Case Name: Gilewski v. Provident Life and Accident Insurance Company
Court: U.S. Court of Appeals for the Sixth Circuit, on appeal from the U.S. District Court for the Western District of Michigan.
Date of Decision: March 22, 2017.
Type of Claim: Long Term Disability pursuant to ERISA.
Insurance Company: Provident Life and Accident Insurance Company.
Claimant’s Occupation / Job Position: Gilewski, born in 1968, was the owner and president of Radiance Mold and Engineering, Inc., an auto supplier in Michigan, for 20 years.
Definition of Disability: The policy at issue in this case required Provident to pay monthly benefits to a participant who satisfies various conditions, including being disabled within the meaning of the term as defined by the policy. The policy states:
Disability, or disabled, means that, due solely to Injuries or Sickness:
1. you have a Loss of Time or Duties in your occupation; and
2. you have a Loss of Earnings of at least 20%.
. . .
Loss of Time or Duties means that:
1. you are not able to perform one or more of the substantial and material duties of your occupation; or
2. you are not able to perform the substantial and material duties of your occupation for as much time as you regularly performed them before you became disabled.
. . .
Your occupation means the occupation . . . in which you are regularly engaged at the time you become disabled.
Benefits Paid? Yes. Then terminated.
Basis For Denial / Termination of Benefits: Provident paid LTD benefits under the second of two policies, but, after four years, it terminated the benefits after it determined that Gilewski was “able to perform the duties of his occupation” and was no longer disabled under the terms of the policy.
Procedural history: After exhausting Provident’s administrative appeals, Gilewski brought this action against Provident. The district court granted judgment on the administrative record to Provident. The Sixth Circuit affirmed.
Other important factors: On June 19, 2013, a Dr. Dudley performed an “independent medical examination”. Dr. Dudley diagnosed Gilewski with “Major Depressive Disorder, Unipolar, stabilized,” and assigned him a Global Assessment of functioning score of 80. Dr. Dudley concluded that Gilewski did not require a psychiatric disability status and that he was able to return to work without restrictions.
Key Physician Opinions: In November 2010, Gilewski underwent a forensic psychiatric examination as part of his bankruptcy proceeding. He was examined by Dr. Gerald Shiener, a board certified psychiatrist. Dr. Shiener diagnosed Gilewski with “Major depression, recurrent and chronic,” and concluded that Gilewski’s “current condition is incompatible with any sort of competitive employment.”
Issue: The sole issue on appeal is whether the district court erred in holding that Provident’s decision to terminate Gilewski’s long-term disability benefits was supported by substantial evidence in the administrative record. Gilewski’s primary complaint is that the Provident did not give enough weight to the opinion of his treating physician, Dr. Shiener, and relied instead on the opinions of nontreating psychiatrists, only one of whom had actually examined Gilewski. Gilewski also contends on appeal that the district court erred in not requiring Provident to consider the evidence submitted by Gilewski regarding a vocational expert who opined about the demands of Gilewski’s occupation, and he also maintains that the administrative process was marred by a conflict of interest because Provident is both the decisionmaker and the payor of benefits.
Holdings: However, the court concluded that the evidence does not support the plaintiff’s claim.
“In addition to a dearth of information from Dr. Shiener, the attending physician statements and reports he did provide were incompatible with Gilewski’s self-reported activity level and abilities in 2012 and 2013, as well as with the other medical opinions, including the opinion of Dr. Dudley, who performed an independent medical examination on Gilewski in June 2013, and the file reviews of Dr. Szylk, Provident’s in-house psychiatrist, and Dr. Brown, the independent reviewer for the administrative appeal. The nontreating physicians all agreed with Dr. Shiener’s diagnosis of major depressive disorder, but the nontreating physicians believed the condition to be “stabilized” and well-treated with Gilewski’s current medications. Dr. Dudley noted that if after four years of treatment Gilewski’s condition and prognosis were as poor as Dr. Shiener believed, Gilewski should be receiving more intensive treatment through changed medications, intensive psychotherapy, or even in-patient treatment at a psychiatric facility. Even after Dr. Dudley sent his report to Dr. Shiener, Dr. Shiener gave no indication that he though a change in treatment was needed at that time.”
Noteworthy court comments: “Generally speaking, an administrator may not summarily reject the opinions of a treating physician, but must instead give reasons for adopting an alternative opinion.” Elliott v. Metro. Life Ins. Co., 473 F.3d 613, 620 (6th Cir. 2006). Administrators, however, are not obligated to accord special deference to the opinions of treating physicians.
Summary: In conclusion, reviewing the administrative record and giving no deference to Provident’s decision to terminate benefits, we find substantial evidence supports Provident’s decision to terminate Gilewski’s long-term disability benefits.