REX T. KEARNEY, JR., Plaintiff-Appellant,
v.
STANDARD INSURANCE COMPANY, Defendant-Appellee.
No. 96-16539
No. 96-16701
United States Court of Appeals for the Ninth Circuit
D.C. No. CV-S-95-415-WBS/JFM
Appeals from the United States District Court for the Eastern District of California William B. Shubb, District Judge, Presiding
Argued and Submitted
August 5, 1997 -- San Francisco, California
Before: Joseph T. Sneed, Betty
B. Fletcher, and Stephen Reinhardt, Circuit Judges.
Marjorie E. Manning, T.D. Bolling, Jr., Bolling Walter & Gawthrop, Sacramento, California, for the plaintiff-appellant.
Shawn Hanson, Michael A. Conley, Pillsbury Madison & Sutro, San Francisco, California, for the defendant-appellee.
Filed April 21, 1998
REINHARDT, Circuit Judge:
Plaintiff-appellant Rex T. Kearney, Jr. is an attorney who was a civil trial partner, and managing partner, at the law firm of Ingoglia, Marskey & Kearney. In 1992, following open heart surgery, he began receiving disability benefits under a Long Term Disability Plan issued by Defendant-Appellee Standard Insurance Company. Within two years of approving such benefits, however, Standard terminated them. Kearney eventually brought suit under the Employment Retirement Income Security Act (ERISA), 29 U.S.C. § 1132(a)(1)(B) (1994), but the district court granted summary judgment in favor of Standard primarily because in its view "the fact that [Kearney] should, like most of us, avoid severe emotional stress or very hard work does not warrant the conclusion that he cannot practice as a trial attorney." We find both the district court' s "diagnosis" and its conclusion very much open to question. Therefore, we reverse and remand.
Because we must review this case de novo,[FOOTNOTE 1] we set forth the facts in some detail.
Rex Kearney regularly worked long hours trying civil lawsuits until he encountered health problems. As a trial attorney, a large part of Kearney' s success was due to his ability to work very hard while retaining excellent cognitive and verbal skills, often under severe pressure. Indeed, one doctor described him as having a classic "Type A" personality -- a frequently obsessive, compulsive worker. On November 3, 1992, however, Kearney -- who had already suffered a heart attack in 1981 at the age of 43 and undergone angioplasty of the diagonal artery in 1988 -- experienced chest pain and nearly collapsed in court during a trial. Six days later, Kearney underwent five-vessel coronary bypass surgery, mitral valve repair, and a closure of a patent pinhole in his heart muscle.
About a month after the surgery, Dr. Stephen Morrison, a Board Certified cardiologist, examined Kearney and noted that he was experiencing musculoskeletal symptoms which should resolve in the next several weeks. Dr. Morrison added, however:
I am also concerned about his memory and I am [sic] told him that I am impressed that this occurs frequently after bypass surgery, and I am hopeful that this will also significantly improve as it is a very large part of his occupation to have a very adequate and perhaps excellent memory as he is a practicing attorney.
Kearney forwarded this letter and a request for disability benefits to his firm' s insurer, Standard Insurance Company ("Standard" ).
Part 6 of Standard' s insurance policy issued to Kearney, the "Long Term Disability Insuring Clause," reads:
Subject to all the terms of the GROUP POLICY, STANDARD will pay the LTD benefit described in Part 8 upon receipt of satisfactory written proof that you have become DISABLED while insured under the GROUP POLICY.
The definition of "disability" is set forth in Part 5 of the policy and reads:
A. DEFINITION OF DISABILITY FOR ATTORNEYS.
You are only required to be DISABLED from your specialty in the practice of law.
You are DISABLED from your own specialty in the practice of law if, as a result of SICKNESS, ACCIDENTAL BODILY INJURY or PREGNANCY, you are EITHER:
1. Unable to perform with reasonable continuity the material duties of your specialty in the practice of law; OR
2. Unable to earn more than 80% of your INDEX PREDISABILITY EARNINGS while working in your specialty in the practice of law.
Under this definition of DISABILITY, you will be considered DISABLED while working in another occupation if you are DISABLED from your specialty in the practice of law.
On December 29, 1992, Standard approved Kearney' s claim for disability benefits.
Over the next several months, Dr. Morrison continued to see Kearney. At one point, Dr. Morrison rated Kearney as a "Class I" cardiac patient -- a patient in whom ordinary activity should not cause undue fatigue, pain, or palpitation. At the same time, however, Dr. Morrison noted Kearney experienced premature ventricular contractions during his examination. In a later report, on May 11, 1993, Dr. Morrison reclassified Kearney as a "Class II" patient and wrote that he believed that he would be unable to return to his usual occupation for 6-12 months and, then, up to only 75% of his pre-surgery workload.
During the same time period, several other doctors examined Kearney and reached similar results. The first was Kearney' s treating physician for 20 years, Dr. Lehman. Initially, Dr. Lehman noted that Kearney "feels he' s lost 20% of his intelligence off the top." In a letter submitted to Standard on February 26, 1993, Dr. Lehman summarized the results of the cardiology examination he performed on Kearney:
Unfortunately, the patient is manifesting evidences of cognitive impairment, which has been well reported after coronary artery bypass surgery, particularly, as in Mr. Kearney' s situation, when the patient does truly have open heart surgery. . . . At the present time, I would have to consider him completely or near completely disabled, though most of these patients recover function within 6 months, and I am hopeful that we still might see some improvement in the relatively near future.
Dr. Lehman diagnosed Kearney with status post-coronary artery bypass and mitral valve angioplasty with "persistent fatigue and diminished intellectual capacity."
Kearney' s psychiatrist, Dr. Kaufman, also submitted medical data to Standard. Dr. Kaufman reported that Kearney had a loss of memory and knowledge. Kearney, for example, failed to recollect a client with whom he had met recently. Dr. Kaufman stated that Kearney suffered from "more than average" loss of memory for this age and concluded that he would not be able to do trial work. The danger for Kearney, according to Dr. Kaufman, was that "[Kearney] doesn' t know what he doesn' t know."
The final doctor to examine Kearney during this period was Dr. Peter Heublein, a medical neurologist. Dr. Heublein noted in his report, which was forwarded to Standard, that Kearney stated that "he cannot return to work as a litigating attorney under the present circumstances." Dr. Heublein wrote that it was impossible to tell whether Kearney was suffering from organic brain syndrome or anxiety and depression-induced memory loss. Furthermore, Dr. Heublein stated that, because Kearney' s MRI scan was "unremarkable," psychometric testing would be necessary to document Kearney' s organic memory and cognitive disturbances as well as potential psychological components.
As concrete evidence of his disability, Kearney informed Standard that during two days of light work -- a settlement conference and two depositions -- he became "stressed out," had "PVC" palpitations, and was hospitalized briefly. Subsequent stress EKG' s while Kearney was on a treadmill did not reproduce those symptoms, indicating that they were most likely stress-induced. Once Kearney was out of the hospital and away from work, he returned to rehabilitation without further problems. In November 1993, due to his debilitated condition, Kearney closed his law office. Kearney also explained to an investigator that he had to cease teaching continuing legal education courses because he could no longer recall the civil code in a manner sufficient to permit him to answer questions. He also stated that he was able, with adequate rest, to play a few sets of doubles tennis on the weekends.
Reports submitted to Standard through the rest of 1993 continued to confirm Kearney' s cognitive and stamina impairments. Dr. Lehman sent Standard a statement concluding that Kearney' s "intellectual impairment precluded legal work." Dr. Lehman was unable to determine when Kearney could return to work, and added, "It' s been so long, I doubt he' ll recover, unfortunately." In addition, in December, 1993, Dr. Morrison informed Standard that Kearney' s condition was unchanged and that he continued to be restricted by his poor memory. Dr. Morrison said that he did not know when Kearney could return to work, but recommended a follow-up appointment in six months.
In April, 1994, Standard asked another doctor of its choosing, Dr. Randall Smith, to conduct an "independent" medical examination of Kearney. Dr. Smith, a neuropsychologist, reported that he found in Kearney no evidence of cognitive deficiencies based on formal testing; that mental status exams resulted in exceptional performance; and that there was no evidence of aphasia, paraphysis, or word-finding pauses. Dr. Smith reported that Kearney' s cognitive "Shipley test" indicated average abstract reasoning skills and above average verbal skills. He characterized Kearney as possessing "superior general memory functioning and unimpaired verbal and visual memory functions" in light of these "average" scores, but noted that Kearney had done "somewhat more poorly on a measure of active attention and concentration." Finally, Dr. Smith reported that Kearney told him he had a hobby of rebuilding and driving race cars in excess of 100 miles per hour.
Despite the fact that Kearney' s responses to a test administered by Dr. Smith indicated that Kearney' s description of his disability symptoms was truthful, realistic, internally consistent, and suggested no psychiatric diagnosis, Dr. Smith concluded that Kearney' s inability to return to work as an attorney was motivational in origin. Dr. Smith summarized his results as follows:
[M]y evaluation of Mr. Kearney does not reveal any evidence of cognitive, verbal skill, or memory deficits which would preclude him from effectively functioning as an attorney at the present time. . . . I can certainly find no evidence of neuropsychological deficits which would prompt him to be labeled disabled. Those physicians who have drawn such conclusions have done so simply based on the patient' s self-report, and not as a result of formal or systematic evaluation.
Based on Dr. Smith' s report -- specifically, his medical diagnosis and his description of Kearney' s hobby of driving race cars -- Robert Case, Standard' s claim analyst, notified Kearney by letter that his long term disability benefits would be terminated because Standard believed he was no longer unable to perform his specialty as a trial attorney.
Kearney soon wrote back to Standard urging it to reverse its decision. In support of his position, he enclosed recent reports from Dr. Irwin Weinreb, a cardiologist, and Dr. Robert Bittle, a diplomat of the American Board of Psychiatry and Neurology, that stated that Kearney probably was disabled from working as a trial attorney and that, upon further testing, this conclusion could be confirmed.
Dr. Weinreb' s complete medical-cardiac evaluation revealed two abnormal EKG' s and demonstrated that Kearney was prone to chronic fatigue and reduced stamina. Dr. Weinreb suspected that Kearney suffered from diminished memory owing to his heart condition and stated that, without question, he had naturally progressing coronary occlusive atherosclerotic artery vascular disease from 1988 forward. Dr. Weinreb concluded that while Kearney could do legal work outside of trial work, he should be precluded "from very heavy work and very severe emotional distress," and "certainly should avoid intense emotional stress and not be on a very tight time schedule."
Dr. Bittle' s report stated that Kearney' s cardiac impairment caused chronic and easily induced fatigue, and reduced stamina. Dr. Bittle also reported that although most neurocognitive deficits tend to improve with time following cardiac surgery, he believed that Kearney fell into the minority who retain neurocognitive behavioral problems. Cognitive problems that might appear subtle, Dr. Bittle emphasized, greatly increase in the face of the stress and situations when one must remember a multitude of facts. Thus, Dr. Bittle concluded that although Dr. Smith may have correctly concluded that Kearney could return to some type of legal work, it was "highly medically probable" that his cognitive deficiency interfered significantly with his ability to function in the highly complex arena of trial work. Equally important, Dr. Bittle stated that more sophisticated testing than Dr. Smith' s was needed in order to determine the extent of Kearney' s potentially subtle but significant residual cognitive deficits. He explained that further neurophysiological studies could document the problems of which Kearney complained, but that Dr. Smith had not conducted such tests.
Dr. Fraback, a rheumatologist employed by Standard, was the first Standard doctor to review Kearney' s supplemental reports, although he never examined Kearney himself. Because Dr. Fraback viewed Kearney' s doctors' results as "suspect," he preliminarily concluded on the basis of the medical reports that Kearney would be able to practice as a trial attorney. (Dr. Fraback provided no explanation regarding his knowledge of the duties of a trial attorney.) At the same time, however, he strongly advised Standard to procure Dr. Weinreb' s EKG' s and other medical data for further study. If the EKG' s were accurate, Dr. Fraback explained, then Kearney' s heart condition would indeed constitute a significant impairment.
In an addendum to his earlier report, Dr. Smith also reviewed the reports of Dr. Weinreb and Dr. Bittle. Without performing any additional physical examination or analysis, Dr. Smith said that he found no neuropsychological reason Kearney could not return to work as an attorney, "even in a trial setting." At the same time, however, Dr. Smith conceded that "whether there are cardiovascular preclusions to returning to the work of a trial attorney is outside of the realm of my expertise to determine." Finally, he admitted to not performing the tests that Kearney' s doctors recommended, but reminded Standard that he had not been asked to perform such tests and claimed that, given Kearney' s symptoms, they were unnecessary in any event.
Standard never sought to obtain the medical data that Dr. Fraback recommended it review. Instead, on January 27, 1995, its Quality Assurance Unit reviewed Kearney' s claim and decided not to reverse its decision to terminate his long term disability benefits. Standard wrote:
The occupation of a trial attorney is sedentary and falls well within the physical restrictions outlined by D. Weinreb. Much of the work involves conducting research and does not require being in court or on a very tight time schedule.
. . . We do not dispute that Mr. Kearney cannot continue to work 75 hours per week managing the business end of his law firm, trying his own cases, and running his leasing company, in addition to pursuing his hobby of racing cars.
. . . [However, t]he issue upon which we must focus is whether or not he has the physical and mental capabilities to perform, with reasonable continuity, the material duties of a trial attorney, as it is performed in the general economy. Based on our review, we do not find satisfactory evidence to support your client' s claim that he is so impaired mentally and physically that he is unable to practice as a trial attorney.
On March 7, 1995, having exhausted his administrative remedies, Kearney filed the instant suit, alleging that Standard had terminated his benefits in violation of ERISA, 29 U.S.C. § 1132(a)(1)(B) (1994).
After the parties filed cross motions for summary judgment, the district court granted summary judgment in favor of Standard. First, the court held that Kearney was entitled to a de novo review of the record, but limited its scope of review to the evidence before Standard when it denied benefits for the last time. Hence, the court prevented Kearney from offering expert evidence describing the material duties of a person engaged in his specialty, as well as additional medical evidence elaborating on his physical condition and on the relationship between cardiac impairments and performance of a trial lawyer' s duties. In a second order, the court ruled that Kearney' s condition failed, as a matter of law, to constitute a disability under the terms of the policy. The court concluded that:
The fact that plaintiff should, like most of us, avoid severe emotional stress or very hard work does not warrant the conclusion that he cannot practice as a trial attorney. . . .
. . . .
[T]here is no question that plaintiff' s physical and mental stamina has been weakened by his heart condition. Unfortunately, the LTD policy does not insure that he would forever remain at his former state of health and stamina. Without sufficient evidence that the condition left him so disabled that he cannot perform the functions of a trial attorney, plaintiff' s claim fails.
In addition, the court held that the second definition of "disabled" in the long term disability policy -- the inability to earn 80% of predisability earning while working in the attorney' s specialty -- did not apply because Kearney was not working at the time Standard decided to terminate his claim.[FOOTNOTE 2]
Kearney then filed a motion under Rule 59(e) to vacate the judgment or, in the alternative, for entry of a new and different judgment. The district court denied his motion without oral argument and ordered him to pay attorneys' fees to Standard to compensate it for the cost of litigating his motion.
Kearney now appeals both of the district court' s decisions, arguing that the district court should have granted summary judgment in his favor (or, at least, should have denied Standard' s motion for summary judgment) and that it erred in assessing attorneys' fees against him on his Rule 59(e) motion.
In Parts I and II, we determine the proper standard and scope of judicial review of Standard' s decision to deny Kearney disability benefits. Then, in Part III, we review the district court' s decision upholding the denial of benefits. Finally, in Part IV, we address the award of attorneys' fees.
Kearney' s policy read, in relevant part, that Standard would pay long term disability benefits "upon receipt of satisfactory written proof that you have become DISABLED while insured under the GROUP POLICY." Because the district court found that this clause did not "unambiguously vest[ ] the administrator with discretionary power" to determine eligibility for long term disability benefits, it reviewed the case de novo. Standard contends that, particularly due to our intervening holding in Snow v. Standard Ins. Co., 87 F.3d 327, 330 (9th Cir. 1996), the policy does vest discretionary authority in the administrator; thus, it asserts, the district court and this court must review the administrator' s decision for an abuse of discretion. Standard is mistaken. We have never held that so imprecise and ambiguous a provision as contained in Kearney' s policy vests discretion in the administrator, and we decline to do so now.
In an action to recover benefits under an ERISA plan, the district court must review the administrator' s denial of benefits de novo "unless the benefit plan gives the administrator or fiduciary discretionary authority to determine eligibility for benefits or to construe the plan." Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989). When the administrator retains such discretionary authority, the district court ordinarily will review the administrator' s determinations for an abuse of discretion. See Snow, 87 F.3d at 330; Winters v. Costco Wholesale Corp., 49 F.3d 550, 552 (9th Cir.), cert. denied, 116 S. Ct. 276 (1995). If the plan' s funding source and its administrator are the same entity, however, and if facts suggest that the entity may have acted out of self-interest, the denial of benefits will be subject to de novo review. See Lang v. Long-Term Disability Plan, 125 F.3d 794 (9th Cir. 1997); Atwood v. Newmont Gold Co., 45 F.3d 1317, 1322-23 (9th Cir. 1995). Here, de novo review is warranted for two reasons, either one of which would be sufficient: (1) Standard did not retain discretionary authority and (2) its decision may have been affected by a conflict of interest.
First, we have previously explained that a plan gives the fiduciary
the authority to determine eligibility only if the plan includes at least
"one important discretionary element, and the power to apply that element is
unambiguously retained by its administrator." Bogue v. Ampex Corp.,
976 F.2d 1319, 1325 (9th Cir. 1992), cert. denied, 507 U.S. 1031
(1993) (emphasis added). If the administrator does not retain the "power to
apply" a discretionary element, it must apply the plan in a purely objective
manner, and, more important, courts do not defer to its judgment. In Snow,
this court applied the principle explained in Bogue, holding that
a plan providing that "there will be no benefit unless Standard is presented
with what it considers to be satisfactory written proof of the claimed
loss" unambiguously vested discretion in the administrator. 87 F.3d at 330
(emphasis added).Snow, does not state
that Standard retains the authority to determine what it considers to
be "satisfactory written proof." At best, from Standard' s viewpoint the
plan that covers Kearney is ambiguous as to whether Standard is granted the
discretion to apply its subjective judgment or whether the question of what
proof is satisfactory must be determined objectively under applicable legal
and medical principles. The distinction is hardly trivial. If, as in Snow,
Standard retains the authority to deny benefits when it believes in good
faith that insufficient proof is offered, it also retains the discretion to
give substance to its own standard. See 87 F.3d at 330; see also
Donato v. Metropolitan Life Ins. Co., 19 F.3d 375, 379-80 (7th Cir. 1994)
(plan used phrase "all proof must be satisfactory to us" ); Miller v.
Metropolitan Life Ins. Co., 925 F.2d 979, 983 (6th Cir. 1991) (plan used
phrase "on the basis of medical evidence satisfactory to the Company" ). If
the standard of proof is an objective one, however, Standard may deny
benefits only to the extent that courts independently would conclude that the
evidence fails to constitute satisfactory written proof. Thus, the different
standards of review.
The plan' s uncertainty on this point is fatal to Standard' s
assertion of discretionary authority and requires us to adopt a purely
objective approach to claimants' eligibility for benefits. This court
explained in Bogue that "[l]anguage that establishes only an entity' s
right to administer or manage a plan does not confer discretion." 976 F.2d
at 1325; see also Bruch, 489 U.S. at 111. More important, we added:
Bogue, 976 F.2d at 1325. Thus, drafters of plans, if they wish the
courts' review to be limited, must leave no doubt in the language of the
plan that an administrator has the authority to construe the terms of the
plan and to exercise its discretion when making eligibility decisions.
Otherwise, ambiguities will be construed against the drafter and eligibility
determinations will be evaluated under an objective standard.
The plan in Snow allowed Standard to deny benefits when not
faced "with what it considers to be satisfactory written proof" ; the
plan in this case, however, speaks only in general terms of the claimant' s
obligation to submit "satisfactory written proof." The district court was,
therefore, right to conclude that the plan fails "unambiguously" to provide
Standard with the discretion to make eligibility determinations. the Sixth Circuit, at least initially,
reached the same conclusion we do. It explained:
Perez v. Aetna Life Ins. Co., 96 F.3d 813, 826 (6th Cir. 1996);Id.
In Mongeluzo, we joined a number of other circuits in
following the Fourth Circuit' s approach to this issue, holding that the
district court was required to admit evidence beyond what was presented to
the administrator "when circumstances clearly establish that additional
evidence is necessary to conduct an adequate de novo review of the benefit
decision." Id. at 944 (quoting Quesinberry v. Life Ins. Co., 987 F.2d
1017, 1025, (4th Cir. 1993) (en banc)).Id. Some of the circumstances that courts should consider in
determining whether to allow additional evidence are set forth in
Quesinberry. They include:
Quesinberry, 987 F.2d at 1026-1027. This list is, of course, not
exhaustive. Id. at 1027. Because Quesinberry involved (1) complex,
medical testimony, (2) the interpretation of a key provision in the plan, and
(3) a circumstance in which the payor was also the administrator, the Fourth
Circuit held that the district court' s decision to allow additional evidence
was proper. Id. at 1027.
The same three factors present in Quesinberry are present in
this case, and one raises especially strong concerns -- namely, that
Standard, acting under a conflict of interest, neglected to obtain additional
medical evidence that its own doctor said could establish Kearney' s
disability. First, the medical issue regarding the extent of Kearney' s
cognitive deficiency, and its connection to his heart condition, is decidedly
complex, as is the question of the extent to which his cardiac condition
limits his ability to undergo stress and perform hard work. The doctors'
reports on these issues do not always meet head-on, and credibility issues
exist. Yet the district court held that it was "well able to review the
issues presented without need for additional evidence." We disagree.
"[W]here the record contains numerous and possibly conflicting medical terms
and diagnoses, excluding new evidence would force this court to become its
own medical expert." Peters v. Life Ins. Co. of N. Am., 816 F. Supp. 615,
618-19 (N.D. Cal. 1993); see also Quesinberry, 987 F.2d at 1027
(stating that "if the court is faced with a complex medical issue on which
testimony from experts is necessary for an adequate understanding of the
issue and the administrative procedures do not have a mechanism for taking
such testimony, allowing such testimony would be appropriate" ); Masella v.
Blue Cross & Blue Shield, 936 F.2d 98, 104-05 (2d Cir. 1991) (same). Here,
this factor weighed heavily against foreclosing Kearney' s ability to submit
additional medical evidence -- recommended by an array of doctors -- that
would help develop an adequate understanding both of the extent of his
cognitive deficits and the relationship to his heart condition, and the
extent of his diminished physical capacity to work long hours and incur
serious stress. The district court, instead, unnecessarily risked becoming,
in effect, "its own medical expert." Peters, 943 F. Supp. at 619.
Second, Kearney' s claim turned on the interpretation of a key
provision of the plan, the definition of the "material duties" of a trial
attorney. The plan administrator' s conclusion that trial attorneys' duties
were "sedentary," and the lack of information in the administrative record
describing the typical duties of trial attorneys, should have alerted the
district court to the possibility that the administrator was misinformed or
uniformed as to the material duties of a trial attorney. The term
"sedentary," as the Social Security Administration defines it, classifies
work according to the required physical exertion only and in no way accounts
for the required mental stamina, stress-related endurance, or memory skills.
See 20 C.F.R. § 404.1567(a) (1997). Similarly, the dictionary
definition of the term "sedentary" refers solely to the amount of physical
exertion involved and does not consider other requirements. See 2 The
New Shorter Oxford English Dictionary 2755 def' n 2 (4th ed. 1993)
("characterized by or requiring much sitting and little physical exercise" ).
All this, of course, is wholly aside from the odd assumption that trial
counsel are primarily chairbound. The mental exertion required and the degree
of stress that is inherent in the performance of one' s duties obviously
makes trial advocacy considerably more demanding for legitimate cardiac
patients than ordinary sedentary work. The administrator' s questionable
conception of the nature of the claimant' s work might, in itself, make it
"necessary for the case to be reevaluated" under the proper definition.
See Mongeluzo, 46 F.3d at 944 (holding that, where the original
hearing was conducted under a misconception of the meaning of the plan' s
provisions, case must be remanded to consider additional evidence); see also
Saffle v. Sierra Pac. Power Co. Bargaining Unit Long Term Disability Income
Plan, 85 F.3d 455, 461 (9th Cir. 1996) (same); Quesinberry, 987 F.2d
at 1027 (same). Additional evidence regarding the nature of trial work would,
at a minimum, have aided the district court in conducting its de novo review
of whether Dr. Weinreb' s warning to avoid stress and hard work rendered
Kearney disabled. See McClure v. Life Ins. Co. of N. Am., 84 F.3d 1129, 1134
(9th Cir. 1996) (per curiam) (holding that pertinent inquiry is whether
plaintiff is prevented from performing a single material duty). It therefore
should have been admitted.
Third, Standard was both the plan' s payor and its administrator,
which should have caused the district court to be alert to questions
regarding impartiality. Quesinberry, 987 F.2d at 1026-1027; see
also Snow, 87 F.3d at 331 (noting that "if the plan administrator is
operating under a conflict of interest, ' that conflict must be weighed as a
factor in determining whether there is an abuse of discretion' ") (quoting
Bruch, 489 U.S. at 115). Standard stood to lose some $1,172,000,
excluding cost of living adjustments, if it continued to pay Kearney' s
claim. Moreover, the record suggests that this conflict may have affected its
review of Kearney' s claim. See Atwood, 45 F.3d at 1322-1323 (if
plaintiff produces evidence of conflict, court should review administrator' s
decisions "very skeptically" ). Standard ignored various doctors'
recommendations, including a recommendation by its own doctor, that it obtain
existing and additional medical data -- including Kearney' s
electrocardiogram and stress EKG performed by Dr. Weinreb (both of which were
abnormal) -- to help develop the particularities of Kearney' s condition.
In fact, Standard' s doctor, Dr. Fraback, although skeptical of Dr. Weinreb'
s report, indicated to Standard that Kearney probably would in fact be
disabled if Dr. Weinreb' s EKG confirmed his diagnosis. It is quite possible
that the administrative record was in conflict in large part because Standard
failed to obtain this information. Because the "procurement of further
evidence" regarding Kearney' s heart condition might have altered the
administrator' s decision, the district court, at the very least, should have
allowed additional evidence regarding the efficacy of the additional tests.
See Snow, 87 F.3d at 333 (emphasizing the importance of obtaining
exams by specialists when decision is reviewed de novo). This factor,
therefore, also strongly counseled in favor of admitting additional evidence.
See Quesinberry, 987 F.2d at 1027.
Given the cumulative weight of these compelling reasons to allow
evidence from outside the administrative record, we hold that the district
court abused its discretion in refusing to permit Kearney to adduce
additional evidence before it. The district court should have allowed Kearney
to present (1) medical evidence aimed at explaining and resolving the
somewhat conflicting medical diagnoses and (2) evidence describing the
material duties of trial attorneys.
Although the district court' s failure to admit evidence beyond
that contained in the administrative record in itself requires us to remand
this case for further proceedings, see Mongeluzo, 46 F.3d at 938, we
are also compelled to reverse the district court' s grant of summary judgment
in favor of Standard because the record, even as it now stands, contains
unresolved issues of material fact. Thus, even if Kearney had not sought to
present additional evidence, or if the additional evidence would not have
further advanced his claim, the district court' s summary judgment decision
would be in error.
The district court held, despite the nearly unanimous agreement to
the contrary among the physicians who treated or examined Kearney, that he
was able to perform all of his duties as a trial attorney. Specifically, the
court ruled that "there is no question that plaintiff' s physical and mental
stamina has been weakened by his heart condition" , but that "the fact that
plaintiff should, like most of us, avoid severe emotional stress or very hard
work does not warrant the conclusion that he cannot practice as a trial
attorney."
We must determine whether Standard has demonstrated that no issues
of material fact remain as to whether Kearney was unable to perform at least
one of the material duties of a trial attorney when Standard terminated his
disability benefits. See Bagdadi v. Nazar, 84 F.3d 1194, 1197 (9th
Cir. 1996) (movant retains burden of persuasion); McClure, 84 F.3d at
1134 (holding that pertinent inquiry is whether plaintiff is prevented from
performing a single material duty). We conclude that the record reflects
genuine issues of material fact regarding (1) the extent of Kearney' s
physical and cognitive impairments and (2) the question whether, even if
those impairments preclude him only from undergoing severe stress and
engaging in very hard work, Kearney was able to perform all of the material
duties of a trial attorney.
First, it is somewhat difficult to understand how the district
court could conclude that Kearney was not disabled as a matter of law when
every one of the treating and examining physicians, save Dr. Smith, either
concluded that he was disabled or recommended further testing on the basis
that he probably was disabled. Cf. Pitzer v. Sullivan, 908 F.2d 502,
506 n.4 (9th Cir. 1990) (noting that nonexamining physician' s opinion should
be given less weight than examining physician). Dr. Weinreb, for example,
reported as late as October, 1994 (four months after Dr. Smith' s exam) that
Kearney "could do legal work outside of trial work, wherein he can work
within his disability described above, both physically and emotionally."
This statement strongly suggested that "trial work" was still out of the
question. Dr. Bittle also reported that Kearney' s cognitive impairments
probably precluded trial work and that further tests could confirm that
prognosis. And all the while, Kearney' s treating physicians, Dr. Morrison
and Dr. Lehman, flatly diagnosed Kearney as disabled. Furthermore, it seems
quite debateable that Kearney' s ability to play some doubles tennis and his
occasional practice of driving a race car -- both of which were heavily
relied on by Standard and the district court in denying Kearney' s claim --
is in any way inconsistent with an inability to perform all of the material
duties of a trial attorney without seriously jeopardizing one' s health. Second, an issue of material fact remains regarding the "material"
duties of trial attorneys. A material duty is any duty that a person must
perform in order to execute the functions of an occupation. See Rowan v. Unum
Life Ins. Co. of Am., 119 F.3d 433, 434, 436-37 (6th Cir. 1997). Kearney
submitted evidence from a Department of Labor handbook stating that trial
attorneys "need an exceptional ability to speak quickly and speak with ease
and authority and must be thoroughly familiar with courtroom rules and
strategy . . . . [ ] Lawyers often work long hours, and about half regularly
work 50 hours or more per week. They are under particularly heavy pressure,
for example, when a case is being tried." Standard, on the other hand,
claimed that the "occupation of a trial attorney is classified as sedentary .
. . . Much of the work involves conducting research and does not require
being in court or on a very tight time schedule." It is unclear whether the
district court agreed with this seemingly odd conclusion of Standard' s
regarding the life of a trial lawyer or whether it substituted a related
definition of its own. Regardless of whether a finding along the lines
suggested by Standard could ever stand up to scrutiny, it was erroneous for
the court to reject the evidence offered by Kearney with the only conflicting
evidence in the record being Standard' s. If the court had accepted as true
Kearney' s evidence that performing the job of a trial attorney involves long
hours, hard work and considerable stress,
it probably would have had to find that Kearney was legally disabled in
light of Dr. Weinreb' s explicit admonitions to avoid such working
conditions. See McClure, 84 F.3d at 1134 (holding that pertinent
inquiry is whether plaintiff is prevented from enduring working condition
necessary to perform even a single material duty of job). For present
purposes, however, we need only conclude that a genuine issue of material
fact remains to be resolved.
Shortly after the district court' s order of summary judgment in
favor of Standard, Kearney moved under Rule 59(e) to vacate the judgment,
pointing out the district court' s errors and arguing that an intervening
Ninth Circuit case, McClure, demonstrated that the district court' s
order of summary judgment was wrong. The district court denied the motion,
and at Standard' s request, ordered Kearney to pay attorneys' fees to
compensate it for its legal fees in litigating what the district court called
a "groundless" motion. Kearney appeals the fee award.Hummel factors very frequently
suggest that attorney' s fees should not be charged against ERISA plaintiffs"
).
The fifth factor alone proves dispositive here. Kearney' s motion
pointed the district court to errors it had made regarding the merits of his
case, which are highlighted by McClure' s emphasis that an
ERISA-disability plaintiff need demonstrate only that he is unable to perform
a single material duty of his specialty. The district court,
therefore, was incorrect in concluding that his motion was "groundless."
Indeed, because Kearney was correct in his assignment of error, he more than
adequately raised a "colorable claim of clear error," Thomassen v. United
States, 835 F.2d 727, 731 (9th Cir. 1987), making an award of fees and
costs inappropriate in any context, let alone under ERISA. See id.
We reverse the district court' s grant of summary judgment in favor
of Standard and remand the case with instructions to allow Kearney to present
additional evidence to support his claim. We also reverse the district court'
s award of attorneys fees to Standard.
REVERSED AND REMANDED.
::::::::::::::::::::::::::::: FOOTNOTE(S):::::::::::::::::::::::::::::
FN2. Because we conclude, infra at Part III, that the
district court erred in granting summary judgment based on the policy' s
first definition of disabled, we need not consider whether its dubious
interpretation of the second definition is correct.
FN3. Despite the fact that Standard issued the plans in both
Snow and the present case, it is apparent that at least some of the
language of the two plans differs. The plan in this case applies only to
attorneys, while the plaintiff in Snow was not an attorney.
Furthermore, given that Standard administered both plans, we assume that if
the relevant language had been the same, Standard would have pointed out that
fact in its seven-page discussion of Snow in its brief, for that would
have made that decision practically res judicata. Instead, Standard claims
merely that the plans are "nearly identical." Because a plan must
"unambiguously" vest discretion in its administrator, however, a difference
that may be small in Standard' s view may well prove determinative here. We
note also, for what it may be worth, that we have reservations as to the
effect we would give any representation by Standard that the language of the
two plans was identical. Snow does not quote the plan' s language, and
we doubt that we are free to look behind the text of the opinion in an effort
to ascertain facts that the court failed to set forth or determine. What
matters here is that we described the policy in Snow as requiring proof
that Standard considers to be satisfactory.
FN4. This conclusion is bolstered by this court' s rule that
ambiguities in ERISA insurance contracts are to be construed against the
drafter. McClure v. Life Ins. Co., 84 F.3d 1129 (9th Cir. 1996),
citing Kunin v. Benefit Trust Life Ins. Co., 910 F.2d 534, 539-540 (9th Cir.)
(as amended), cert. denied, 498 U.S. 1013 (1990).
FN5. The plan stated that: "Subsequent written proof of the
continuance of such disability must be furnished to [the company] at such
intervals as [the company] may reasonably require. . . . [The company] shall
have the right to require as part of the proof of claim satisfactory
evidence." 96 F.3d at 825.
FN6. The Sixth Circuit has since vacated this decision and reheard
the case en banc to reconsider this issue and others. 106 F.3d 146 (6th Cir.
1997). The en banc court has not yet announced its decision. However, our
decision is in no way dependent on the en banc court' s adopting the panel
decision with which we agree.
FN7. See also Casey v. Uddeholm Corp., 32 F.3d 1094, 1098-99 & n.4
(7th Cir. 1994); Luby v. Teamsters Health, Welfare and Pension Trust Funds,
944 F.2d 1176, 1184-85 (3rd Cir. 1991); Moon v. American Home Assurance Co.,
888 F.2d 86, 89 (11th Cir. 1989).
FN8. Whether it is wise for a person with a heart condition, or
indeed anyone, to drive race cars occasionally, or frequently, is a question
beyond the scope of this opinion. It is sufficient to note for our purposes
that if people who are sick or disabled engage in unhealthy or unwise
activities it does not render them physically unimpaired. People who continue
to smoke after contracting lung cancer may not for that reason be classified
as cancer-free.
FN9. Kearney also correctly reminded the court that one of his
material duties is his ethical obligation to his clients to withdraw from
representation when he cannot devote sufficient time, energy or quality
service to their cause. See Cal. R. Prof. Conduct 3-110, 3-700; Cal.
Bus. & Prof. Code § 6190. The court made no findings as to whether
Kearney could properly carry on his specialty in light of this obligation.
FN10. Kearney also seeks attorneys' fees under 29 U.S.C. §
1132(g)(1) (1994), which permits plan participants who prevail in ERISA
actions to recover fees. Since we remand this case for further proceedings,
neither party has "prevailed" in this matter. We, therefore, dismiss this
claim as not yet ripe. See McClure, 84 F.3d at 1136.
We do not want to encourage an employer to insulate himself from
effective appellate review through the abuse of vague phrases that fail to
make clear to the employees that the employer will have the final
determination of benefit decisions. Employees who lose promised benefits
should not lose the additional benefit of judicial review because their
employer reserved discretionary power to itself without making that
reservation clear.
Simply because [the administrator] has the ability to require
written proof before continuing disability benefits does not mean that [the
administrator] has the discretionary authority to decide whether that proof
is sufficient within the meaning of the Plan. Second, simply because [the
administrator] may require ' satisfactory proof' does not give the insurance
company discretionary authority. . . . The quoted plan provision does not
specify to whom the proof should be satisfactory. [The plaintiff] probably is
correct in arguing that this language creates an objective standard --
proof "satisfactory" to a reasonable person. But all we need decide at this
point is that the language does not clearly give [the administrator]
discretion, which is what the language of an ERISA plan must do under
Bruch to trigger abuse of discretion review.
claims that require consideration of complex medical questions or
issues regarding the credibility of medical experts; the availability of very
limited administrative review processes with little or no evidentiary record;
the necessity of evidence regarding interpretation of the terms of the plan
rather than specific historical facts; instances where the payor and the
administrator are the same entity and the court is concerned about
impartiality; . . . and circumstances in which there is additional evidence
that the claimant could not have presented in the administrative
process.