company. After Principal Life denied plaintiff’s claims for short-term, long-term, and
total disability, plaintiff filed a complaint under the Employee Retirement Income Security Act of
1974 (“ERISA”), 29 U.S.C. § 1132(a)(1)(B), alleging that Principal Life breached its disability
insurance contract with plaintiff by wrongfully denying her claim. The complaint further alleges
that plaintiff was denied a full and fair review, due in part to Principal Life’s inherent conflict of
interest as both the evaluator and payor of claims under the policy. After the parties filed cross
motions for summary judgment, the district court entered judgment for Principal Life. Because
we conclude that Principal Life’s decision was arbitrary and capricious, we vacate the judgment Case No. 18-6095, Card v. Principal Life Ins.
of the district court. The record does not support the conclusion that Principal Life’s denial of
plaintiff’s claim was the result of a deliberate, principled reasoning process regarding plaintiff’s
ability to perform her duties as a nurse given her condition. Because we cannot say on the record
that plaintiff is entitled to short-term and/or long-term disability benefits, we remand to Principal
Life for further review consistent with this opinion.
I.
Plaintiff Susan Card, born in 1956, was employed as a registered licensed practical nurse.
Before she stopped working in December 2013, she worked at a long-term care and skilled
rehabilitation center in Maine owned by Continuum Health Services. She worked the night shift,
providing patient care and supervising nursing assistants. Plaintiff’s long-time, primary-care
physician, Dr. Timothy Baum, referred her to Dr. Helen Ryan, a specialist in
hematology/oncology. After a series of tests, she was diagnosed in February 2013 with chronic
lymphocytic leukemia1 by Dr. Ryan. At the time of her diagnosis, plaintiff was essentially
asymptomatic according to Dr. Ryan’s notes, although she had experienced some fatigue plaintiff
thought might be due to changes in other medications or a thyroid issue. Plaintiff was scheduled
to return in six months for further tests. Over the next few months, plaintiff began to experience
1 Chronic lymphocytic leukemia (“CLL”) is a typically slow-growing blood cancer found in a type of white blood cell called a B-lymphocyte (lymphocytes are white blood cells in lymph tissue). Leukemia is a type of cancer that affects the blood and bone marrow. CLL is characterized by the accumulation of small, mature-appearing lymphocytes in the blood, marrow and lymphoid tissues. Normally, lymphocytes help the body fight infection; however, in CLL, the body produces abnormal lymphocytes that cannot do this effectively. It is typically a chronic, long-term, slowly developing leukemia. Most people do not have symptoms when they are diagnosed with CLL, and the disease is discovered after a routine blood test shows abnormalities. Symptoms of CLL include fatigue, enlarged lymph nodes, unintentional weight loss, chronic fever (without other signs of infection), easy bruising, or night sweats. The clinical progression of CLL is varied and ranges from patients who require treatment soon after diagnosis to others who do not require therapy for many years, if at all. Treatment, when called for, includes chemotherapy, chemoimmunotherapy and/or drugs targeting B cell receptor signaling. CLL impairs the immune system and the patient is not as able to resist infection like someone with a normal immune system. Infection (usually pneumonia) is the most likely cause of death of a CLL patient. A patient with CLL needs to be vigilant about avoiding germs and infections. Information gathered from Chronic Lymphocytic Leukemia Society website (found at www.cllsociety.org).
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worsening fatigue and she reduced her work hours to 32 hours per week. On August 30, 2013,
six months after her diagnosis, plaintiff went to see her primary care physician, Dr. Baum. She
did not return to the specialist, Dr. Ryan, because she could not afford it. Dr. Baum’s notes indicate
that plaintiff complained of night sweats, “dramatic fatigue and easy exhaustion,” chronic vaginal
bleeding, and “feel[ing] depressed and wiped out.” Dr. Baum concluded that “she is failing work
because of her disease and needs to go out on disability.” The bloodwork done that day showed
an increase since February in plaintiff’s white blood cell count and lymphocytes. Dr. Baum noted
that he would like to do more bloodwork, but plaintiff could not afford the tests. He recommended
follow up as needed, with no specific time period established.
Plaintiff did not stop working at that point, but her employer tried to accommodate her with
decreased hours and lighter duty than her regular work as a charge nurse, but it had no “light” or
“sedentary” positions. Plaintiff stopped working on December 13, 2013, due to fatigue and
weakness that left her feeling unable to perform her job. She filed for short-term, long-term and
total disability benefits with Principal Life on December 16, 2013. The required “Attending
Physician’s Statement” was completed by Dr. Baum and filed with plaintiff’s claim application.
He diagnosed chronic lymphocytic leukemia, fatigue and depression. Dr. Baum indicated that
“maximum medical improvement” had been achieved and he checked the box indicating that that
plaintiff could not return to work. Plaintiff saw Dr. Baum on January 28. 2014, for follow up
bloodwork. She complained of fatigue, easy bruising, and weakness. Dr. Baum opined that he
did not think she would be able to return to work, and scheduled her to come back in four months.
On March 17, 2014, plaintiff received a letter from Principal Life denying her short-term
disability benefits because “she did not meet the definition of Disability” under the plan. Plaintiff
returned to Dr. Baum on May 28, 2014, as directed at the January visit. She continued to suffer
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from fatigue, as well as lack of energy and motivation. She had lost 15 pounds. She reported she
had not been able to return to work, and she would be moving to Kentucky to live with her sister
because she lost her house to foreclosure. Dr. Baum noted that her bloodwork “looked better”
because “she has not been working[,] allowing her body to deal with her CLL better.” He opined
that she is “still dealing with chronic fatigue and I do not see her being able to have any work
capacity.” He instructed plaintiff to follow up with new doctors in Kentucky.
Plaintiff moved to Lexington, Kentucky, in July of 2014. In September 2014, she appealed
the denial of her short-term disability benefits and informed Principal Life that she was pursuing
her claim for long-term and total disability benefits as well. Principal Life indicated that it would
need further medical records, to which plaintiff agreed. Plaintiff applied and was accepted for
Medicaid in Kentucky, but she had difficulty finding physicians in the area who would take new
Medicaid patients. Plaintiff saw Dr. Amy Schell, a specialist in hematology and oncology, on
November 12, 2014. Dr. Schell noted that plaintiff’s chronic fatigue was probably due to her
chronic lymphocytic leukemia, but she wanted to do more testing, including bloodwork and CT
scans. Plaintiff also saw Dr. Elvis Donaldson, a gynecological oncologist, in December 2014 for
her chronic post-menopausal vaginal bleeding. Neither Dr. Schell nor Dr. Donaldson opined in
detail on plaintiff’s functionality, limitations or restrictions, except that Dr. Schell noted that
plaintiff was at ECOG (Eastern Cooperative Oncology Group) grade 1, which restricts physically
strenuous work, but allows light or sedentary work such as housework. These appear to have been
initial visits with plaintiff’s new Kentucky doctors. No further treating-physician medical records
appear in the administrative record after December 2014.
Principal Life sent plaintiff a letter on December 2, 2014, denying her appeal for short-
term disability benefits because the “information considered . . . does not support impairment from
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your own job.” Two weeks later, on December 13, 2104, Principal Life informed plaintiff by letter
that it was denying her claim for long-term and total disability benefits because she was not “under
the Regular and Appropriate Care of a Physician or [did not] meet the definition of Disability.”
Plaintiff appealed the denial of long-term and total disability benefits. On February 24, 2015,
Principal Life denied plaintiff’s application for all disability benefits because “you do not meet the
definition of Disabled” under the plan. The final denial letter does not list lack of “Regular and
Appropriate Care of a Physician” as a reason for denial.
Plaintiff filed a complaint in federal court on May 17, 2015, pursuant to ERISA, 29 U.S.C.
§§ 1132 (a)(1)(B), (a)(3),2 seeking legal and equitable relief. The parties filed cross motions for
summary judgment and the district court granted defendant Principal Life’s motion and denied
plaintiff’s motion. Card v. Principal Life Ins. Co., No. 5:15-cv-139, 2018 WL 4344455 (E.D. Ky.
Sept. 11, 2018). This appeal followed.
II.
In her summary judgment motion and now on appeal, plaintiff argues she is entitled to
relief because the medical evidence supports her claim of disability, and Principal Life both
ignored relevant evidence and relied on flawed medical records in denying her claims. In response,
2 29 U.S.C. § 1132(a) provides in relevant part: (a) Persons empowered to bring a civil action A civil action may be brought-- (1) by a participant or beneficiary-- ... (B) to recover benefits due to him under the terms of his plan, to enforce his rights under the terms of the plan, or to clarify his rights to future benefits under the terms of the plan; ... (3) by a participant, beneficiary, or fiduciary (A) to enjoin any act or practice which violates any provision of this subchapter or the terms of the plan, or (B) to obtain other appropriate equitable relief (i) to redress such violations or (ii) to enforce any provisions of this subchapter or the terms of the plan; . . . .
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Principal Life argues that the denial of benefits was not arbitrary and capricious because the
decision is supported by substantial evidence in the administrative record.
A. Standard of Review of Principal Life’s Decisions
As a threshold matter, we review the parties’ arguments regarding the proper standard of
review applicable in this case to Principal Life’s decision to deny disability benefits based on the
administrative record. Prior to its final decision, the district court ruled that it would review
Principal Life’s determination under the deferential “arbitrary-and-capricious” standard of review
because Principal Life had sufficiently shown that the benefit plan in this case gives it authority to
determine eligibility for benefits and construe the terms of the plan. Card v. Principal Life Ins.
Co., No. 5:15-139, 2016 WL 1298723 (E.D. Ky. Mar. 31, 2016). Plaintiff renewed her attack on
the standard of review in her motion for summary judgment, and again in this appeal, arguing
(1) that the plan’s grant of discretionary authority was not final because Principal Life’s internal
procedures allowed for an “exception” process through which plaintiff’s employer could request
that a claim be paid under the plan, and (2) that because Principal Life is both the evaluator and
payor of claims under the policy, the standard of review is altered. We agree with the district
court’s thorough analysis of plaintiff’s arguments on this issue, and we will apply the arbitrary-
and-capricious standard of review.
1. Discretionary authority
Plaintiff argues that the express terms of the plan prohibit Continuum from granting authority
to another entity to determine benefit eligibility. ERISA allows employers such as Continuum to
designate other fiduciaries to implement aspects of the plan, see 29 U.S.C. § 1102(c), and
Continuum has delegated such authority to Principal Life. Here, the plan language explicitly
provides Principal Life with the “discretion to construe or interpret the provisions of this Group
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Policy, to determine eligibility for benefits, and to determine the type and extent of benefits.”
Policy at Article 9. The policy language tracks that used by the Supreme Court to grant
discretionary authority to the plan administrator. See Firestone Tire & Rubber Co. v. Bruch, 489
U.S. 101, 115 (1989) (applying the deferential “arbitrary and capricious” standard of review to
administrative record because “the benefit plan gives the administrator or fiduciary discretionary
authority to determine eligibility for benefits or to construe the terms of the plan”); accord Evans
v. UnumProvident Corp., 434 F.3d 866, 875 (6th Cir. 2006); Calvert v. Firstar Fin., Inc., 409 F.3d
286, 292 (6th Cir. 2005).
Plaintiff also contends that Principal Life’s internal operating procedures include a process
whereby the employer may request that Principal Life grant benefits to the employee after a denial
has been issued. She argues that the existence of such an “exception” procedure robs Principal
Life of its authority as the final decisionmaker under the plan, which in turn requires de novo
review of Principal Life’s decision instead of the more deferential arbitrary-and-capricious
standard. Plaintiff cites to a portion of deposition testimony by Nancy Taylor, an employee of
Principal Life, to demonstrate the existence of an “exception” process, which is defined as “any
decision that is not consistent with normal plan policy provisions and administrative processes.”
Taylor Dep. at 86.3 While such a procedure may well exist, plaintiff does not cite any evidence
showing that an exception request by an employer is automatically granted, or that any exception
request otherwise usurps the final discretionary authority of Principal Life. The only reference in
the administrative record to the process by which an exception is approved—here, taken from a
section of Taylor’s deposition—contemplates an examiner “not[ing] something and tak[ing] it to
senior staff [of Principal Life] . . . to have a discussion about it.” Id. at 88. In support of its position
3 The language cited purportedly comes from Principal Life’s claim manual, but the manual itself is not part of the administrative record.
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that exceptions are not automatically granted, Principal Life provided the sworn statement of Lisa
Dickhoff, Assistant Director of Disability Claims for Principal Life, which states that
Exceptions are not automatically granted when requested and had Principal Life received this Request [from Continuum], Principal Life would not have granted it because it does not request an exception Principal Life would agree to . . . .
Dickhoff Decl. at ¶ 4. This unrebutted evidence indicates that Principal Life preserved its
discretion, even in the case of an exception request by an employer. Even if it may grant exceptions
at the request of employers in certain circumstances, plaintiff has not presented any evidence that
Principal Life is not the final decisionmaker.
2. Conflict of Interest
The fact that Principal Life is both the evaluator and payor of claims under the policy does
not alter the standard of review. See Smith v. Cont’l Cas. Co., 450 F.3d 253, 260 (6th Cir. 2006).
Rather, the conflict of interest should be considered a factor in a court’s review of the denial. Id.
The district court allowed the parties to conduct limited discovery for the purpose of determining
how the conflict should impact its review. Aside from a blanket claim of conflict, plaintiff makes
no specific allegation supported by particularized evidence that a conflict of interest affected
Principal Life’s denial. As such, there is an insufficient basis to find that the inherent conflict had
an adverse effect on Principal Life’s denial of benefits. We will review Principal Life’s decision
under the arbitrary-and-capricious standard, with the inherent conflict of interest viewed as a factor
in the review of the denial of benefits.
B. The Denial of Benefits
Under the arbitrary-and-capricious standard, the question is whether a plan offered a
reasoned explanation based on evidence for why a claimant was not disabled under the plan’s
terms. Evans, 434 F.3d at 876 (“[A] decision will be upheld if it is the result of a deliberate
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principled reasoning process, and if it is supported by substantial evidence.”) (quoting Killian v.
Healthsource Provident Adm’rs, Inc., 152 F.3d 514, 520 (6th Cir. 1998)). The review, however,
“inherently includes some review of the quality and quantity of the medical evidence and the
opinions on both sides of the issues.” Id. (quoting McDonald v. W.-S. Life Ins. Co., 347 F.3d 161,
172 (6th Cir. 2003)). Although the arbitrary-and-capricious standard is deferential, it is not a
rubberstamp of an administrator’s decision. McDonald, 347 F.3d at 172 (citation omitted). Rather,
ERISA obligates courts to ensure that an administrator conducted a “‘full and fair’ review of claim
denials.” Met. Life Ins. Co. v. Glenn, 554 U.S. 105, 117 (2008) (quoting Firestone, 489 U.S. at
113). In reviewing the decision of the plan administrator, we may only consider the evidence in
the administrative record, as that is the evidence that the plan administrator considered. Wilkins v.
Baptist Healthcare Sys., Inc., 150 F.3d 609, 615 (6th Cir. 1998).
1. Exception Procedure
In addition to relying on the “exception” procedure described above to argue for a stricter
standard of review, plaintiff also argues that the procedure, which allows Continuum to request a
“decision that is not consistent with normal plan policy provisions and administrative processes,”
warrants judgment in her favor because Principal Life failed to inform Continuum that it could
request an exception, and, if Continuum had requested an exception, it would have been granted.
We agree with the district court that there is no evidence that an employer’s request for an
exception somehow supersedes a disability determination under the plan or that Principal Life is
required to remind Continuum of its right to request an exception if it wishes. Principal Life
introduced unrebutted evidence that exceptions are not automatically granted, and that the
exception request in this case would have been denied in any event. Dickhoff Decl. at ¶ 4.
Furthermore, in a letter informing Continuum of its denial of plaintiff’s benefits claim, Principal
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Life invited Continuum to write a “letter” explaining in detail why plaintiff could not perform her
job. The record does not indicate that Continuum wrote such a letter until December 2016 after
this litigation had commenced, or that it was unaware before that time that it could request an
exception. The existence of an exception procedure of which plaintiff was unaware and that can
be initiated only by her employer does not mandate that Principal Life grant her benefits claim.
2. Principal Life’s Denial of Benefits
Plaintiff also argues that Principal Life’s denial of her claim is not supported by the
evidence in the administrative record. The burden lies with plaintiff to prove that she is entitled
to benefits under the plan. The district court found that substantial evidence in the record supports
Principal Life’s decision. We, however, are not convinced. Plaintiff filed for three different types
of disability benefits under the plan: short-term, long-term and total disability (the latter is referred
to as Life Coverage During Disability). Each benefit type requires plaintiff to meet a different
definition concerning her ability to perform work in order to show disability, and each covers a
different timeframe. Despite the clear terms of the plan, the administrative record does not
demonstrate that Principal Life applied the plan definitions when deciding plaintiff’s claim for
short-term and long-term disability benefits, and it failed to provide a reasoned explanation for its
rejection of plaintiff’s treating physicians’ multiple opinions about her inability to work as a nurse
based on the specific physical limitations the physicians imposed.
The plan language requires that the administrator consider whether each claimant can
perform the specific duties of his or her job or occupation before making benefits determinations
regarding short-term and long-term disability. A plan may not “completely ignore[ ] favorable
evidence from [a claimant’s] treating physicians” or “reject summarily the opinions of a treating
physician, but must instead give reasons for adopting an alternative opinion.” Shaw v. AT & T
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Umbrella Ben. Plan No. 1, 795 F.3d 538, 548–49 (6th Cir. 2015). As demonstrated below,
Principal Life failed to apply the medical evidence to the definitions from the plan, rendering its
decision arbitrary and capricious and requiring remand.
a. Short-term disability
Short-term disability under the plan applies to the first 90 days that a claimant is unable to
work. In this case, the time period covered is from December 13, 2013, plaintiff’s last day of
work, to March 24, 2014. The plan defines “Disability” when “solely and directly because of
sickness, injury, or pregnancy, . . . [the employee] cannot perform the majority of the Substantial
and Material Duties if his or her Own Job.” Your “Own Job” is defined as “[t]he job the
[employee] is routinely performing for the Policyholder or a Participating Unit when his or her
Disability begins.” “Substantial and Material Duties” is defined as “[t]he essential tasks generally
required by employers from those engaged in a particular job that cannot be modified or omitted.
If [an employee] routinely works on average 40 hours or more per week, [Principal Life] will
consider the [employee] able to perform the Substantial and Material Duties of the job if he or she
is working, or has the capacity to work, 40 hours per week.”
Plaintiff’s job description at Continuum as a charge nurse required her to stand, walk,
push/pull, lift, and bend “frequently,” which means 30-45 minutes per hour. It also involves
“frequent” exposure to infections, and exposure to “infectious waste, diseases, . . . [and blood-
borne] pathogens. See Continuum’s Job Description for Charge Nurse. Principal Life repeatedly
acknowledged that plaintiff’s “Own Job” as a charge nurse is classified as “heavy.” See, e.g.,
Principal Life’s March 17, 2014, letter denying short-term disability benefits; Principal Life’s file-
review request to Reliable Review Services, dated Feb. 28, 2014. According to Principal Life’s
own “Occupational Analysis,” this classification requires “[e]xerting 50 to 100 pounds of force
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occasionally, and/or 25 to 50 pounds of force frequently, and/or 10 to 20 pounds of force constantly
to move objects.
Given this information about plaintiff’s “Own Job,” we must determine whether Principal
Life made a deliberate, principled, reasoned decision that plaintiff’s condition did not preclude her
from performing her “Own Job” as a charge nurse at Continuum. On March 17, 2014, Principal
Life sent a denial letter to plaintiff. The denial letter correctly states that in order to qualify for
short-term disability benefits, “you must be restricted from working by your treating Physician,
and be unable to perform the majority of the Substantial and Material Duties of your Own Job.”
The denial letter explained that Principal Life had reviewed Dr. Ryan’s and Dr. Baum’s notes and
the labs on her bloodwork. The letter also stated that her file had been reviewed by an oncologist,
Dr. Chao. The letter describes the technical contents of the treating physicians’ notes and Dr.
Chao’s report, including plaintiff’s complaints of extreme fatigue and weakness, but conclude that
because her bloodwork is “essentially normal,” “there is nothing from the diagnosis of CLL that
would preclude you from working.” There is no indication that Principal Life took into
consideration plaintiff’s physically demanding duties as a charge nurse or her ability to perform
them. There is no discussion of why it ignored Dr. Baum’s August 30, 2013, recommendation that
plaintiff “needs to go out on disability,” or his response in the attending physician’s statement
accompanying plaintiff’s claim application that plaintiff could not work and he did not expect her
to be able to return to work because “maximum medical improvement” had been achieved.
Principal Life’s initial decision denying short-term disability benefits was not “reasoned” in
explaining how plaintiff’s condition was compatible with her performing her “Own Job” as a
charge nurse.
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In September 2014, plaintiff appealed the denial of short-term disability benefits. After
receiving more information from her treating physician, Dr. Baum, and obtaining a file review
from a specialist in Occupational Medicine, Dr. Frank Polanco,4 Principal Life denied the appeal
on December 2, 2014. Despite the fact that plaintiff was appealing the denial of short-term
benefits, which requires that she not be able to perform her “Own Job” as a charge nurse, Dr.
Polanco’s report concluded that plaintiff is “capable of performing sedentary work.” He did not
opine on plaintiff’s ability to do “heavy” work in her job as a charge nurse, such as frequent
walking and standing, and the ability to lift patients. Dr. Polanco’s File Review Report dated Nov.
12, 2014 at 3. Principal Life also indicated it reviewed a list of restrictions Dr. Baum provided
that included standing no more than 15 minutes per hour and lifting no more than 5 pounds. It
also stated that plaintiff is “unable to be exposed to sick patients due to her diagnosis of CLL.”
The denial letter states: (1) “there is nothing from the diagnosis of CLL that would preclude
you from working,” (2) “[T]here are no findings that would preclude you from full-time work. No
restrictions are supported.”; and (3) “This review concluded that medical documentation does not
support impairment from working full-time.” Dec. 2, 2014, Denial letter at 1, 2. The letter fails
to mention anywhere what exertional level of full-time work plaintiff can maintain, and there is no
discussion of the actual duties of her job as a charge nurse or acknowledgment that Principal Life
had previously labeled it as “heavy” work. There is no discussion of why it rejected Dr. Baum’s
list of specific restrictions despite the fact that Principal Life had requested them in September
2014, and no discussion of how a charge nurse with a job classified as “heavy” could follow the
listed restrictions as to both the exertional level and the exposure to infected persons. The failure
4 Principal Life indicates that it relied on the file-only review because plaintiff refused to schedule an appointment for an independent medical evaluation with an occupational specialist to assess her functionality. Plaintiff maintains that she agreed to the evaluation at first, but subsequently refused to go when she began to believe that Principal Life was stalling in giving her an answer on her appeal of her denial of short-term benefits.
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to analyze plaintiff’s claim relative to her specific job as a charge nurse does not present a
“reasoned” explanation for the denial. On remand, Principal Life must reevaluate plaintiff’s claim
for short-term disability benefits, taking into consideration the requirements of plaintiff’s “Own
Job,” as well as the restrictions imposed by Dr. Baum.
b. Long-term disability
Under the terms of the plan, an employee will be considered “Disabled” and qualify for
long-term disability benefits if “solely and directly because of sickness, injury, or pregnancy . . .
[d]uring the Elimination Period [first 90 days employee is unable to work] and the Own
Occupation Period . . . [the employee] cannot perform the majority of the Substantial and Material
Duties of your Own Occupation.” Your “Own Occupation” is defined as “[t]he occupation the
[employee] is routinely performing when Disability begins. The occupation of the [employee] as
it is performed in the national economy when Disability begins. Own Occupation does not mean
the specific tasks or job the [employee] is performing for the Policyholder or a Participating Unit
or at a specific location.” The “Own Occupation Period” is defined as “[t]he first two year(s) of
the Benefit Payment Period.”
Sheila Thompson, a vocational consultant for Principal Life, concluded that plaintiff’s
“Own Occupation” is as a licensed practical nurse, which is classified as a “medium strength” job.
According to Principal Life’s own “Occupational Analysis,” medium-strength work requires
“[e]xerting 20 to 50 pounds of force occasionally, and/or 10 to 25 pounds of force frequently,
and/or greater than negligible up to 10 pounds of force constantly to move objects. The description
of the duties of a licensed practical nurse include “[collect[ing] samples, such as urine, blood, and
sputum, from patients for testing and performs routine laboratory tests on samples. . . . Bath[ing],
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dress[ing], and assist[ing] patients in walking and turning. . . . Washes and dresses bodies of
deceased persons.”
The denial letter for plaintiff’s application for long-term disability benefits was combined
with the denial of her application for total disability benefits (Life Coverage During Disability).
Letter from Principal Life dated Dec. 13, 2014. The letter states that plaintiff’s claim was denied
because she did not meet the definition of “Disability,” and she did not have documentation to
support that she was under the “Regular and Appropriate Care” of a physician.5 The denial letter
states that Principal Life relied on the same medical documentation received from treating
physicians Dr. Ryan and Dr. Baum that it had relied on for plaintiff’s appeal of the denial of short-
term disability benefits on December 2, 2014. It also relied on the same file reviews it had relied
on previously by Dr. Chao, an oncologist, and Dr. Polanco, an Occupational Medicine specialist.
It also referenced phone calls and letters exchanged with plaintiff, as well as a “Supplemental
information Form” and “Activities Check.” Letter dated Dec. 13, 2014.
The definitions of “Disability” to qualify for long-term benefits or total disability benefits
differ, and this difference was not clearly acknowledged or explained in the denial letter. To
qualify for long-term disability benefits, plaintiff must demonstrate that she cannot perform her
“Own Occupation.” For purposes of claims for total disability, a claimant must demonstrate that
she cannot perform “any” job. The denial of plaintiff’s claim for long-term disability benefits
5 Regular and Appropriate Care of a Physician is defined as follows: [An employee] will be considered to be receiving Regular and Appropriate Care if he or she: a. is evaluated in person by a Physician; and b. receives treatment appropriate for the condition causing the Disability; and c. undergoes evaluations and treatment that is provided by a Physician whose specialty is appropriate for the condition causing the Disability; and d. undergoes evaluations and treatment at a frequency intended to return the [employee] to full-time work; and e. pursues reasonable treatment options or recommendations to achieve maximum medical improvement.
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suffers from the same shortcomings as the denial of short-term benefits discussed above. There is
no discussion or analysis that acknowledges the duties of plaintiff’s “Own Occupation” as a
licensed practical nurse, a profession requiring “medium” exertional strength. Dr. Polanco’s
review mentioned only “sedentary” work. While evidence that the plaintiff is capable of sedentary
work may preclude her from claiming disability under the “Any Occupation” standard articulated
in the plan for total disability benefits, it does not preclude the plaintiff from receiving disability
benefits under the “Own Occupation” standard because the job of a licensed practical nurse
requires more than the ability to sit, walk, stand, and type, as acknowledged by Principal Life in
its own Occupational Analysis. Principal Life does not explain why it disregarded Dr. Baum’s
restrictions on plaintiff’s exertional level, which limit plaintiff’s activities to a level well below
that required under the job description for a licensed practical nurse. In addition, there is no
discussion of why Dr. Baum’s restrictions on plaintiff’s exposure to persons with infection and
disease due to her compromised immune system were ignored when exposure to infections and
pathogens occurs in the normal course of the work day for a licensed practical nurse (“[collect[ing]
samples, such as urine, blood, and sputum, from patients for testing and performs routine
laboratory tests on samples.”).
The December 13, 2014, denial of long-term benefits also states that plaintiff’s claim was
denied because “we do not have documentation to support that you were under the Regular and
Appropriate Care of a Physician.” Principal Life’s denial letter offers scant support for this reason
to form the basis of the denial of long-term benefits.6 Plaintiff adhered to the treatment plans of
6 Principal Life points out that plaintiff refused to undergo an independent medical evaluation in the fall of 2014 that would have, in part, provided information about plaintiff’s functionality. Plaintiff contends that she originally agreed to the evaluation, but when the exam was not scheduled within the 45-day period for Principal Life to render a decision on her long-term disability claim and her short-term disability appeal, she refused to schedule the appointment because she believed Principal Life was looking for an excuse to take an additional 45 days to make its decision. She argues that Principal Life should have known earlier in the process if it needed such an examination and not waited until the decision deadline to request it.
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her treating physicians Dr. Ryan and Dr. Baum. Neither treating physician thought that treatment
of plaintiff’s chronic lymphocytic leukemia was necessary in the months following her diagnosis,
which is not outside the norm for the early stages of the disease. As the name indicates, the disease
is chronic and generally worsens over time, and treatment such as chemotherapy is sometimes
used in latter stages of the disease. Although Dr. Ryan told plaintiff to return to see her in six
months, plaintiff could not afford to return to Dr. Ryan, a specialist, but she saw Dr. Baum instead.
Dr. Baum’s notes do not indicate a strict schedule of follow-up visits, instead telling plaintiff to
see him on an as-needed basis. On January 28, 2014, he told plaintiff to return in four months and
she returned on May 28, 2014, exactly four months later. Blood work was performed at each of
her visits. Plaintiff moved from Maine to Kentucky in July 2014 and applied for Medicaid. She
stated she had difficulty finding doctors who would accept Medicaid, but she started seeing treating
physician Dr. Schell, a specialist in hematology and oncology, on November 12, 2014, less than
six months after her last visit with Dr. Baum. Principal Life has not demonstrated that plaintiff
failed to follow the treatment plans of her treating physicians, or that she failed to attend
appointments as directed by her treating physicians.
Plaintiff appealed Principal Life’s denial of long-term and total disability benefits. On
February 24, 2015, Principal Life sent plaintiff a letter denying short-term, long-term and total
disability benefits on the sole ground that plaintiff did not meet the definition of “Disabled.”
Reliance on plaintiff’s alleged lack of “Regular and Appropriate Care” is not mentioned. In
addition to referencing all of its three earlier denial letters, the letter states that it also relied on
medical records from plaintiff’s treating physicians Dr. Schell and Dr. Donaldson, a file review by
a psychiatrist, Dr. Antrin, and a file review by Dr. Chedid, an internist specializing in oncology
and hematology. This denial letter stated in its conclusion that “[w]ith all the information in the
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review and claim file, it shows you do not have limitations that would impact your functioning;
thus you would be able to perform the Majority of the Substantial and Material Duties of your
Own Job and your Own Occupation on a normal and consistent basis.”
Dr. Chedid, an oncologist who conducted a file review on February 11, 2015, answered
specific questions from Principal Life as to whether plaintiff could perform her “heavy” job as a
charge nurse, or her “medium” job as a licensed practical nurse. He opined in response to both
questions:
From an oncology standpoint, there is no evidence to support the claimants’ diagnosis of chronic lymphocytic leukemia as a cause of functional impairment, or restrictions and limitations. There was no indication that the claimant’s diagnosis of chronic lymphocytic leukemia would prevent her from working. A stage 0, per the ECOG Performance Status, indicates the claimant should be fully active and able to carry on all pre-disease performance without restrictions.
File review of Dr. Silwan Chedid at 3. Dr. Chedid also listed Dr. Baum’s exertional restrictions,
but he did not offer any explanation as to why they should be disregarded, except to repeat that
plaintiff is at stage 0 of the disease. Dr. Chedid does not discuss plaintiff’s specific job duties at
Continuum or the duties performed by most licensed practical nurses. While Principal Life need
not give greater weight to a treating physician’s opinion, Black &Decker Disability Plan v. Nord,
538 U.S. 822, 830-32 (2003), the fact that it apparently gave greater weight to Dr. Chedid’s opinion
than to Dr. Baum’s without explanation lends force to the conclusion that it acted arbitrarily and
capriciously. See Elliott v. MetLife Ins. Co., 473 F.3d 613, 620-21 (6th Cir. 2006). It is also true
that plan administrators “may not arbitrarily repudiate or refuse to consider the opinions of a
treating physician.” Glenn v. MetLife, 461 F.3d 660, 671 (6th Cir. 2006).
The final denial letter merely recites medical terminology and the results of plaintiff’s
bloodwork without any reasoning as to why the diagnosis of chronic lymphocytic leukemia with
symptoms of fatigue and weakness would permit her to function in a physically demanding
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workplace. Principal Life’s repeated reliance on only objective evidence from plaintiff’s medical
records to deny benefits is problematic in this case. We are troubled by the fact that there is so
little evidence of a process anywhere in the administrative record—either by Principal Life or by
the physicians it hired to review plaintiff’s file—that relates plaintiff’s condition to her expected
job duties. Principal Life failed properly to consider the strength level needed for plaintiff to fulfill
her duties as a charge nurse and as a licensed practical nurse, disregarded the opinions of her
treating physicians without explanation, and then offered conclusory and unsupported or erroneous
statements about plaintiff’s functional capacity based only on file reviewers that either ignored or
did not have the necessary information about plaintiff’s “Own Job” and “Own Occupation.”
Principal Life’s apparent reliance on these file-review reports to uphold its denial of plaintiff’s
claim was not reasonable in this case, and we conclude that the denial of plaintiff’s disability
claims and subsequent appeals was arbitrary and capricious.
Remand is necessary because Principal Life failed in at least two stages of its benefits
determination to account adequately for plaintiff’s actual job duties.7 Our precedent on this point
is clear: a plan administrator “could have made a reasoned judgment [that plaintiff could perform
her occupation] only if it relied on medical evidence that assessed [plaintiff’s] physical [and
psychiatric] ability to perform job-related tasks.” Elliott, 473 F.3d at 618. “Put differently,
medical data, without reasoning, cannot produce a logical judgment about a claimant’s work
ability.” Id. “[M]erely recount[ing] the technical contents of [a claimant’s] various [lab results
7 If a court concludes that an administrator acted arbitrarily and capriciously, it may either remand the case to the administrator for a new review or award benefits to the beneficiary. Elliott, 473 F.3d at 621–22. Remand to the plan administrator is appropriate “where the problem is with the integrity of the plan’s decision-making process, rather than that a claimant was denied benefits to which he was clearly entitled.” Id. at 622 (brackets and quotation marks omitted). We will not remand for additional consideration if we believe plaintiff has clearly established that she is disabled under the plan. See Kalish v. Liberty Mut./Liberty Life Assur. Co., 419 F.3d 501, 513 (6th Cir. 2005) (concluding that the appropriate remedy was an immediate award of benefits rather than a remand to allow the plan administrator to consider evidence that it had previously ignored).
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and] medical evaluations,” without “reason[ing] from [the claimant’s] condition to her ability to
perform her occupation” is not enough. Id. at 618–19. The reviewing physicians failed to consider
in any reasoned manner whether the nature of plaintiff’s job as a licensed practical nurse and
charge nurse rendered her unable to do that work, in light of the identified duties for each
classification. It is not clear whether all the reviewers had access to plaintiff’s job duties or the
normal duties of a licensed practical nurse when reviewing her file during the various benefits
determinations. None of the reviewers critically assessed plaintiff’s specific health issue, with its
attendant fatigue and low resistance to infection, against the actual demands of her job and the
profession.
Conclusion
Principal Life failed squarely to address whether plaintiff’s persistent symptom of fatigue
and weakness, common with a chronic lymphocytic leukemia diagnosis, were compatible or
incompatible with plaintiff’s ability to perform the essential duties of her job as a licensed practical
nurse. The fact that plaintiff might be able to perform a sedentary job that would allow her to sit
most of the time does not mean that plaintiff could perform a job that requires the frequency of
standing, walking and lifting listed in her own job description and in the occupational listing for a
licensed practical nurse. Both descriptions include duties that exceed the strength needed for
typical “sedentary” positions.
Even when it is reviewed under the deferential standard applicable in this case, we conclude
that Principal Life’s determination to deny benefits to plaintiff cannot be sustained. For the reasons
set out above, we conclude that Principal Life’s decision to deny short-term and long-term benefits
in this case was not the product of a principled and deliberative reasoning process. In denying
benefits, it relied solely on lab reports, ignoring her treating physicians’ repeated opinions that
- 20 - Case No. 18-6095, Card v. Principal Life Ins.
plaintiff could not keep up with the demands of working as a nurse. We therefore remand the case
to Principal Life for further proceedings consistent with this opinion.
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LARSEN, Circuit Judge, dissenting. I agree with the majority that the arbitrary-and-
capricious standard of review applies in this case. In my view, however, application of that
standard requires us to affirm the district court. Arbitrary-and-capricious review is the “least
demanding form of judicial review.” Donati v. Ford Motor Co., Gen. Ret. Plan, Ret. Comm.,
821 F.3d 667, 671 (6th Cir. 2016) (quoting McClain v. Eaton Corp. Disability Plan, 740 F.3d
1059, 1064 (6th Cir. 2014)). It requires us to extend “extreme deference” to Principal Life’s
decision to deny Card’s application for benefits. McClain, 740 F.3d at 1067. “When it is possible
to offer a reasoned explanation, based on the evidence, for a particular outcome, that outcome is
not arbitrary or capricious.” Id. at 1065 (quoting Shields v. Reader’s Digest Ass’n, 331 F.3d 536,
541 (6th Cir. 2003)).
ERISA does not “impose a heightened burden of explanation on administrators when they
reject a treating physician’s opinion.” Black & Decker Disability Plan v. Nord, 538 U.S. 822, 831
(2003). In rejecting the opinion of a treating physician, a plan administrator need only offer
“reasons for adopting an alternative opinion” for its decision to survive arbitrary-and-capricious
review. Shaw v. AT&T Benefit Plan No. 1, 795 F.3d 538, 549 (6th Cir. 2015). Principal Life
rejected the opinions of Card’s treating physicians based on the opinions of four specialist
physicians, who concluded that the objective medical evidence in Card’s file did not support any
restrictions on her ability to work. These physicians noted that Card was diagnosed with CLL with
an ECOG performance status of zero. An ECOG performance status of zero indicates a patient is
“[f]ully active, able to carry on all pre-disease performance without restriction.” ECOG
Performance Status, ECOG-ACRIN Cancer Res. Group, https://ecog-acrin.org/resources/ecog-
performance-status (last visited Oct. 23, 2019) (cited in Appellant Br. at 21 n.6). The physicians
further concluded that none of Card’s subsequent laboratory reports or clinical findings indicated
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that her CLL had worsened. A “reasonable mind” could therefore conclude, as Principal Life did
in its final denial letter, that Card’s medical documentation did not support the limitations indicated
by her treating physicians. See Dupont Dow Elastomers, LLC v. NLRB, 296 F.3d 495, 500 (6th
Cir. 2002) (defining “substantial evidence” under arbitrary-and-capricious review as “such
relevant evidence as a reasonable mind might accept as adequate to support a conclusion”).
I therefore disagree with the majority that Principal Life rejected the opinions of Card’s treating
physicians “without explanation.”
The majority also makes much of the fact that Principal Life never discussed Card’s job
requirements in detail, but this is not an absolute requirement for surviving arbitrary-and-
capricious review. Under this standard, we examine only whether Principal Life’s decision
“results from a deliberate principled reasoning process and is supported by substantial evidence.”
McClain, 740 F.3d at 1064–65 (quoting Schwalm v. Guardian Life Ins. Co. of Am., 626 F.3d 299,
308 (6th Cir. 2010)). In other words, did Principal Life articulate “a rational connection between
the facts found and the choice made”? Hosseini v. Nielsen, 911 F.3d 366, 371 (6th Cir. 2018)
(quoting GTE Midwest, Inc. v. FCC, 233 F.3d 341, 345 (6th Cir. 2000)). If Principal Life had
found that Card’s CLL in some way limited her functions, the majority would be right that
Principal Life would then have to look to Card’s actual duties to see whether she could still perform
them. But Principal Life reasonably concluded from the objective medical evidence that Card’s
condition did not place any limitations on her at all. From this, Principal Life could reasonably
infer that Card was not disabled, because however demanding Card’s job duties were, her CLL
could not have prevented her from performing them. This logical conclusion drawn from premises
supported by substantial evidence is all that the arbitrary-and-capricious standard demands of a
plan administrator.
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Lastly, the majority makes the puzzling claim that it was “problematic” for Principal Life
to rely “on only objective evidence from plaintiff’s medical records to deny benefits.” Under the
plan terms, however, Card bears the burden of establishing that she is disabled. We have
previously noted that “subjective complaints of fatigue . . . are easy to make, but almost impossible
to refute.” Yeager v. Reliance Standard Life Ins. Co., 88 F.3d 376, 382 (6th Cir. 1996) (internal
record citation omitted). I therefore disagree that no reasonable mind could conclude that a
claimant has failed to prove she is disabled when the objective medical evidence from her record
does not support her subjective claims of fatigue. See id. (“In the absence of any definite anatomic
explanation of plaintiff’s symptoms, we cannot find that the administrator’s decision to deny
benefits was arbitrary and capricious.”).
Principal Life based its denial of Card’s claims on four specialist physicians’ analyses of
the evidence in her medical records. We must apply “extreme deference” to its decision because
the plan grants discretion to Principal Life to interpret its terms. McClain, 740 F.3d at 1064. Since
I cannot say that it is “[im]possible to offer a reasoned explanation, based on the evidence, for
[this] particular outcome,” id. at 1065 (quoting Shields, 331 F.3d at 541), I respectfully dissent.
I would AFFIRM the district court’s grant of summary judgment to Principal Life.
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