United States District Court, N.D. Iowa, Central Division
JEREMY J. TIMM, Plaintiff,
UNUM LIFE INSURANCE COMPANY OF AMERICA, Defendant.
REPORT AND RECOMMENDATION
Williams Chief United States Magistrate Judge
J. Timm (“plaintiff”) seeks judicial review of
Unum Life Insurance Company's (“defendant”)
denial of plaintiff's long-term disability claim brought
under an employee benefit pension plan. This Court has
jurisdiction to review defendant's denial of
plaintiff's claim under the Employee Retirement Income
Security Act of 1974 (“ERISA”), 29 U.S.C.
§§ 1001, et. seq. The Honorable Linda R. Reade,
United States District Court Judge, referred this case to me
for a Report and Recommendation. For the following reasons, I
respectfully recommend that the Court affirm
was a participant in a long-term disability plan offered by
his employer. (Docs. 13, at 3; 14, at 5). The policy was
issued by defendant and became effective on September 1,
2015. (Id.). The policy did “not cover any
disabilities caused by, contributed to by, or resulting from
[plaintiff's] . . . pre-existing condition.” (AR
97- 98). A pre-existing condition, in relevant
part,  is present if plaintiff “received
medical treatment, consultation, care or services including
diagnostic measures, or took prescribed drugs or medicines in
the 6 months just prior to [his] effective date of
coverage.” (AR 98). The six-month period prior to the
plan's effective date of coverage began on March 1, 2015.
(AR 223-24). Therefore, if plaintiff “received medical
treatment, consultation, care or services including
diagnostic measures, or took prescribed drugs or
medications” for his disability between March 1, 2015,
and August 31, 2015, he would be ineligible to receive
benefits under the terms of the plan.
approximately June 1, 2016, plaintiff submitted a disability
claim to defendant alleging that optic neuropathy in his
right eye rendered him unable to continue working. Plaintiff
previously suffered from optic neuropathy in his left eye,
but the condition in his right eye had neither been diagnosed
nor treated as of the effective date of the policy.
Plaintiff's condition caused him to go legally blind in
both eyes. Although defendant approved plaintiff's claim
for short-term disability benefits, defendant denied
plaintiff's claim for long-term disability benefits on
the basis that plaintiff's condition was pre-existing.
The parties agree that the plan gave defendant discretionary
authority to determine eligibility for benefits and to
interpret the terms and provisions of the plan. (Docs. 13, at
7; 14, at 7). Plaintiff now asks the Court to reverse
defendant's decision as to the long-term disability
issue, then, is whether the alleged disability was a
pre-existing condition within the meaning of the policy.
Specifically, plaintiff alleges that the optic neuropathy in
his right eye was not a pre-existing condition because he did
not begin receiving treatment for it until February 29, 2016.
(Doc. 13, at 5). Defendant, on the other hand, contends that
plaintiff's claim is actually for bilateral
sequential non-arteritic anterior ischemic optic neuropathy.
(Doc. 14, at 5). The principle difference between the two
claims is whether the disability alleged is one affecting
only plaintiff's right eye versus both eyes. Plaintiff
agrees that he received treatment for optic neuropathy in his
left eye on July 29, 2015, which was within the
six-month period prior to the policy's effective date.
(Doc. 13, at 4). As a result, if plaintiff became disabled as
a result of bilateral optic neuropathy, as opposed
to optic neuropathy in his right eye only, plaintiff's
condition would have been “pre-existing” within
the language of the policy.
is empowered to bring this suit under 29 U.S.C. §
1132(a)(1)(B), which provides that a plan participant may
bring suit “to recover benefits due to him under the
terms of his plan.” Where, as here, “a plan gives
discretion to the plan administrator, then a plan
administrator's decision is reviewed for an abuse of
discretion. Under an abuse of discretion standard of review,
a plan administrator's decision will stand if reasonable;
i.e., supported by substantial evidence.”
Ortlieb v. United HealthCare Choice Plans, 387 F.3d
778, 781 (8th Cir. 2004) (internal citations and quotation
marks omitted). “‘Substantial evidence . . .
means such relevant evidence as a reasonable mind might
accept as adequate to support a conclusion.'”
Id. at 781-82 (quoting Consol. Edison Co. of New
York v. NLRB, 305 U.S. 197, 229 (1938)).
however, a plaintiff presents “material, probative
evidence demonstrating that (1) a palpable conflict of
interest . . . existed, which (2) caused a serious breach of
the plan administrator's fiduciary duty to [the
plaintiff], ” the plan administrator's decision is
entitled to a less deferential standard of review.
Id. at 782 (quoting Woo v. Deluxe Corp.,
144 F.3d 1157, 1160 (8th Cir. 1998), abrogated in part by
Glenn, 554 U.S. 105 (2008)). To establish a serious
breach of the plan administrator's fiduciary duty, the
plaintiff need only show that the conflict of interest
“has some connection to the substantive decision
reached.” Id. (internal quotation marks
omitted). The existence of a conflict of interest, without
more, however, will not result in the Court applying a less
deferential standard of review. Boyd, 879 F.3d at
320 (holding that the Supreme Court of the United States
“abrogated Woo to the extent Woo
allowed a less deferential standard of review based on
merely a conflict of interest” (emphasis in
original)). “This less deferential standard is a
sliding scale approach, [whereby] the evidence supporting the
plan administrator's decision must increase in proportion
to the seriousness of the conflict . . ..” Boyd v.
ConAgra Foods, Inc., 879 F.3d 314, 320 (8th Cir. 2018)
(alteration in original) (citation and internal quotation
the entity that administers the plan “both determines
whether an employee is eligible for benefits and pays
benefits out of its own pocket, ” the dual role the
administrator plays creates a conflict of interest that the
Court should consider “as a factor in determining
whether the plan administrator has abused its discretion in
denying benefits.” Glenn, 554 U.S. at 108. The
significance given to the conflict of interest will depend
upon the circumstances of the particular case. Id.
The Eighth Circuit Court of Appeals has held that the
conflict may be given more weight if certain factors are
present, such as a biased claims review process, the
employment of reviewing medical professionals whose
compensation was tied to their findings or who were employed
by the insurer, and a review process that merely
“rubberstamp[ed] favorable medical opinions.”
Boyd, 879 F.3d at 320-21. When “the record
contains no evidence about [the plan administrator]'s
claims administration history or its efforts to ensure that
claims assessment is not affected by the conflict, ”
the conflict is given only “some weight.”
Id. (alterations in original) (citations and
internal quotation marks omitted).
contends that defendant operated under an inherent conflict
of interest because it was both the entity responsible for
determining whether benefits were to be paid, and it was the
entity responsible for paying those benefits. (Doc. 13, at
8). Defendant does not dispute that it assumed both roles.
(Doc. 14). Plaintiff argues that the Court should give
substantial weight to defendant's conflict of interest
because “[t]here is no evidence in the record of any
measures taken to either remedy or resolve [the] inherent
conflict of interest, ” and “previous case law
suggests [defendant] has a history of biased claims
administration.” (Doc. 13, at 8).
support of its argument that defendant has a history of
biased claims evaluations, plaintiff turns to Fought v.
Unum Life Insurance Company of America, in which
defendant admitted that it operated under a conflict of
interest in assessing Ms. Fought's disability claim. 379
F.3d 997, 1007 (10th Cir. 2004), abrogated on other
grounds by Glenn, 554 U.S. 105. (Doc. 13, at 8). As in
this case, defendant conceded in Fought that it
operated as both the plan administrator and the payor. 379
F.3d at 1007. This concession of operating under an inherent
conflict of interest, however, was not proven to create a
per se inference of biased claim evaluation.
Id. Instead, the Tenth Circuit Court of Appeals
found that the inherent conflict of interest was to be
considered as one factor in sliding the scale in favor of
granting the administrator's decision less deference.
Id. Plaintiff offers no other support for the
contention that defendant “has a history of biased
claims administration, ” and, as a result, I find that
plaintiff has failed to establish that defendant has a
history of biased claims evaluations. (Doc. 13, at 8).
has not alleged in this case that the reviewing professionals
were employed by defendant or that their compensation was
linked to their findings. Nor has plaintiff pointed to any
evidence in the record to suggest that either of the
propositions is true. As such, I find that these factors
cannot slide the scale in favor of granting less deference to
defendant's denial of benefits. I do find it appropriate,
however, to examine the record for evidence that the
examiners merely “rubberstamped” defendant's
determination that plaintiff was not entitled to benefits.
Boyd, 879 F.3d at 320-21. In scouring the record, I
am persuaded that the examiners undertook a legitimate review
of the record and did not simply provide opinions that would
be favorable to defendant. Plaintiff correctly asserts,
however, that there is no evidence of measures taken to
minimize the effects of the inherent conflict under ...