Disclaimer: This was not a case handled by disability attorney Nick A. Ortiz. The court case is summarized here to give readers a better understanding of how Federal Courts decide long term disability ERISA claims.
Case Name: Griffin v. Hartford Life & Accident Insurance Company
Court: United States Court of Appeals for the Fourth Circuit.
Type of Claim: Long Term Disability.
Insurance Company: Hartford Life & Accident Insurance Company (hereinafter “Hartford Life”).
Claimant’s Employer: MedQuist Transcriptions, Ltd.
Claimant’s Occupation / Job Position: medical transcriptionist.
Disabilities: pain in his forearm and wrist, which prevented him from typing; and a herniated disc in the spine, causing neck and right shoulder pain.
Definition of Disability:
Griffin’s long-term disability benefits were governed by a long-term disability policy that defined disability as follows:
Disability or Disabled means You are prevented from performing one or more of the Essential Duties of:
(1) Your Occupation during the [180-day] Elimination Period;
(2) Your Occupation, for the 24 month(s) following the Elimination Period, and as a result Your Current Monthly Earnings are less than 80% of Your Indexed Pre-disability Earnings; and
(3) after that, Any Occupation.
Note: Under this policy, the applicable definition of disability changes from the inability to perform one or more of the essential duties of one’s prior occupation to an inability to perform one or more of the essential duties of “any occupation.”
Benefits Paid? Hartford Life initially approved the LTD claim for a few months, and then denied the claim for ongoing long-term disability benefits.
Functional Assessments? It is worth noting that The Hartford had a really difficult time obtaining any functionality forms or physical functionality assessments from Mr. Griffin’s treating physicians. As Mr. Griffin’s treating physicians were not willing to opine as to his level of functional impairment, Hartford Life obtained a “peer-review” assessment (a review and assessment of the medical records without an in-person medical evaluation of the patient).
Procedural history: The claimant received LTD benefits during the “own occupation” period, but benefits were terminated after about 2 ½ years, during the “any occupation” period. Aetna terminated the plaintiff’s benefits, “because it had determined that he was no longer disabled as defined in the long-term disability policy.” The Plaintiff appealed his long-term disability denial. Hartford Life’s appeals unit affirmed Hartford Life’s termination decision. Griffin then filed a lawsuit action against Hartford Life under ERISA, seeking long-term disability benefits and claiming that Hartford Life improperly terminated them. On cross-motions for summary judgment, the district court granted Hartford Life’s MSJ and denied Griffin’s MSJ. Griffin appealed to the Fourth Circuit Court of Appeals.
Issues: The district court granted summary judgment to Hartford Life, and Griffin filed an appeal, contending that the district court erred (1) in reviewing the administrator’s decision for abuse of discretion, rather than de novo, and (2) in concluding that Griffin failed to provide evidence sufficient to support a conclusion that Hartford Life’s decision to terminate the long-term disability benefits was unreasonable. The Fourth Circuit Court disagreed and affirmed the District Court’s opinion.
Note: On the merits, Griffin contended that Hartford Life’s decision to terminate his LTD benefits was an unreasonable exercise of discretion, giving four relatively common arguments in support of that contention. First, he argued that Hartford Life’s decision rested on a flawed employability analysis that ignored his medical records. Second, he claims that Hartford Life, once having found him eligible for long-term disability benefits, should have been required to carry the burden of showing that Griffin’s condition had improved. Third, Griffin maintains that Hartford Life was required to have Griffin physically examined by a medical professional before finding him ineligible for disability benefits. And fourth, he asserts that Hartford Life, given its dual role of determining eligibility for benefits and paying those benefits, had an inherent conflict of interest that “infect[ed] the claims process,” rendering it unreasonable.
Holdings: “Hartford Life’s appeals specialist, after conducting an independent review of Griffin’s file, likewise reasonably concluded that Griffin had failed to show that he was eligible for the continuation of long-term disability benefits. At bottom, the record reveals that the entire claims process was thorough, deliberate, and reasoned, and the evidence available to Hartford Life reasonably supported the discretionary decision it made. In making its decision, Hartford Life relied on observations of Griffin made by its investigators, Griffin’s answers during his in-person interview, and general statements from his past medical providers that he likely had more functionality than he thought and that he had appeared to be moving normally. And again, the long-term disability policy states explicitly that it is Griffin’s obligation, not Hartford Life’s, to “furnish Proof of Loss,” defined in part as evidence of the claimant’s disability. As the district court noted, Griffin’s only substantive evidence of his current disability was his own self-reporting regarding his condition, none of which provided objective medical evidence of his current functionality.” The Court also knocked down the burden-shifting argument: “The policy, however, by its terms places the continuing burden of providing proof of disability on the claimant.” As to whether Hartford Life was required to do an “in-person” medical exam: “But this again is belied by the actual language of that provision. While the policy does provide that Hartford Life could require Griffin to submit to a medical examination if it were to deem it necessary to determine his eligibility, that provision does not impose a duty on Hartford Life to do so.” And as to the “conflict of interest” argument: “Finally, on Griffin’s conflict-of-interest argument, we recognize that an inherent conflict can exist when a plan administrator has both the discretion to make eligibility determinations and the responsibility for paying benefits to those found eligible. But in this case, there is no evidence that any such conflict impacted Hartford Life’s adjustment and review of Griffin’s claim.”
Findings of Particular Interest: (1) As Hartford Life explained in its letter to Griffin terminating his benefits, none of the medical providers whom Griffin had seen were willing to give a current opinion on Griffin’s level of functionality. (2) Moreover, Hartford Life collected video surveillance evidence of Griffin that showed him walking at a quick pace and moving “without observable bracing or support.” (3) Hartford Life’s investigator, who conducted an in-person interview of Griffin, personally observed Griffin walking, standing, sitting, reaching, and effectively using a pen without significant trouble over the course of the interview. (4) Griffin also disclosed during the interview that he was not then receiving any treatment for his condition and that he had not seen any of his medical providers for over six months. (5) When Hartford Life sought recent updates from Griffin’s doctors on his level of functionality, both Dr. Carmouche and Dr. Bravo responded that they had not seen Griffin in nearly a year and that they were not providing any functionality restrictions or limitations. (6) Griffin’s chiropractor, Dr. McGlothlin, did state that he had imposed restrictions on Griffin in 2012, but he clarified that he was not restricting Griffin anymore because, although Griffin had self-reported some pain, Dr. McGlothlin had observed him moving reasonably well. (7) On Griffin’s appeal of Hartford Life’s termination decision, Griffin did provide additional evidence in the form of a letter from Dr. McGlothlin, in which he stated that he believed Griffin was “being honest” and that “he [was] very likely to have some disability.” But in subsequent telephone calls between Hartford Life and Dr. McGlothlin, Dr. McGlothlin acknowledged that his assertions were based solely on Griffin’s self-reported pain and that they were not based on any physical examination.
Summary: Judgment in favor of the Defendant. “In this case, we agree with the district court that Hartford Life’s decision was reasonable and therefore did not amount to an abuse of discretion. The record readily shows that Griffin received a fair and thorough consideration of his claim and that Hartford Life’s conclusion was reasonably supported by the available evidence.”