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May 2010

Kim Iann Manning v. American Republic Insurance Company ? Plan Administrator May Require Objective Medical Evidence of Disability

Denial Of Short-Term Disability Benefits Proper In Absence of Objective Medical Evidence of Disability

(May 12, 2010) 2010 U.S. App. LEXIS 9674 (8th Cir. 2010, S.D. Iowa)

Plaintiff Kim Iann Manning worked for American Republic Insurance Company ("ARIC") selling insurance products over the telephone.  ARIC sponsored and administered a short-term disability plan ("the Plan") for its employees.  To qualify for benefits, eligible employees must, in part, be under the care of an "Approved Health Care Provider," defined to include licensed doctors but not physician assistants. 

About five months after she began work at ARIC, Manning submitted a claim for benefits under the Plan by providing documentation from Physician Assistant Andra Kennedy that Manning had elevated blood pressure, increased frequency of migraines, and increased anxiety.

Jodi Lanphier, an ARIC benefit specialist, responded by asking Manning to specify why she was unable to work.  Manning responded with an additional document from Kennedy that did not explain why Manning's conditions prevented her from working.  Lanphier replied with a letter explaining that the Plan required that claims be submitted by an Approved Health Care Provider, not by a physician assistant, and that a decision on eligibility could not be made until ARIC received objective medical evidence supporting Manning's disability. 

Manning responded with medical records from office visits with Dr. Kenneth Moon.  The first said that Manning "feels the best she has felt in a long time," and the other said that Manning felt "stressed out."  In a subsequent telephone conference with ARIC, Dr. Moon said that Manning's blood pressure level did not require placement on disability status.  Inconsistent with this statement, Dr. Moon said Manning would not be able to return to work due to her blood pressure and migraines.  Dr. Moon then said he could not determine Manning's eligibility to return to work without a further examination.

Dr. Moon then returned to ARIC a completed Certification of Health Care Provider form and notes from an examination of Manning.  The form said that Manning had been under stress from her bankruptcy, and that the stress would likely soon be lifted.  Dr. Moon responded "yes" to the question "is the employee unable to perform work of any kind," without explanation.

ARIC denied Manning's short-term disability claim.  Manning appealed the determination without providing any additional information concerning her medical status.  ARIC upheld the decision "due to lack of objective medical information that illustrates that you are disabled from performing your job duties, as defined by American Republic's Short Term Disability Plan."

ARIC told Manning she could either return to work with certification from her doctor that she was able to do so, or provide objective medical information that she was disabled.  ARIC also advised that her employment would be terminated if she failed to return to work on August 31, 2005.  Manning did not return to work, and ARIC terminated her employment. 

After exhausting her administrative remedies, Manning sought judicial review of ARIC's denial of her short-term disability benefits under ERISA.  Manning also made an ERISA retaliation claim in which she asserted that ARIC fired her based on her application for short-term disability benefits.  Finally, Manning made an ERISA interference claim that ARIC's wrongful termination prevented her from obtaining future rights and benefits under ARIC's long-term disability benefits plan. 

The Iowa District Court held ARIC did not abuse its discretion in denying benefits, and granted ARIC summary judgment on Manning's ERISA retaliation and interference claims.  Manning appealed, and the Eighth Circuit Court of Appeals affirmed. 

In reaching its conclusion, the Eighth Circuit explained that substantial evidence supported ARIC's decision, and ARIC did not abuse its discretion, because the records submitted to ARIC did not constitute objective medical evidence of disability.  Specifically, the Court of Appeals found that Dr. Moon merely provided a subjective opinion with no explanation as to how Manning's condition prevented her from performing her regular job duties. 

The Eighth Circuit also held ARIC's request for objective medical evidence was not a procedural irregularity requiring the Court of Appeals apply a less deferential standard of review.  The Court of Appeals held it was not unreasonable for a plan administrator to deny benefits based on a lack of objective evidence, and noted that a plan administrator is not required to order an IME when the claimant's evidence is facially insufficient to support a finding of disability. 

The Court of Appeals explained that the plan administrator's interpretation of the plan was reasonable using the five-factor test set forth in Finley v. Special Agents Mut. Benefit Ass'n, 957 F.2d 917, 921 (8th Cir. 1992).  The factors a court must consider include (1) whether the administrator's language is contrary to the clear language of the plan; (2) whether the interpretation conflicts with the substantive or procedural requirements of ERISA; (3) whether the interpretation renders any language in the plan meaningless or internally inconsistent; (4) whether the interpretation is consistent with the goals of the plan; and (5) whether the administrator has consistently followed the interpretation. 

Citing Darvell v. Life Ins. Co. of North America, 597 F.3d 929, 934 (8th Cir. 2010) the Court of Appeals explained, "the dispositive principle remains . . . that where plan fiduciaries have offered a reasonable interpretation of disputed provisions, courts may not replace it with an interpretation of their own – and therefore cannot disturb as an abuse of discretion the challenged benefits determination."

Finally, the Court of Appeals upheld the district court's grant of summary judgment on Manning's ERISA retaliation and interference claims.  The Court of Appeals explained that Manning provided no direct evidence that ARIC terminated her either in retaliation for making an ERISA benefits claim or in interference with any right to attain future benefits.  The Court of Appeals held that ARIC's request for a medical certification form did not constitute direct evidence to support Manning's ERISA retaliation or interference claim, as such a request did not establish a causal link between the alleged discriminatory animus and the challenged decision denying benefits. 

This opinion may be cited as precedent now.  The result in this case could change, however, if a subsequent petition for rehearing or a petition for certiorari to the United States Supreme Court is granted. 

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