Robert Mems v. City of St. Paul

1 The Honorable Joseph F. Bataillon, United States District Judge for the
District of Nebraska.
United States Court of Appeals
FOR THE EIGHTH CIRCUIT
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No. 02-2651
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Donna J. Farfalla, *
*
Appellant, *
* Appeal from the United States
v. * District Court for the District
* of Nebraska.
Mutual of Omaha Insurance Company, *
*
Appellee. *
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Submitted: January 17, 2003
Filed: April 3, 2003
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Before MORRIS SHEPPARD ARNOLD, BRIGHT, and SMITH, Circuit Judges.
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MORRIS SHEPPARD ARNOLD, Circuit Judge.
This case involves a decision by the Mutual of Omaha Insurance Company
(Mutual) to deny Donna Farfalla long-term disability benefits. Following a trial on
Ms. Farfalla's action based on the Employee Retirement Income Security Act
(ERISA), 29 U.S.C. §§ 1101-1461, the district court 1 granted judgment in favor of
Mutual. We affirm.

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I.
Mutual was the claims administrator for a long-term disability plan that
Creighton University, Ms. Farfalla's former employer, provided to its employees.
(Creighton was the plan administrator, but Mutual retained responsibility for
investigating and deciding claims.) Where a disability plan gives an administrator
"discretionary authority to determine eligibility for benefits," as the present plan does,
a court usually reviews the administrator's decision for an abuse of discretion. See
Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989). A less deferential
standard of review, however, is required when the claimant presents "material,
probative evidence demonstrating that" there exists "a palpable conflict of interest"
or "a serious procedural irregularity" that caused a "serious breach" of the
administrator's fiduciary duty to the claimant. See Woo v. Deluxe Corp., 144 F.3d
1157, 1160 (8th Cir. 1998).
We agree with the district court's conclusion that an abuse-of-discretion
standard is appropriate here, for although Mutual had a "palpable conflict of interest"
because it served both as administrator and insurer of the plan (and no "ameliorating
circumstances," as our case law terms them, exist), see Schatz v. Mutual of Omaha
Ins. Co., 220 F.3d 944, 948 (8th Cir. 2000) (internal quotations omitted), we do not
believe that the conflict affected Mutual's determination. Less deferential review is
warranted only when the conflict of interest or procedural irregularity "give[s] rise
to serious doubts as to whether the result reached was the product of an arbitrary
decision or the ... administrator's whim." Id. (internal quotations omitted).
The facts are undisputed. Under the plan, Ms. Farfalla was entitled to total
disability benefits for twenty-four months if she was unable to perform the functions
of her job. Thereafter, however, she became entitled to total disability benefits only
if she could not "work for pay at any job for which [she was] reasonably fitted by
education, training, or experience." When Ms. Farfalla fractured her wrist, which

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adversely affected her performance as a cardiac arrhythmia technician, she filed a
claim for long-term disability benefits, which Mutual paid for two years.
During this two-year period, Ms. Farfalla suffered other injuries (and
experienced complications from her first one), and Mutual continued to monitor her
condition. An in-house reviewing physician noted his belief that she no longer
qualified as totally disabled based on her job description, and recommended a
functional capacity assessment (FCA). The FCA revealed that she had difficulty with
such tasks as typing and manipulating small objects, but that she was able to work at
a medium physical capacity for occasional lifting and carrying. Dr. Jeffrey Tiedeman,
Ms. Farfalla's treating physician, soon thereafter reviewed the FCA and released
Ms. Farfalla for certain work. A few months later, she underwent surgery for carpal
tunnel syndrome, after which Dr. Tiedeman again released her to return to work (with
named restrictions). Despite job placement assistance from Mutual, Ms. Farfalla was
unable to find employment.
At the end of the two-year period, Mutual terminated Ms. Farfalla's benefits.
She appealed the decision and underwent two additional FCAs. These FCAs
confirmed that she might have difficulty with certain tasks but noted that "she would
be able to use the hands for gross manipulation" and could lift and carry certain items.
Dr. Tiedeman reviewed the FCA and endorsed its recommendations as to the type of
work that Ms. Farfalla could perform. Mutual then submitted the claim for medical
peer review. The physician who performed the review concluded, based on
Ms. Farfalla's records, that she "was able to perform some occupation as of January
1, 1997," but noted that "she may have some yet undiagnosed and untreated
mental/nervous condition" that, though not rendering her "unable to work on that
basis," might have contributed to her perception that she was disabled. Mutual then
upheld its previous denial of benefits. Around a year and a half later, Ms. Farfalla
was awarded social security disability benefits on account of fibromyalgia and related
problems.

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In our view, Mutual exhibited ample "reflection and judgment" before denying
Ms. Farfalla's claim. Cf. Clapp v. Citibank, N.A. Disability Plan (501), 262 F.3d 820,
828 (8th Cir. 2001). Mutual did not merely use an in-house medical consultant to
review Ms. Farfalla's claim; it sought independent review. Nothing in her records,
her treating physician's opinion, or the FCAs ever indicated that she was unable to
perform any job for which she was "reasonably fitted by education, training, or
experience." Cf. Heaser v. Toro Co., 247 F.3d 826, 833-34 (8th Cir. 2001).
Ms. Farfalla points to her later diagnosis of fibromyalgia and the fact that the
peer review physician referred to an "undiagnosed and untreated mental/nervous
condition," and argues that Mutual had an obligation to investigate further. We
disagree. Even where a claimant is diagnosed with fibromyalgia before the
administrator's final denial of benefits, the decision not to seek a specialist to review
the total disability claim does not necessarily constitute a "serious breach" of the
administrator's fiduciary duty. See Clapp, 262 F.3d at 827-28; cf. Heaser, 247 F.3d
at 834. Given the steps that Mutual took to investigate Ms. Farfalla's claim here, we
do not believe that further evaluation of her condition was required before denying
her total disability benefits.
II.
We turn next to the question of whether the district court erred in upholding
Mutual's decision. Mutual's determination is entitled to stand if it is supported by
substantial evidence, see Ferrari v. Teachers Ins. & Annuity Ass'n, 278 F.3d 801, 807
(8th Cir. 2002), and in reviewing that determination we will "consider only the
evidence that was before the administrator when the claim was denied." Farley v.
Arkansas Blue Cross & Blue Shield, 147 F.3d 774, 777 (8th Cir. 1998).
Ms. Farfalla contends that the district court erred because, among other things,
she suffered from numerous other medical difficulties besides her wrist injury, the

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purpose of the plan is to benefit disabled employees, and Ms. Farfalla was later
deemed to be totally disabled by the Social Security Administration (SSA).
We disagree. First, there is no evidence anywhere in the record that
Ms. Farfalla's condition met the definition of total disability that applied when her
initial benefits were terminated, and there is considerable evidence to the contrary.
Cf. Heaser, 247 F.3d at 834. Second, the purpose of the Plan is to benefit all covered
employees, a purpose that is not furthered by paying an uncovered claim. Cf. Tillery
v. Hoffman Enclosures, Inc., 280 F.3d 1192, 1199-1200 (8th Cir. 2002). Third, an
"ERISA plan administrator or fiduciary generally is not bound by a[n] SSA
determination that a plan participant is 'disabled,' " even when the plan's definition
of disabled is similar to the definition the SSA applied. See Jackson v. Metro. Life
Ins. Co., 303 F.3d 884, 889 (8th Cir 2002). The onset date of Ms. Farfalla's SSA
disability, moreover, was later than Mutual's reconsideration and denial of her claim.
For these reasons and those expressed by the district court, we thus conclude that the
district court did not err by entering judgment in favor of Mutual.
III.
Accordingly, we affirm the judgment of the district court.
A true copy.
Attest:
CLERK, U.S. COURT OF APPEALS, EIGHTH CIRCUIT.

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