Trottier v . CNA Group Life Ins. CV-03-544-SM 11/29/04 UNITED STATES DISTRICT COURT
DISTRICT OF NEW HAMPSHIRE
Margaret Trottier, Plaintiff
v. Civil N o . 03-544-SM Opinion N o . 2004 DNH 170 CNA Group Life Assurance, Defendant
O R D E R
Plaintiff Margaret Trottier asserts that CNA Group Life
Assurance (“CNA”) denied her claim for disability benefits in
violation of the Employee Retirement Income Security Act. 29
U.S.C. § 1001 et seq. Before the court are cross-motions for
summary judgment. For the reasons given, defendant’s motion for
summary judgment is granted.
Standard of Review
The employee welfare benefit plan at issue “reflects a
‘clear grant of discretionary authority to determine eligibility
for benefits,’” Matias-Correa v . Pfizer, Inc., 345 F.3d 7 , 11
(1st Cir. 2003) (quoting Leahy v . Raytheon Co., 315 F.3d 1 1 , 15
(1st Cir. 2002); citing Firestone Tire & Rubber C o . v . Bruch, 489 U.S. 1 0 1 , 115 (1989)). Accordingly, CNA’s determination that
Trottier was not eligible for disability benefits is reviewed
only for arbitrariness and capriciousness. Matias-Correa, 345
F.3d at 1 1 . Under that standard, “the administrator’s decision
must be upheld if it is reasoned and supported by substantial
evidence.” Gannon v . Metro. Life Ins. Co., 360 F.3d 2 1 1 , 213
(1st Cir. 2004) (citing Vlass v . Raytheon Employees Disability
Trust, 244 F.3d 2 7 , 30 (1st Cir. 2001)). “Evidence is
substantial if it is reasonably sufficient to support a
conclusion, and the existence of contrary evidence does not, in
itself, make the administrator’s decision arbitrary.” Gannon,
360 F.3d at 212 (citation omitted).
Relying on decisions from other circuits,1 plaintiff argues
that in cases such as this, where the plan administrator also
funds the benefit plan, a “heightened arbitrary and capricious”
standard of review should be applied. In this circuit, however,
the court of appeals “adhere[s] to the arbitrary and capricious
principle, with special emphasis on reasonableness, but with the
1 Levinson v . Reliance Std. Life Ins. Co., 245 F.3d 1321, 1326 (11th Cir. 2001); Doe v . Group Hosp. & Med. Servs., 3 F.3d 8 0 , 86 (4th Cir. 1993).
2 burden on the claimant to show that the [insurer’s] decision was
improperly motivated.” Pari-Fasano v . ITT Hartford Life &
Accident Ins. Co., 230 F.3d 415, 418 (1st Cir. 2000) (quoting
Doyle v . Paul Revere Life Ins. Co., 144 F.3d 1 8 1 , 184 (1st Cir.
1998)). It is not the law in this circuit that “a wrong but
apparently reasonable interpretation is arbitrary and capricious
if it advances the conflicting interest of the fiduciary at the
expense of the affected beneficiary or beneficiaries unless the
fiduciary justifies the interpretation on the ground of its
benefit to the class of all participants and beneficiaries.”
Levinson, 245 F.3d at 1326 (quoting Brown v . Blue Cross & Blue
Shield, Inc., 898 F.2d 1556, 1566-67 (11th Cir. 1990)). If it
were, the result might be different, but not assuredly s o .
Background
On October 7 , 2002, Trottier made a claim for disability
benefits. (Administrative Record (hereinafter “A.R.”) at 265-
69.) By letter dated November 1 1 , 2002, CNA disability
specialist Robert D. Manning informed plaintiff that:
At this time, additional medical information is being obtained from D r . Shearman concerning the details
3 of your disability status, exact limitations, treatment plan, prognosis, etc.
CNA cannot complete our evaluation of your claim until we receive this information. If we do not receive the required information from your attending physician within 10 business days from the date of this letter, your file will be closed. However, should we receive this information later, we will re-open your claim and give it our full consideration.
(A.R. at 261-62.) Trottier’s claim was denied in a letter dated
January 1 6 , 2003, from Faye Bernabe, a CNA claims consultant.
(A.R. at 186-88.) In that letter, Bernabe explained the appeal
process and stated: “If you have additional medical information
not mentioned above or wish us to reconsider our decision, you
should submit your formal request for reconsideration in writing
to my attention within 180 days of the date of this letter.”
(A.R. at 187 (emphasis in the original).)
On February 1 1 , 2003, the Social Security Administration
(“SSA”) determined that Trottier had been disabled since July 1 7 ,
2002, and was, therefore, eligible for Social Security disability
insurance benefits. (A.R. at 44.)
4 On June 2 6 , 2003, Trottier sought reconsideration of CNA’s
January 16 decision to deny her benefits. (A.R. at 42-43.) By
letter dated July 2 5 , 2003, Faye Bernabe declined to change CNA’s
previous decision, and forwarded the claim for a formal appeal
review. (A.R. at 20.) In her July 25 letter, Bernabe stated
that “[t]he medical consultant that reviewed M s . Trottier’s claim
feels that the claim is driven by the self-reported symptoms of
the claimant and there [were] no objective physical examination
findings or test results to support the physician’s restrictions
and limitations.” (Id.) On August 2 5 , 2003, Trottier’s appeal
was denied. (A.R. at 10-11.) In reaching its decision, CNA
considered evidence and opinions provided by D r . Shearman (a
treating physician), D r . Luchsinger (a treating physician), D r .
Passas (an examining physician, to whom Trottier had been
referred by D r . Luchsinger), and D r . Gerstenblitt (a non-
examining physician who conducted a review of Trottier’s medical
records). On September 8 , 2003, Trottier sent CNA a letter from
Dr. Shearman, dated August 1 2 , 2003, opining that Trottier was
disabled. (A.R. at 4-6.) Doris Gloss, a CNA appeal consultant,
responded:
5 The additional information submitted by D r . Shearman was dated 10 months after the period of disability in question. . . . This information dated 8/12/03 would not speak to M s . Trottier’s condition prior to 10/14/02. Therefore, this information does not alter the decision that was made by CNA . . .
(A.R. at 3.)
Discussion
In her “Statement of Facts,” Trottier makes the following
recitation:
On November 1 1 , 2002, M s . Trottier applied for long-term disability benefits through the Defendant corporation.
On January 1 6 , 2003, Defendant issued a denial letter without having informed M s . Trottier of the date and time when documentation of her inability to work could no longer be submitted.
On February 1 1 , 2003, Plaintiff Margaret Trottier was awarded Social Security Disability benefits due to her inability to perform her work as a visa processing specialist.
On June 2 6 , we sent a letter requesting reconsideration.
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Trottier v . CNA Group Life Ins. CV-03-544-SM 11/29/04 UNITED STATES DISTRICT COURT
DISTRICT OF NEW HAMPSHIRE
Margaret Trottier, Plaintiff
v. Civil N o . 03-544-SM Opinion N o . 2004 DNH 170 CNA Group Life Assurance, Defendant
O R D E R
Plaintiff Margaret Trottier asserts that CNA Group Life
Assurance (“CNA”) denied her claim for disability benefits in
violation of the Employee Retirement Income Security Act. 29
U.S.C. § 1001 et seq. Before the court are cross-motions for
summary judgment. For the reasons given, defendant’s motion for
summary judgment is granted.
Standard of Review
The employee welfare benefit plan at issue “reflects a
‘clear grant of discretionary authority to determine eligibility
for benefits,’” Matias-Correa v . Pfizer, Inc., 345 F.3d 7 , 11
(1st Cir. 2003) (quoting Leahy v . Raytheon Co., 315 F.3d 1 1 , 15
(1st Cir. 2002); citing Firestone Tire & Rubber C o . v . Bruch, 489 U.S. 1 0 1 , 115 (1989)). Accordingly, CNA’s determination that
Trottier was not eligible for disability benefits is reviewed
only for arbitrariness and capriciousness. Matias-Correa, 345
F.3d at 1 1 . Under that standard, “the administrator’s decision
must be upheld if it is reasoned and supported by substantial
evidence.” Gannon v . Metro. Life Ins. Co., 360 F.3d 2 1 1 , 213
(1st Cir. 2004) (citing Vlass v . Raytheon Employees Disability
Trust, 244 F.3d 2 7 , 30 (1st Cir. 2001)). “Evidence is
substantial if it is reasonably sufficient to support a
conclusion, and the existence of contrary evidence does not, in
itself, make the administrator’s decision arbitrary.” Gannon,
360 F.3d at 212 (citation omitted).
Relying on decisions from other circuits,1 plaintiff argues
that in cases such as this, where the plan administrator also
funds the benefit plan, a “heightened arbitrary and capricious”
standard of review should be applied. In this circuit, however,
the court of appeals “adhere[s] to the arbitrary and capricious
principle, with special emphasis on reasonableness, but with the
1 Levinson v . Reliance Std. Life Ins. Co., 245 F.3d 1321, 1326 (11th Cir. 2001); Doe v . Group Hosp. & Med. Servs., 3 F.3d 8 0 , 86 (4th Cir. 1993).
2 burden on the claimant to show that the [insurer’s] decision was
improperly motivated.” Pari-Fasano v . ITT Hartford Life &
Accident Ins. Co., 230 F.3d 415, 418 (1st Cir. 2000) (quoting
Doyle v . Paul Revere Life Ins. Co., 144 F.3d 1 8 1 , 184 (1st Cir.
1998)). It is not the law in this circuit that “a wrong but
apparently reasonable interpretation is arbitrary and capricious
if it advances the conflicting interest of the fiduciary at the
expense of the affected beneficiary or beneficiaries unless the
fiduciary justifies the interpretation on the ground of its
benefit to the class of all participants and beneficiaries.”
Levinson, 245 F.3d at 1326 (quoting Brown v . Blue Cross & Blue
Shield, Inc., 898 F.2d 1556, 1566-67 (11th Cir. 1990)). If it
were, the result might be different, but not assuredly s o .
Background
On October 7 , 2002, Trottier made a claim for disability
benefits. (Administrative Record (hereinafter “A.R.”) at 265-
69.) By letter dated November 1 1 , 2002, CNA disability
specialist Robert D. Manning informed plaintiff that:
At this time, additional medical information is being obtained from D r . Shearman concerning the details
3 of your disability status, exact limitations, treatment plan, prognosis, etc.
CNA cannot complete our evaluation of your claim until we receive this information. If we do not receive the required information from your attending physician within 10 business days from the date of this letter, your file will be closed. However, should we receive this information later, we will re-open your claim and give it our full consideration.
(A.R. at 261-62.) Trottier’s claim was denied in a letter dated
January 1 6 , 2003, from Faye Bernabe, a CNA claims consultant.
(A.R. at 186-88.) In that letter, Bernabe explained the appeal
process and stated: “If you have additional medical information
not mentioned above or wish us to reconsider our decision, you
should submit your formal request for reconsideration in writing
to my attention within 180 days of the date of this letter.”
(A.R. at 187 (emphasis in the original).)
On February 1 1 , 2003, the Social Security Administration
(“SSA”) determined that Trottier had been disabled since July 1 7 ,
2002, and was, therefore, eligible for Social Security disability
insurance benefits. (A.R. at 44.)
4 On June 2 6 , 2003, Trottier sought reconsideration of CNA’s
January 16 decision to deny her benefits. (A.R. at 42-43.) By
letter dated July 2 5 , 2003, Faye Bernabe declined to change CNA’s
previous decision, and forwarded the claim for a formal appeal
review. (A.R. at 20.) In her July 25 letter, Bernabe stated
that “[t]he medical consultant that reviewed M s . Trottier’s claim
feels that the claim is driven by the self-reported symptoms of
the claimant and there [were] no objective physical examination
findings or test results to support the physician’s restrictions
and limitations.” (Id.) On August 2 5 , 2003, Trottier’s appeal
was denied. (A.R. at 10-11.) In reaching its decision, CNA
considered evidence and opinions provided by D r . Shearman (a
treating physician), D r . Luchsinger (a treating physician), D r .
Passas (an examining physician, to whom Trottier had been
referred by D r . Luchsinger), and D r . Gerstenblitt (a non-
examining physician who conducted a review of Trottier’s medical
records). On September 8 , 2003, Trottier sent CNA a letter from
Dr. Shearman, dated August 1 2 , 2003, opining that Trottier was
disabled. (A.R. at 4-6.) Doris Gloss, a CNA appeal consultant,
responded:
5 The additional information submitted by D r . Shearman was dated 10 months after the period of disability in question. . . . This information dated 8/12/03 would not speak to M s . Trottier’s condition prior to 10/14/02. Therefore, this information does not alter the decision that was made by CNA . . .
(A.R. at 3.)
Discussion
In her “Statement of Facts,” Trottier makes the following
recitation:
On November 1 1 , 2002, M s . Trottier applied for long-term disability benefits through the Defendant corporation.
On January 1 6 , 2003, Defendant issued a denial letter without having informed M s . Trottier of the date and time when documentation of her inability to work could no longer be submitted.
On February 1 1 , 2003, Plaintiff Margaret Trottier was awarded Social Security Disability benefits due to her inability to perform her work as a visa processing specialist.
On June 2 6 , we sent a letter requesting reconsideration.
On August 2 5 , 2003, this reconsideration request was returned along with a letter of additional denial, which failed to consider additional evidence submitted in support of M s . Trottier’s claim.
6 (Pl.’s Mem. of Law at 1-2.) The argument section of plaintiff’s
memorandum of law states, in its entirety:
CNA’s failure to inform M s . Trottier of the deadline to submit medical evidence of her disability is clearly arbitrary and capricious. This decision prevented M s . Trottier from submitting additional evidence in support of her claim, including the expert opinion of D r . Shearman, as well as evidence from the Social Security Administration which has found M s . Trottier to be disabled and therefore qualified for Social Security Disability benefits.
(Pl.’s Mem. of Law at 8.)
Plaintiff’s argument is without merit. As a factual matter,
even assuming that CNA did fail to inform Trottier of deadlines
for submitting documentation of her disability prior to denying
her benefits on January 1 6 , 2003, any such failure was completely
mitigated by the language of the January 16 letter, which
expressly invited the submission of additional information.2
Similarly, it is inaccurate to say that CNA failed to consider
the additional evidence submitted after its August 2 5 , 2003,
2 As well, even after CNA issued its final decision on Trottier’s appeal, on August 2 5 , 2003, CNA allowed Trottier to submit, and did in fact consider, at least two additional pieces of documentation – D r . Shearman’s August 12 office note and his opinion letter of the same date.
7 final decision. CNA did consider that evidence, but declined to
rely upon i t , concluding from an examination of the evidence that
it did not pertain to the relevant time period. In sum, nothing
in the record supports a claim that CNA ever rejected any of
plaintiff’s evidence as untimely or failed to substantively
consider any of her evidence.
Regarding plaintiff’s award of Social Security disability
benefits, defendant was made aware of that fact by letter dated
June 2 6 , 2003 (A.R. at 4 2 ) , and, as a result, defendant knew of
the award when its Appeals Committee affirmed the denial of
benefits on August 2 5 , 2003 (A.R. at 1 0 ) . “[B]enefits
eligibility determinations by the Social Security Administration
are not binding on disability insurers.” Pari-Fasano, 230 F.3d
at 420 (citing Doyle, 144 F.3d at 186 n . 4 ) . “[A]lthough a
related Social Security benefits decision might be relevant to an
insurer’s eligibility determination, it should not be given
controlling weight except perhaps in the rare case in which the
statutory criteria are identical to the criteria set forth in the
insurance plan.” Pari-Fasano, 230 F.3d at 420. While plaintiff
argues that it was arbitrary and capricious for defendant to
8 preclude her from submitting evidence concerning her eligibility
for Social Security disability benefits, she has failed to allege
harm because she does not contend that the CNA plan set forth
criteria identical to those used by the Social Security
Administration. Because Social Security disability
determinations are not binding on disability insurers, and
because plaintiff has made no showing that CNA’s disability
determination was governed by standards identical to those used
by SSA, it was not arbitrary and capricious for CNA to find that
plaintiff was not disabled, simply because the SSA determined
that she was.
Defendant argues that it is entitled to summary judgment
because plaintiff failed t o : (1) provide objective medical
findings to support her disability claim; and (2) prove
restrictions and limitations that prevented her from doing her
job. Defendant further argues that it was not an abuse of
discretion for it t o : (1) discount D r . Shearman and D r .
Luchsinger’s favorable opinions, given both the lack of objective
findings to support those opinions and the contradictory opinions
of Drs. Passas and Gerstenblitt; (2) rely on an independent
9 review of plaintiff’s medical records; and (3) determine that
plaintiff was not disabled after the Social Security
Administration had determined that she was eligible for SSA
disability insurance benefits.
Defendant’s decision to deny coverage was not arbitrary and
capricious because it was supported by substantial evidence in
the form of opinions from an independent medical records examiner
and an examining physician to whom plaintiff had been referred by
her own treating physician.3 The record does contain medical
opinions supportive of plaintiff’s position, i.e., those of Drs.
Luchsinger and Shearman, but that evidence did not compel
defendant to discredit the contradictory and non-supportive
medical opinions of Drs. Gerstenblitt (A.R. at 27) and Passas
(A.R. at 1 6 2 ) . See Gannon, 360 F.3d at 212 (citation omitted).
It was not, in other words, “arbitrary and capricious” of CNA to
credit one set of medical experts over another.
3 The fact that plaintiff was referred to D r . Passas by her own physician considerably hampers plaintiff’s ability to demonstrate improper motivation on the part of CNA. See Pari- Fasano, 230 F.3d at 418 (explaining that claimant bears the burden of showing that the insurer’s decision was improperly motivated).
10 Conclusion
For the reasons given, plaintiff’s motion for summary
judgment (document n o . 7 ) is denied, and defendant’s motion for
summary judgment (document n o . 10) is granted. The clerk of the
court shall enter judgment in accordance with this order and
close the case.
SO ORDERED.
Steven J. McAuliffe United States District Judge
November 2 9 , 2004
cc: Linda E . Fraas, Esq. Vicky S . Roundy, Esq.