02-2934 Wallace v. Reliance Standard Life Ins. Co.

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“Wallace … contends that Reliance was obliged to obtain additional medical evaluations, which would be submitted to an independent physician for assessment. Nothing in the policy, the employer’s plan, or the summary plan description, requires Reliance to take such steps. Nonetheless, Wallace insists, Reliance was acting as his fiduciary, and as his fiduciary was obliged to seek out additional evidence supporting his claim, even if (especially if) the medical evidence he submitted was inadequate. Yet why is Reliance a fiduciary when implementing a contract of insurance? It has promised a particular set of benefits, to be sure, and must act with care in fulfilling its promises, but it did not undertake to evaluate all claims with a thumb on the scale in the participant’s favor. Indeed, a genuine fiduciary would go to bat for Wallace as an advocate; but this is not the role Reliance undertook to perform.

“Now it is true, as we observed in Hightshue v. AIG Life Insurance Co., 135 F.3d 1144, 1148 (7th Cir. 1998), that when an insurer permits an independent medical evaluator to make the coverage decision, it will be hard to show that the decision was influenced by a conflict of interest. Contentions that insurers deny claims to save money, and that judicial review should be more searching as a result even when the plan or policy confers interpretive discretion, are before the Supreme Court in Nord; no such issue is at stake here, because the district judge did not defer to Reliance’s decision but made her own. Hightshue does not hold that an insurer must pay for independent medical evaluations or accept their conclusions; it gives plans an option, not an obligation. Insurers remain free (as do judges) to resolve conflicts in the medical submissions. Their obligation is to evaluate claims competently and dispassionately-and even that duty plays a limited role when the judge proceeds de novo. No case of which we are aware holds that, when a plan participant’s own doctors opine that he is again able to work, the insurer or plan administrator must refer the participant to additional physicians in quest of one who will find a disabling condition. Adding to the bureaucracy would augment administrative costs, which in the long run would reduce the net benefits that employees enjoy under the plan.”

Affirmed.

Appeal from the United States District Court for the Western District of Wisconsin, Crabb, J., Easterbrook, J.