In short, the justifications given by the MRC for its decisionâ€”although certainly not indisputableâ€”are reasonable, which is all that is required. See Davis, 444 F.3d at 576-77 (â€œThe judicial task here is not to determine if the administratorâ€™s decision is correct, but only if it is reasonable.â€); Sisto, 429 F.3d at 701 (â€œRaising debatable points does not entitle [the claimant] to a reversal under the arbitrary-and capricious standard.â€). Because the record contains rational support for the MRCâ€™s assessment, we will not disturb its decision to deny Specialeâ€™s claim for disability benefits.
Fibromyalgia claims face long odds in federal court, and this Seventh Circuit decision fits the typical pattern. As a post MetLife v. Glenn decision, the case does nonetheless present some surprise in that it does not address the standard of review in more than a passing manner.
The district court held, and the parties concede, that review of the MRCâ€™s denial of benefits proceeds under the arbitrary-and-capricious standard, and we will only look to ensure that the Programâ€™s decision â€œhas rational support in the record.â€ Davis v. Unum Life Ins. Co. of Am.,444 F.3d 569, 576 (7th Cir. 2006) (internal quotationmarks omitted). â€œPut simply, an administratorâ€™s decision will not be overturned unless it is downright unreasonable.â€Id.
Notwithstanding that statement of the law, the Court is concerned to say that it does not â€œrubber stampâ€ the administratorâ€™s decision. Having noted that ostensible limitation, the Court went on to say that it would:
. . . uphold the planâ€™s decision as long as
(1) it is possible to offer a reasoned explanation, based on the evidence, for a particular outcome,
(2) the decision is based on a reasonable explanation of relevant plan documents, or
(3) the administrator has based its decision on a consideration of the relevant factors that encompass the important aspects of the problem.â€
Sisto v. Ameritech Sickness & Accident Disability Benefit Plan, 429 F.3d 698, 700 (7th Cir. 2005) (internal quotation marks omitted).
The claim was evidently a toss up. The question boiled down to a conflict of opinions provided by the experts:
The only evidence of Specialeâ€™s functional capabilities provided to the MRC consisted of the questionnaires completed by Drs. Winny and Keane and Dr. Blonskyâ€™s reports. The committee was therefore faced with the conflict between Dr. Winnyâ€™s questionnaire and Dr. Keaneâ€™s belief that Speciale could work, along with Dr. Winnyâ€™s later statement that Speciale could attempt a position that did not require travel.
On the “not downright unreasonable” standard, the tie goes to the disability carrier.
Note: The claim did not go unpaid. The opinion notes that “[a]fter her appeal failed, Speciale sent the MRC a copy of a favorable ruling by the Social Security Administration granting her application for disability benefits.”
Tie-Breaker? In the event of a structural conflict of interest, any one factor can serve as a tie-breaker per the Supreme Court in MetLife v. Glenn:
We believe that Firestone means what the word “factor” implies, namely, that when judges review the lawfulness of benefit denials, they will often take account of several different considerations of which a conflict of interest is one. . . . In such instances, any one factor will act as a tiebreaker when the other factors are closely balanced, the degree of closeness necessary depending upon the tiebreaking factor’s inherent or case-specific importance.
This argument was evidently not pressed upon the Seventh Circuit