The claimant in Archer v. Hartford Life and Accident Insurance Company was an Assistant Store Manager at TJX Marshall’s Department Store. She had group Long Term Disability (LTD) coverage. She also had life insurance benefits. Both of these categories of group benefits were issued and administered by Hartford.
Hartford had what we call “discretionary authority”. As claims administrator for both the Plan’s LTD Policy and Life Policy, Hartford had “full discretion and authority to determine eligibility for benefits and to construe and interpret all terms and provisions of the Policy” for both plans.
Plaintiff Archer stopped working for TJX on May 8, 2010, due to spinal stenosis (i.e. spinal narrowing), degenerative disc disease, and carpal tunnel syndrome. Hartford approved Plaintiff’s claim and paid LTD benefits for two years under the “any occupation” definition of disability. However, towards the end of the two-year “any occ” period, Hartford informed Plaintiff she must be disabled from “Any Occupation” to continue to be eligible for benefits under the LTD Policy.
On June 20, 2012, Hartford informed Plaintiff that it determined she was disabled from “Any Occupation” as of August 8, 2012, and therefore she continued to be eligible for benefits under the LTD Policy. The letter also advised Plaintiff that she would be required to periodically furnish “continued proof of Disability” to Hartford. Hartford also approved Plaintiff’s claim for Waiver of Premium (“WOP”) of life insurance benefits as of January 21, 2011. Hartford informed Plaintiff that her Supplemental Group Life insurance benefit in the amount of $81,000.00 “will remain in effect without premium payment, until date of termination, 10/26/2031, provided she remained Disabled as defined by the Policy.”
In 2016, Hartford asked Plaintiff’s treating physicians, Dr. Tan and Dr. Davids (who had recently replaced Dr. Maltese), whether Plaintiff was capable of full time sedentary or light exertion work. Dr. Davids and Dr. Tan indicated Plaintiff was capable of full time sedentary or light exertion work on the questionnaire.
In a letter dated January 10, 2017, Hartford informed Plaintiff that “all the information contained in Plaintiff’s file was reviewed as a whole” and that her claim for continuing LTD benefits was denied effective January 10, 2017, because she purportedly no longer satisfied the definition of being disabled from “Any Occupation” under the LTD Policy.
Subsequently, in a letter dated January 24, 2017, Dr. Davids backtracked a bit and stated “due to the severity of [Plaintiff’s] pain, severe limitations in range of motion, severe spasms, and difficulty in performing such activities as prolonged standing and sitting, I do not recommend that she return to work.”
Plaintiff Archer appealed Hartford’s termination of her benefits. She submitted additional documentation for Hartford to review on appeal, including updated medical records and opinions from her treating physicians, as well as a sworn telephonic statement from Dr. Davids. Dr. Davids said that she “feel[s] that the wording” of the completed functionality questionnaire her office submitted to Hartford on October 19, 2016 was “confusing” and that she did not agree with the restrictions and limitations stated in the questionnaire.”
Hartford referred Plaintiff Archer’s medical records to an “independent” third-party vendor to arrange for two “Independent” Physician Consultants (“IPCs”) to provide an expert medical opinion with respect to Plaintiff’s restrictions and limitations as of January 10, 2017: (1) Dr. Benjamin Kretzmann, board certified in Internal Medicine with Rheumatology fellowship; and (2) Dr. Marvin Pietruszka, board certified in Occupational Medicine.
As expected, Hartford affirmed its prior decision to terminate benefits. Archer then filed an ERISA lawsuit to recover her Long Term Disability benefits and her Waiver of Premium (WOP) for life insurance benefits.
The parties filed cross-motions for summary judgment. The parties agreed that the termination of benefits should be reviewed under an “arbitrary and capricious” standard.
The scope of a Court’s review under the arbitrary and capricious standard is narrow and “the court may overturn a denial of benefits only if it was without reason, unsupported by substantial evidence or erroneous as a matter of law.” (quoting Topalian v. Hartford Life Ins. Co., 945 F. Supp. 2d 294, 340 (E.D.N.Y. 2013)).
The Court specifically noted, however, that courts cannot “substitute their own judgment for that of the insurer” as if “considering the issue of eligibility anew,” and “the mere existence of conflicting evidence does not render the plan administrator’s decision arbitrary or capricious.”
Unfortunately for Plaintiff Archer, the Court determined that Hartford’s decision to terminate Plaintiff’s benefits was not arbitrary and capricious because it was reasonable and relied on substantial evidence.
Plaintiff Archer’s first argument was that Defendant inappropriately relied on the opinions of the independent physician reviewers instead of her treating physicians’ opinions. However, the Court rejected this argument, stating: “there is no requirement that insurers give special weight to treating physicians.” Thus, “when faced with a conflict between the opinion of the treating physician and the opinions of reviewing doctors and independent consultants, it is not arbitrary and capricious for the plan to prefer the reviewing doctors.”
The Court further noted that “The question for this court is not whether Defendant made the ‘correct’ decision but whether Defendant had a reasonable basis for the decision that it made.” Here, the Court found that the objective evidence in the record, primarily gathered from Plaintiff’s treating physicians, can support a reasonable conclusion that Plaintiff is not totally disabled.“ Ouch.
Plaintiff’s second argument was that Defendant Hartford improperly relied on opinions of Dr. Tan and Dr. Davids, which they both later repudiated. The Court rejected this argument, stating: “Second, although it is true that claims administrators must not rely on any repudiated opinions or corrected errors, that did not occur here. Defendant indicated that both IPCs reviewed Plaintiff’s updated opinions and the final adverse appeal determination listed the updated opinions as part of the full review.”
Plaintiff Archer’s third argument was that Defendant improperly relied on the opinions of reviewing physicians, who had never seen or treated Plaintiff. The Court rejected this argument, stating “Third, Insurers are not prohibited from relying on independent medical consultants, who have not treated the Plaintiff.”
Plaintiff Archer’s fourth argument was that Hartford did not allow Plaintiff to review medical reports they relied upon prior to the final denial. The Court rejected this argument, stating “And finally, Plaintiff is not entitled to review the IPC reports that supported Defendant’s decision.” The Court continued, “Defendant allowed Plaintiff to submit any additional documents on appeal and reviewed them fully. Therefore, Plaintiff’s arguments are unavailing.”
Plaintiff’s fifth and final argument was that Defendant was improperly influenced by a conflict of interest. The Court disagreed, stating, “Plaintiff has produced no evidence to show that a conflict of interest should be considered in deciding whether Hartford abused its discretion. Plaintiff only reasserts that Hartford’s termination decision was unfounded, and thus, the Court should infer that there was a conflict of interest. Without more, the Court does not find that there is any reason to suspect a conflict of interest which would render Hartford’s decision arbitrary and capricious.”
In short, the Court denied Plaintiff’s Motion for Summary Judgment and approved Defendant Hartford’s Motion for Summary Judgment, which closed the case.
If Hartford or any other insurer has denied your claim for long-term disability benefits, it is imperative to consult with our law firm prior to handling any appeal on your own. Our law firm has the requisite knowledge and experience to help you perfect your appeal and obtain benefits. If Hartford or any other insurer has denied your claim, please call us at (888) 321-8131 to evaluate your claim.
Here is a copy of the decision in PDF: Archer_v_Hartford
[Note: this claim was not handled by the Ortiz Law Firm. It is merely summarized here for a better understanding of how Federal Courts are handling long-term disability insurance claims.]