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Cosey v. Prudential Ins. Co. of America

United States Court of Appeals, Fourth Circuit

November 12, 2013

Beth A. COSEY, Plaintiff-Appellant,
v.
The PRUDENTIAL INSURANCE COMPANY OF AMERICA; BioMerieux, Inc., Defendants-Appellees.

Argued: Sept. 20, 2013.

Page 162

Norris Arden Adams, II, Essex Richards, P.A., Charlotte, North Carolina, for Appellant.

Patrick C. DiCarlo, Alston & Bird LLP, Atlanta, Georgia, for Appellees.

Before DAVIS, KEENAN, and FLOYD, Circuit Judges.

Vacated and remanded by published opinion.

KEENAN, Judge wrote the opinion, in which Judge DAVIS and Judge FLOYD joined.

BARBARA MILANO KEENAN, Circuit Judge.

In this appeal, we primarily consider whether certain short-term and long-term

Page 163

disability benefits plans provided by an employer unambiguously confer discretionary decision-making authority on the plan administrator, requiring judicial review of the administrator's benefits determinations under an abuse-of-discretion standard.

Upon our review, we conclude that the language at issue in both plans is ambiguous and does not clearly confer discretionary decision-making authority on the plan administrator. Therefore, we hold that the administrator's eligibility determinations denying benefits to a covered employee are subject to de novo judicial review, and that the district court erred in reaching a contrary conclusion. We further hold that the district court erred in concluding that the employer's group insurance plan requires objective proof of disability in order for an employee to qualify for plan benefits. Accordingly, we vacate the district court's judgment and remand the case for further proceedings.

I.

Beth A. Cosey was employed as a senior clinical marketing manager for BioMerieux, Inc., a large medical diagnostics company. BioMerieux has a group insurance contract with the Prudential Insurance Company of America (Prudential), which acts as claims administrator for short-term disability (STD) and long-term disability (LTD) benefits under employee welfare benefits plans (collectively, the benefits plans) issued by Prudential. Cosey was a participant in the STD and LTD benefits plans. Under both plans, a participating employee is entitled to disability benefits if she is " unable to perform the material and substantial duties of [her] regular occupation due to [her] sickness or injury" (emphasis omitted).

Near the end of May 2007, Cosey did not report for work and submitted a claim for disability benefits, citing fatigue, hypotension, weight loss, and sleep apnea.[1] Prudential initially approved Cosey's claim and allowed benefits covering about a three-week period, after which Prudential determined that Cosey had presented insufficient evidence of an impairment preventing her from performing the material and substantial duties of her regular occupation. BioMerieux eventually terminated Cosey's employment in June 2008, and Cosey filed a civil action in federal court to recover STD and LTD benefits.

BioMerieux re-hired Cosey in August 2008, allowing her to work from home and assigning her to a limited travel schedule.

Page 164

Several months later, BioMerieux and Cosey reached a settlement agreement in Cosey's lawsuit.

In March 2009, after Cosey had been working at BioMerieux in a limited capacity for about seven months, Cosey took unscheduled leave and filed another claim for disability benefits. In support of her claim, Cosey complained of fatigue, sleep disorder, fibromyalgia, dysautonomia, myoclonus, and dizziness. Prudential initially approved Cosey's claim and paid her STD benefits for about seven weeks.

Cosey's consultations with various physicians produced varying medical opinions with regard to her condition. For instance, Cosey initially was evaluated for " overwhelming fatigue" by a primary care physician in May 2007, but that physician noted that Cosey had " [n]o diagnosis/treatment established." Later that month, a different doctor diagnosed Cosey with hypersomnia despite her " normal sleep at night," an essential tremor that was " currently asymptomatic," and chronic disequilibrium despite there being " no evidence of cerebellar dysfunction."

Further consultations yielded similarly inconclusive impressions. A neurologist diagnosed Cosey with sleep apnea, but stated that the disorder was " not severe enough to explain the degree of day time sleepiness." An endocrinologist remarked that Cosey had lost more than thirty pounds in six months, but also noted that Cosey had " improved 60% over the last few months" of that period and was " spontaneously getting better."

Although Cosey reported experiencing dizziness, fatigue, and tremors, one neurologist stated that an examination of Cosey was " relatively unremarkable" after a " near complete workup," and a neuropsychologist stated that " there are not suggestions of neurocognitive impairment." A cardiologist reported that Cosey had experienced a temporary drop in blood pressure, but opined that she otherwise was in normal cardiovascular condition. Cosey initially told the cardiologist that she was experiencing " overwhelming fatigue," but later told the same doctor that she was " able to play golf on the weekends," and was " no longer having the dizziness or lightheaded episodes."

On the basis of this mixed record, the various physicians reached different conclusions about Cosey's ability to return to work. In support of Cosey's claim for disability benefits, Cosey's primary care physician opined that " [t]here is no occupation that [Cosey] can sustain at this time and I deem her condition permanent." Also, Cosey's chiropractor thought that Cosey suffered from a " ...


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