Keyton Benson (“Benson”) was employed by Tower Hill Insurance Group. Through his employer, Benson was eligible for long term disability benefits through a policy issued by Hartford Life & Accident Insurance Company (“Hartford”). The policy language states that it will provide a policyholder with monthly payments if he has:
“1. Become Disabled while insured under The Policy;
- Are Disabled throughout the Elimination Period;
- Remain Disabled beyond the Elimination Period; and
- Submit Proof of Loss to Us.”
In addition, the policy defined “disability” or “disabled” as:
“Disability or Disabled means You are prevented from performing one or more of the Essential Duties of:
- Your Occupation during the Elimination Period;
- Your Occupation, for the 2 years following the Elimination Period and as a result Your Current Monthly Earnings are less than 80% of Your Indexed Pre-Disability Earnings; and
- After that; Any Occupation.”
This specifically means that Benson must prove that he was disabled throughout the entire term of the Elimination Period, which has been agreed upon as May 15, 2016, to August 27, 2016. Hartford believed that Benson was not disabled during that entire term, which eventually resulted in the instant suit.
Here, the court’s standard of review was set out by the Blankenship v. Metropolitan Life Ins. Co. case, which is a pertinent part outlined below:
“(1) Apply the de novo standard to determine whether the claim administrator’s benefits-denial decision is ‘wrong’ (i.e. the court disagrees with the administrator’s decision); if it is not, then end the inquiry and affirm the decision.
(2) If the administrator’s decision is ‘de novo wrong,’ then determine whether he was vested with discretion in reviewing claims; if not, end judicial inquiry and reverse the decision.
(3) If the administrator’s decision is ‘de novo wrong’ and he was vested with discretion in reviewing claims, then determine whether ‘reasonable’ grounds supported it (hence, review his decision under the more deferential arbitrary and capricious standard).
(4) If no reasonable grounds exist, then end the inquiry and reverse the administrator’s decision; if reasonable grounds do exist, then determine if he operated under a conflict of interest.
(5) If there is no conflict, then end the inquiry and affirm the decision.
(6) If there is a conflict, the conflict should merely be a factor for the court to take into account when determining whether an administrator’s decision was arbitrary and capricious.”
In this case, that means that the court must determine whether Hartford was “wrong” when it decided that Benson failed to prove he was disabled during the entire Elimination Period. Hartford’s primary reasoning stems from the assertions of two doctors who reviewed Benson’s file. More particularly, Hartford indicated that Benson was not disabled from May 15, 2016, to July 19, 2016, after which he subsequently had knee replacement surgery. In addition, he would have at minimum recovered from surgery by August 26, 2016.
The court overall affirmed Hartford’s decision based on “(1) the substance of Benson’s claims for both short-term and long-term disability benefits, (2) the contemporaneous treatment notes from Benson’s physicians, and (3) the ability of Benson to perform the essential duties of his job.” On the first account, the court determined that Benson’s claims seemed to be in conflict. Benson stated that he was disabled as a result of both fatigue and pain from polymyalgia rheumatica (“PMR”). However, the court indicated that PMR was never identified on either Benson’s short or long-term disability applications. Instead, both applications were specifically related to Benson’s knee replacement.
Secondly, the court agreed that Benson was not disabled for the entire elimination period based on the records from his own physicians. A Dr. Erbay cited that Benson’s main complaints were related to his knee, with PMR symptoms infrequently or never making an appearance. On May 26, 2016, Dr. Erbay’s notes indicate that Benson was experiencing short-term stiffness and fatigue. However, Dr. Erbay did not go so far as to say that Benson was disabled at this time. A June 3rd appointment also had similar outcomes. Following Benson’s knee surgery, Benson said his PMR was “great” and that he had not been experiencing fatigue or headaches.
Benson’s other interactions with medical providers were similar. On June 27, 2016, Dr. Seldon Longley, rheumatologist, cited that Benson’s PMR was “well controlled” through Prednisone. In addition, on August 2, 2016, a Dr. Rocca indicated no symptoms of PMR and instead opined that Benson was experiencing a good recovery from his knee surgery. The only indications that PMR seemed to be causing Benson much trouble at all came after the Elimination Period on August 31, 2016, and again on September 8, 2016. As a result of the above treatment notes, the court determined that Benson only met the definition of “disabled” during the recovery period of his knee surgery.
Thirdly, the court considered Benson’s ability to perform his job duties. An examination of his job duties revealed that his work was primarily sedentary, including sitting for two hours at a time, standing or walking for thirty minutes at a time, and not lifting anything heavy. On a daily basis, Benson had to sit for seven hours, walk for thirty minutes, and stand for thirty minutes. Dr. Rocca provided a statement to Hartford on August 25, 2016, which opined that Benson was able to sit or stand for eight hours and walk for thirty minutes up to six or eight hours per day. As such, the court held that Benson was able to perform his job duties as early as that August 25th date.
Overall, the court affirmed that Hartford’s decision was not “wrong” in determining that Benson was not entitled to receive long-term disability benefits. As this decision met the first element of the Blankenship standard, the court chose to end its inquiry. However, the court further stated that if it had continued with the Blankenship review, it would have found that Hartford had not acted in an arbitrary and capricious manner because Hartford’s reasoning had been so clearly outlined.
[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.]Here is a copy of the decision in PDF: