USCA4 Appeal: 22-2173 Doc: 33 Filed: 02/04/2025 Pg: 1 of 14

PUBLISHED

UNITED STATES COURT OF APPEALS FOR THE FOURTH CIRCUIT

No. 22-2173

JEREMY SMITH,

Plaintiff - Appellant,

v.

COX ENTERPRISES, INC. WELFARE BENEFITS PLAN,

Defendant - Appellee.

Appeal from the United States District Court for the Eastern District of Virginia, at Alexandria. Patricia Tolliver Giles, District Judge. (1:20–cv–01434–PTG–IDD)

Argued: November 1, 2024 Decided: February 4, 2025

Before WYNN and RUSHING, Circuit Judges, and Mary Geiger LEWIS, United States District Judge for the District of South Carolina, sitting by designation.

Reversed and remanded by published opinion. Judge Wynn wrote the opinion, in which Judge Lewis joined. Judge Rushing wrote an opinion concurring in the judgment.

ARGUED: Benjamin W. Glass, III, BENJAMIN W. GLASS & ASSOC. PC, Fairfax, Virginia, for Appellant. Nikole M. Crow, WOMBLE BOND DICKINSON (US) LLP, Atlanta, Georgia, for Appellee. ON BRIEF: Ian R. Dickinson, WOMBLE BOND DICKINSON (US) LLP, Charlottesville, Virginia, for Appellee. USCA4 Appeal: 22-2173 Doc: 33 Filed: 02/04/2025 Pg: 2 of 14

WYNN, Circuit Judge:

After receiving long-term disability benefits from his employer for seven years,

Jeremy Smith was informed that these benefits would be terminated. Seeking to have his

benefits restored, Smith filed suit under the Employee Retirement Income Security Act of

1974 (“ERISA”) against Cox Enterprises, Inc. Welfare Benefits Plan, an ERISA plan

operated by Smith’s employer. The district court found that Smith was not “totally

disabled” as defined by the plan and granted summary judgment to the defendant.

For the reasons set forth below, we hold that the plan administrator failed to discuss

conflicting evidence and thus did not engage in a principled and reasoned decision-making

process. Accordingly, we reverse and remand to the district court for further proceedings.

I.

In January 2008, Smith began working for Cox Enterprises, Inc., as a customer care

technician. Four years later, he had to leave the job when a herniated disk began causing

severe pain in his lower back. That year, he had a lumbar discectomy and then a spinal-

fusion surgery. In 2014, he underwent a laminectomy and revision fusion. He was then

diagnosed with post-laminectomy syndrome.

In 2012, Aetna, 1 Cox’s ERISA plan administrator, approved Smith’s claim for long-

term disability which proceeded in two phases. For the first twenty-four months of long-

term disability—the “own occupation” period—Smith needed to show that “solely because

1 In 2017, Hartford Life and Accident Insurance Company acquired Aetna’s group benefits business. To avoid confusion, we follow the district court in referring only to “Aetna.”

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of injury or disease” he could not work at his own occupation. J.A. 798. 2 After those first

twenty-four months—the “any occupation” period—Smith needed to show that he is “not

able, solely because of injury or disease, to work at any reasonable occupation.” Id.

The plan defines “reasonable occupation” as “any gainful activity which you are or

reasonably could become qualified to perform through education, training or experience

earning equal to your [long-term disability] benefit but no less than 60 percent of pre-

disability earnings.” Id. Smith entered the “any occupation” period in 2014. In that and

several subsequent years, Aetna reapproved Smith’s long-term disability, concluding that

Smith remained unable to perform “any reasonable occupation.”

In June 2016, the Social Security Administration determined that Smith had become

disabled on June 1, 2015, and thus qualified for disability benefits on that date. In 2018, as

part of his first review for Social Security Disability Insurance, he underwent a consultative

examination conducted by Dr. Lisa Harris on behalf of the Virginia Department of

Rehabilitative Services, a state disability determination agency capable of making

decisions on disability claims for Social Security Disability Insurance. Dr. Harris assessed

that Smith could only sit for about half an hour for each hour during the workday. The

Social Security Administration thereafter recertified his disability benefits.

In late 2018, Aetna began another periodic review of Smith’s claim. His primary

care physician, Dr. Steven Hartline, informed Aetna that Smith was only capable of

working two hours a day for two days a week due to his chronic pain and inability to sit or

2 Citations to the “J.A.” refer to the Joint Appendix filed by the parties in this appeal.

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stand for more than ten or fifteen minutes at a time. Reviewing the claim for Aetna, nurse

Holly Shepler assessed that Smith had “residual work capacity” and sought additional

information. J.A. 370. Dr. Hartline responded that Smith could “walk for about 15 minutes

normally” but that “his main issue [was] staying in [one] position for more than 15

minutes[, that he] need[ed] to alternate between sitting[,] standing[,] and laying,” and that

he would “do each for 15–20 min[utes] through the day.” J.A. 555 (capitalization

standardized).

Aetna continued the investigation by having Dr. Timothy Lee perform an

independent medical evaluation on June 14, 2019. Dr. Lee concluded that Smith was able

to work an eight-hour day for forty hours a week subject to numerous conditions, including

that he needed to change positions every thirty minutes and limit standing and walking to

thirty minutes every hour. Based on this evaluation, vocational counselor Maria O’Brien

conducted a transferable-skill analysis for Aetna and identified four sedentary jobs she

asserted Smith could reasonably perform. On July 16, 2019, Aetna mailed a termination

letter to Smith, informing him that he was capable of working and thus would no longer

receive benefits through Cox’s plan.

On November 6, 2019, Smith submitted a pro se appeal of the termination of

benefits to Aetna. As part of the appeal, Smith sent Dr. Harris’s consultative examination

report from his 2018 Social Security recertification. In turn, Aetna hired two independent

doctors, Dr. Joseph Walker III and Dr. Neil Gupta, to review the appeal. These doctors

evaluated Smith’s medical records but never examined him themselves.

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Dr. Walker found that Smith was capable of working an eight-hour day five days a

week and that he could sit for 45 minutes at a time, for a total of six hours in an eight-hour

day; could stand for 30 minutes at a time, for a total of four hours in an eight-hour day; and

could walk for 15 minutes at a time, for a total of two hours in an eight-hour day. Dr. Gupta

found that Smith could stand for up to two hours and walk for up to two hours in an eight-

hour day.

On April 16, 2020, Aetna sent an appeal denial letter affirming its termination of

Smith’s benefits prompting Smith to initiate this lawsuit.

In a written opinion, the district court granted summary judgment to the plan. Smith

v. Cox Enters. Inc., No. 1:20-cv-01434,

(E.D. Va. Sept. 30, 2022). The

court found that Aetna’s termination decision was supported by adequate materials and

substantial evidence.

at *5–6. It reasoned that it was permissible for Aetna to discount

Dr. Hartline’s opinion, as he had only been Smith’s physician for one week when he wrote

his opinion recommending work limitations and he admitted that his opinion was based on

the assessment of another doctor. Id. at *6. The court was satisfied that the two independent

reviewing doctors had considered Dr. Harris’s report, even though they did not discuss it,

because they included the report in a list of records they reviewed. Id. at *8. In response to

Smith’s claim that Aetna had improperly discounted the Social Security Administration’s

determination that he was disabled, the court found that it was reasonable for Aetna to do

so because Aetna had never received the medical information underlying Social Security’s

initial 2016 determination. Id. Smith timely appealed.

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II.

“In an appeal under ERISA, we review a district court’s decision de novo,

employing the same standards governing the district court’s review of the plan

administrator’s decision. When, as here, an ERISA benefit plan vests with the plan

administrator the discretionary authority to make eligibility determinations for

beneficiaries,” we apply an abuse-of-discretion standard to the plan administrator’s

determination. Williams v. Metro. Life Ins. Co.,

, 629–30 (4th Cir. 2010)

(citation omitted).

“Under the abuse-of-discretion standard, we will not disturb a plan administrator’s

decision if the decision is reasonable, even if we would have come to a contrary conclusion

independently.”

. “To be held reasonable, the administrator’s decision must result

from a ‘deliberate, principled reasoning process’ and be supported by substantial

evidence.”

(quoting Guthrie v. Nat’l Rural Elec. Coop. Ass’n Long-Term Disability

Plan,

(4th Cir. 2007)).

To assess the reasonableness of a plan administrator’s decision, this Court has

identified eight nonexclusive factors to consider, including “whether the decisionmaking

process was reasoned and principled” and “whether the decision was consistent with the

procedural and substantive requirements of ERISA.” Booth v. Wal-Mart Stores, Inc.

Assocs. Health & Welfare Plan,

, 342 (4th Cir. 2000). The “procedural and

substantive requirements of ERISA” relevant here include that when an employee benefit

plan denies an employee’s claim, it must “provide adequate notice in writing to [the]

participant or beneficiary . . . setting forth the specific reasons for such denial, written in a

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manner calculated to be understood by the participant.”

(1). The plan must

then “afford a reasonable opportunity to [the] participant . . . for a full and fair review by

the appropriate named fiduciary of the decision denying the claim.”

§ 1133(2).

III.

A.

Smith first challenges Aetna’s denial of his appeal on the grounds that it did not

properly consider Dr. Harris’s consultative examination related to his Social Security

recertification. We agree and conclude that Aetna abused its discretion when it denied his

appeal.

Federal regulations promulgated for the administration and enforcement of ERISA

oblige a plan administrator’s adverse disability benefit determination to “set forth, in a

manner calculated to be understood by the claimant . . . [a] discussion of the decision,

including an explanation of the basis for disagreeing with . . . [a] disability determination

regarding the claimant presented by the claimant to the plan made by the Social Security

Administration.”

(j)(6)(i)(C) (emphasis added).

The termination letter provided the following discussion regarding Smith’s Social

Security determination:

We understand that you have been approved for Social Security Disability (SSD) benefits. However, our disability determination and the SSD determination are made independently and are not always the same. The difference between our determination and the SSD determination may be driven by the Social Security Administration (SSA) regulations. For example, SSA regulations require that certain disease/diagnoses or certain education or age levels be given heavier or even controlling weight in determining whether an individual is entitled to SSD benefits. Or, it may be

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driven by the fact that we have information that is different from what SSA considered.

We have not been provided with the basis for the SSD determination, and the evidence that was relied on for the SSD determination has not been identified to us. Therefore, even though you are receiving SSD benefits, we are unable to give it significant weight in our determination, and we find that you are not (or you are no longer) eligible for LTD benefits based on the plan definition of Totally Disabled quoted above.

J.A. 381–82.

In response, in his appeal of that decision, Smith submitted Dr. Harris’s consultative

examination. Yet Aetna left the relevant language virtually unchanged when it sent the

appeal denial letter. In fact, it altered only the last sentence, which now reads: “As of

January 3, 2014 the definition of disability changed from the inability to perform your own

occupation to the inability to perform any reasonable occupation. Even though you are

receiving SSD benefits, we are unable to give it significant weight in our determination.”

J.A. 404.

These boilerplate statements do not constitute a “discussion of the decision” within

the meaning of the regulations. The appeal denial letter makes no mention of Dr. Harris.

Aetna never engages in a meaningful discussion of the Social Security determination,

initially or on recertification. And the uncertainty inherent in the use of the word “may”

belies the fact that it did not do so: Aetna does not state why it reaches the opposite

conclusion of the Social Security Administration; rather, it merely suggests possible

reasons that the Social Security Administration’s determination could be discounted.

Worse yet, these suggestions are revealed to be meaningless boilerplate, as the very next

paragraph claims that Aetna never received the records forming the basis of the

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determination. But Smith did submit Dr. Harris’s consultative examination in response to

Aetna’s initial termination letter. Aetna thus did not “includ[e]” a sufficient “explanation

of the basis for disagreeing with . . . [the] disability determination . . . made by the Social

Security Administration.”

(j)(6)(i)(C).

We are not alone in reaching such a conclusion. As other circuits have held,

“[e]vidence of a Social Security award of disability benefits is of sufficient significance

that failure to address it offers support that the plan administrator’s denial was . . . an abuse

of discretion” because such “[w]eighty evidence . . . cannot be ignored.” Salomaa v. Honda

Long Term Disability Plan,

(9th Cir. 2011) (footnote omitted); see, e.g.,

Schexnayder v. Hartford Life & Accident Ins. Co.,

(5th Cir. 2010)

(“Failure to address a contrary SSA award can suggest ‘procedural unreasonableness’ in a

plan administrator’s decision.”); Glenn v. MetLife,

(6th Cir. 2006)

(“[A]n ERISA plan administrator’s failure to address the Social Security Administration’s

finding that the claimant was ‘totally disabled’ is yet another factor that can render the

denial of further long-term disability benefits arbitrary and capricious.”); Holmstrom v.

Metro. Life Ins. Co.,

, 772–73 (7th Cir. 2010) (“An administrator is not forever

bound by a Social Security determination of disability, but an administrator’s failure to

consider the determination in making its own benefit decisions suggests arbitrary

decisionmaking.”); cf. Austin v. Cont’l Cas. Co.,

(W.D.N.C.

2002) (“Although [Social Security] determinations are not infallible, federal courts are

keenly aware of the close scrutiny which claims for Social Security disability benefits

receive.”).

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In addition to failing to abide by an applicable regulation, the absence of discussion

in Aetna’s letters contravenes our case law. “While an administrator has the authority to

weigh conflicting pieces of evidence, it abuses its discretion when it fails to address

conflicting evidence.” Helton v. AT&T Inc.,

(4th Cir. 2013). Aetna’s

appeal denial letter nowhere weighs—and does not even mention—Dr. Harris’s

consultative evaluation, which formed a critical basis for the Social Security

Administration’s disability recertification. Indeed, the only place in the administrative

record that Aetna arguably considers the consultative report is in Dr. Walker and Dr.

Gupta’s independent medical evaluations. In each report, Dr. Harris’s consultative report

is listed under the label “records submitted for review.” J.A. 407, 425 (capitalization

standardized). Yet, despite summarizing the findings by at least ten other doctors, Dr.

Walker never mentions Dr. Harris again. And Dr. Gupta neglected to mention Dr. Harris

in a reverse chronology summarizing Smith’s clinical file since 2012.

In sum, there is not one sentence dedicated to Dr. Harris’s findings in Aetna’s appeal

denial letter or either of its independent medical evaluations. The failure to address

conflicting evidence—especially the highly probative evidence created for the Social

Security Administration—denied Smith his statutory right to “a full and fair review.”

(2). Aetna did not engage in a deliberate, principled reasoning process.

Because we conclude Aetna abused its discretion, we must decide the remedy. This

Court has held that “remand should be used sparingly” but “is most appropriate ‘where the

plan itself commits the [plan administrator] to consider relevant information which [it]

failed to consider.’” Elliott v. Sara Lee Corp.,

(4th Cir. 1999) (quoting

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Berry v. Ciba-Geigy Corp.,

(4th Cir. 1985)). And, here, the plan

documents mirror the language of the statute, providing that the appeal committee or

reviewer “is required to conduct a ‘full and fair review’ of all comments, documents and

records submitted by you related to your appeal.” J.A. 804; cf.

(2). We

will thus remand this case to the district court to remand the matter to Aetna.

B.

Smith has therefore prevailed on part of his case, and Aetna must reconsider his

claim. He asks for more, however, and presses other arguments about Aetna’s process in

support of reversal and the award of past-due benefits. We are not persuaded. 3

First, Smith contends that our decision in Harrison v. Wells Fargo Bank, N.A.,

(4th Cir. 2014), compelled Aetna to seek out his Social Security records—and that

Aetna’s failure to do so merits reversal and the award of past benefits. He notes that Aetna

had prior authorization permitting the Social Security Administration to release his records

directly to it. At oral argument, Aetna represented that procuring the records would be

impracticable because the Social Security Administration processes the requests too slowly

for plan administrators to meet the statutory ERISA deadline. See Oral Arg. at 22:30–

3 Nor are we persuaded by Smith’s argument that the district court’s reasoning relied on post hoc justifications created by Cox for the purposes of litigation. While we agree with Smith that post hoc explanations undermine claimants’ statutory right to a “full and fair review” of their denials, see, e.g., Thompson v. Life Ins. Co. of N. Am.,

, 163–64 (4th Cir. 2002) (per curiam), we do not believe that the district court improperly relied on Cox’s lower court briefing to arrive at its interpretation of the termination letter. The district court was clear that its “review [was] limited to the reasons stated in Aetna’s denial notice,” and not post hoc explanations. Smith,

, at *10 n.10.

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23:30, https://www.ca4.uscourts.gov/OAarchive/mp3/22-2173-20241101.mp3. We need

not address this issue because Smith can present his full Social Security records to Aetna

on remand. See Bernstein v. CapitalCare, Inc.,

(4th Cir. 1995).

Second, Smith argues that Aetna’s ultimate determination regarding his work

restrictions was arbitrary and unsupported and thus necessitates reversal. As evidence of

the unsupported nature of Aetna’s determination, Smith notes that the opinion of a non-

examining doctor, Dr. Walker, formed the basis of the finding that he can sit for six hours

in a workday despite none of the examining doctors determining that he can sit for that

duration. But we need not decide whether the six-hour limitation falls within the

permissible bounds set by the available medical evidence. On remand, Aetna will be

obliged to rebalance the medical evidence in light of Dr. Harris’s report and thus will have

to reconsider how much weight to give the independent medical reports. Similarly, because

Aetna has not yet considered all of the evidence and has not “demonstrated a manifest

unwillingness to give fair consideration to evidence that supports the claimant,” we find no

reason to grant reversal at this time. Helton,

(quoting Miller v. United

Welfare Fund,

(2d Cir. 1995) (Calabresi, J., concurring in part and

dissenting in part)).

Finally, Smith seeks attorneys’ fees, costs, and prejudgment interest. The district

court never passed upon the question of attorneys’ fees, and we decline to do so in the first

instance. Cf. Quesinberry v. Life Ins. Co. of N. Am.,

, 1028–29 (4th Cir.

1993) (en banc) (noting that “ERISA places the determination of whether attorneys’ fees

should be awarded in an ERISA action completely within the discretion of the district

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court,” guided by a fact-intensive five-factor test). We leave this issue for the district court

to consider at its discretion on remand.

IV.

For the foregoing reasons, we reverse the district court’s entry of summary judgment

and remand for further proceedings consistent with this opinion.

REVERSED AND REMANDED

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RUSHING, Circuit Judge, concurring in the judgment:

A federal regulation required Aetna to explain to Smith its “basis for disagreeing

with or not following” the Social Security Administration’s “disability determination” that

Smith “presented” to Aetna.

(j)(6)(i)(C). Our precedent recognizes

a related duty for a plan administrator to “address conflicting evidence” when denying

benefits. Helton v. AT&T Inc.,

(4th Cir. 2013). After Aetna terminated

Smith’s disability benefits, Smith appealed and sent Aetna Dr. Harris’s consultative

examination report, which she completed for his 2018 Social Security Disability (SSD)

recertification. In the letter affirming its termination of Smith’s benefits, Aetna did not

mention Dr. Harris’s report and stated: “We have not been provided with the basis for the

SSD determination, and the evidence that was relied on for the SSD determination has not

been identified to us.” J.A. 404.

While it appears accurate that Smith did not provide Aetna “the basis” for Social

Security’s determination that he is disabled, it is not accurate that Smith failed to identify

any “evidence that was relied on” for his recertification, namely, Dr. Harris’s report.

Aetna’s incorrect assertion that it lacked this evidence calls into question whether Aetna

considered it in affirming termination of Smith’s benefits. Because Aetna failed to address

Dr. Harris’s conflicting report, I agree with the majority’s decision to remand this matter

for Aetna to confront this evidence and exercise its discretion. See Elliott v. Sara Lee

Corp.,

(4th Cir. 1999).

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