Plan Determination That Fails To Consider Long Medical History And Summarily Dismisses Functional Capacity Evaluation Results Is Arbitrary And Capricious
LEGER v. TRIBUNE COMPANY LONG TERM DISABILITY BENEFIT PLAN (March 9, 2009)
Lisa Leger suffered from osteoarthritis for years. Prior to 1990, she underwent three different arthroscopic procedures but was able to hold a job and engage in a rehabilitative exercise program. However, in 1990, she stopped working for WGN-TV and went on short-term disability. She began receiving long-term disability benefits in December 1990. She continued to receive benefits through 2005. During that time, she continued to have pain and problems with her knees and underwent multiple additional surgeries. The plan administrator reviewed her benefits in 2005 and requested updated information. Her treating physician advised that she was essentially unable to walk. The plan administrator's medical review concluded that she had significant osteoarthritis but that she was not precluded from sedentary work. A vocational rehabilitation consultant identified several employment positions for which she was qualified. The plan administrator therefore terminated her benefits in October of 2005. Leger appealed and provided additional medical information. The plan administrator arranged for another review of the file. That review highlighted some inconsistencies in her records. For example, the records indicated that she could not sit for more than 30 minutes at a time but she nevertheless was wheelchair bound. The plan administrator upheld the decision to terminate her benefits. Leger brought an action pursuant to ERISA’s section 1132 (a)(1)(b) to reinstate her benefits. The lower court granted summary judgment to the plan, stating that it advanced a reasonable explanation for its decision to terminate the benefits. Leger appeals.
In their opinion, Judges Bauer, Ripple and Evans reversed and remanded. The Court first rejected Leger's position, first brought out on appeal, that the arbitrary and capricious standard was the inappropriate standard of review. It added, however, that the claims determination still must comply with ERISA and that the claimant must be afforded a full and fair review. The Court also rejected Leger's arguments that the fifteen year history of payments or the plan's reliance on a medical file review only created a presumption that the termination decision was arbitrary and capricious. Instead, in determining whether a decision is arbitrary and capricious, the Court said it would look to the specific reasons for the denial, whether the claimant was afforded a full and fair review, and whether there is an absence of reasoning in support of the determination. Here, the Court was concerned that the determination failed to mention Leger's voluminous medical record spanning almost 20 years and 17 surgeries. The Court was also concerned about the treatment of the functional capacity evaluation. The plan ignored the FCE evidence that Leger's complaints of pain were real. The Court indicated that the plan was required to do more than just dismiss the complaints. As such, there was an absence of reasoning in the record and the determination was arbitrary and capricious. The Court recognized that it had the option of either remanding the case for further proceedings or reinstating the benefits. Here, because the plan failed to consider the lengthy medical history and to provide adequate reasoning for its treatment of the FCE, the Court was unable to say definitively that the determination was unreasonable. It therefore remanded the case for further proceedings.
