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Foster v. Principal Life Insurance Co.

United States Court of Appeals, Fifth Circuit

April 4, 2019

AMANDA C. FOSTER, Plaintiff - Appellant

          Appeal from the United States District Court for the Eastern District of Louisiana

          Before SMITH, DUNCAN, and ENGELHARDT, Circuit Judges.

          STUART KYLE DUNCAN, Circuit Judge

         Amanda Foster worked as an attorney in New Orleans before-by her account-intractable migraines made her stop working. She applied for disability benefits through her law firm's insurer, Principal Life Insurance Company ("Principal"). After multiple reviews by various doctors, Principal denied her claim, concluding she was not disabled within the meaning of the policy. Foster sued, arguing that Principal abused its discretion by denying her benefits. The district court ruled for Principal. We affirm.


         Foster was a healthcare attorney at the New Orleans law firm Sullivan, Stolier & Knight ("Sullivan"). She began working at the firm in November 2005 and described her duties as "review and draft leases and agreements; research and advise clients regarding government laws and regulations; represent clients in administrative appeals; [and] draft compliance plans." On March 8, 2013, Foster decreased her work hours to part-time capacity, allegedly due to intractable headaches, and she subsequently took complete disability leave on July 1, 2013.

         Sullivan has a group benefits plan ("Group Policy" or "policy") issued by Principal, which, as relevant here, provides employees with long term disability benefits ("LTD").[1] It is undisputed that Foster's claims under the policy are governed by the Employee Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. § 1001 et seq. See, e.g., Pilot Life Ins. Co. v. Dedeaux, 481 U.S. 41 (1987). It is also undisputed that the policy confers on Principal the discretion to construe the policy provisions and determine eligibility, meaning that Principal is both the insurer and the plan administrator.

         With respect to LTD, the policy states that a member is "disabled" if she "cannot perform one or more of the substantial and material duties of his or her Own Occupation." "Substantial and material duties" are "essential tasks generally required by employers from those engaged in a particular occupation that cannot be modified or omitted." The policy defines "Own Occupation" for attorneys as "[t]he specialty in the practice of law the Member is routinely performing for the Policyholder when his or her Disability begins."

         On July 8, 2013, Foster filed a claim for LTD under the policy, alleging she was "unable to practice law due to the pain of headaches as of March 8, 2013." An accompanying neurologist's statement (from Dr. Mohnot) described Foster's subjective symptoms as "intractable migraines," and reported March 8, 2013 as the date she was "advised . . . to stop working." Principal received Foster's medical records throughout August 2013, including records of her psychotherapy with Dr. Phyllis Shnaider. Principal then requested a review of the medical records by an internal medical consultant. Principal provisionally approved Foster's claim (after completion of a mandatory 180-day elimination period) from September 4, 2013 to December 9, 2013, based on the information it had at the time, while informing Foster it would need additional information.

         On November 4, 2013, Principal requested surveillance on Foster, which showed her performing routine tasks like shopping and picking up children. It also requested updated medical records. Initially, two doctors (Dr. Ethel Condon and Dr. Pranathi Kondapaneni) provided Principal with reports reviewing those records. Dr. Condon's report stated that Foster's "chronic headaches and intractable migraines" would not allow her "consistent full time employment" for "sedentary work." Similarly, Dr. Kondapaneni's report confirmed that Foster was experiencing daily migraines that resulted in her "functional impairment," limiting her to part-time work to avoid continuous "work-place stress and light exposure."

         Principal also hired two additional physicians, Dr. Sydney Kroll Register (a psychologist) and Dr. David Hoenig (a neurologist), to review Foster's file. For her part, Dr. Register concluded from a review of the medical records that "[t]here is no indication of functionally impairing psychological symptoms," and she noted "generally mild psychological symptoms consistently across time." She also concluded that "[n]o limitations are supported" that would result in Foster's "total inability to perform any type of occupation." For his part, Dr. Hoenig concluded that Foster's "objective neurological exam is consistently normal," as well as her MRI and EEG. He also concluded that, whereas her headaches were "subjectively affecting her functionality," her records showed "no objective/clinical evidence which demonstrates that Mrs. Foster is functionally impaired," given that she "exhibits no deficits on examination and her neurological workup is normal, [and] . . . she is seen on video surveillance to be functional." Additionally, Dr. Hoenig specifically disagreed with the previous recommendation of Foster's neurologist that she not work: "Based on the documentation provided, . . . the recommendation that [Foster] not work is not reasonable and is not medically supported," given that "[t]here is no clinical evidence that demonstrates that Ms. Foster is functionally impaired." Dr. Hoenig therefore concluded that "Ms. Foster has capabilities to perform work activities on a full-time basis, in a sedentary capacity."

         Principal terminated Foster's LTD benefits on December 18, 2014, effective December 9, 2014. In relevant part, Principal's denial letter stated that a report from her reviewing psychologist "indicated that no limitations or functional impairment were supported from a psychological perspective." The letter also stated that her "objective neurological exam was consistently normal," as were her MRI and EEG, and that, despite her complaints of headaches, "there was no objective/clinical evidence which demonstrated [she] w[as] functionally impaired." In other words, Foster's "subjective complaints did not correlate with objective findings" and her "reported functional and daily activity level was not consistent with the severity of the complaints [she] reported." Principal additionally relied on the fact that Foster was "seen on video surveillance to be functional and apparently without activity limitation." Finally, Principal noted that Foster's "monthly online blog posts" reflected an "undiminished ability to write, focus, and concentrate as would also be required in [her] occupation." In sum, Principal concluded that, "[o]n the basis of these [psychological and neurological] reviews, we have determined that there is no objective medical or psychological evidence supporting an ongoing claim of Disability as it is defined in the policy."

         On April 28, 2015, Foster submitted her mandatory appeal to Principal.[2]Foster attached letters from her treating physician Dr. Mohnot, an independent medical examination (IME) by Dr. Shelly Savant, an affidavit by founding partner Jack Stolier attesting to Foster's struggles with her headaches and her inability to work as an attorney, and additional medical records detailing Foster's continued struggle with migraines.

         On July 24, 2015, Principal denied Foster's mandatory appeal. As part of this review, Principal relied on the opinions of two more doctors, Dr. Daniel Harrop (a psychiatrist) and Dr. Norman Miller (a psychiatrist and neurologist). While not commenting on neurological issues, which were beyond his expertise, Dr. Harrop concluded that Foster was "not disabled for psychiatric reasons"; that "the psychiatric restrictions suggested by the attending clinicians . . . are not supported by clinical findings or diagnostic evidence or the clinical records on file"; that her "[m]emory, cognition, and concentration are not demonstrated by mental status examinations to be impaired"; and finally that "[t]he medical documentation does not support that there are restrictions and limitations which ...

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