The Second Circuit recently decided an LTD claim involving MS in favor of The Hartford
Case Title: Ingravallo v. Hartford Life and Accident Ins. Co.
Insurance Company: The Hartford
Disabilities: Relapsing-remitting multiple sclerosis (“MS”)
Court: United States Court of Appeals, Second Circuit (on Appeal from the United States District Court for the Eastern District of New York)
Lower Court Ruling: The District Court ruled in favor of the claimant, granting summary judgment and awarding her approximately $19,000 in benefits on her claim pursuant to the Employee Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C. § 1001 et seq. (See, Ingravallo v. Hartford Life & Acc. Ins. Co., 10-cv-5150 (FB) (JO), 2013 WL 1346283 (E.D.N.Y. Apr. 3, 2013)).
- Whether the Hartford should have provided a more substantial explanation for its decision because it ran counter to the SSA’s (unchanged) disability determination.
- Whether the Hartford’s reviewers adequately addressed medical evidence on record in the claim.
- Since the only evidence in the record concerning plaintiff’s Social Security award was the 2006 Notice of Award letter, the Hartford was not required to address the determination in any detail without substantive evidence.
- Although an administrator “may not arbitrarily refuse to credit a claimant’s reliable evidence, including the opinions of a treating physician,” courts may not “impose on plan administrators a discrete burden of explanation when they credit reliable evidence that conflicts with a treating physician’s evaluation.”
Diana Ingravallo was employed by BDP International (“BDP”) as an air import coordinator. Her full-time, sedentary job required her to sit for most of an eight-hour day, and, occasionally, to lift or carry a small amount of weight. In the late 1990s, the claimant was diagnosed with relapsing-remitting multiple sclerosis (“MS”), but she was able to work as a coordinator at BDP until May 2005, when she suffered an exacerbation that caused her to experience difficulty walking, among other serious symptoms. Her treating neurologist opined that she was “no longer able to work in any capacity,” and advised that she withdraw from work “on a permanent basis.” She stopped working that year.
As a BDP employee, Ingravallo participated in the company’s long-term disability plan (the“Plan”), which was governed by ERISA and administered by Hartford. The Plan defined “disability” as “Injury or Sickness” that “causes physical or mental impairment to such a degree of severity” that the claimant is “continuously unable to perform the Material and Substantial Duties of [her] Regular Occupation” and is “not Gainfully Employed.” It grants Hartford “discretionary authority to determine [a claimant’s] eligibility for and entitlement to benefits.”
Ingravallo applied for benefits under the Plan. In September 2005, Hartford determined that the exacerbation of Ingravallo’s symptoms rendered her disabled under the Plan and qualified her to receive long-term disability benefits. In 2006, under applicable regulations, the Social Security Administration (“SSA”), also determined that Ingravallo was disabled and qualified her for governmental benefits, which she then began to receive.
Prompted by inconsistencies that it perceived between Ingravallo’s then-recent accounts of her condition and the accounts provided by her treating neurologist, in late 2008 Hartford undertook a re-assessment of Ingravallo’s eligibility for benefits. Several months later, having obtained an updated peer review of her medical condition and two brief surveillance videos, covertly made, of Ingravallo performing chores outside her home, Hartford determined that Ingravallo no longer met the Plan’s definition of “disabled.” In response to her request for an administrative review, Hartford sought an additional medical evaluation and Ingravallo submitted further input from her treating neurologist. In 2010, Hartford upheld the denial.
In support of its detailed final decision it cited, among other factors, the opinions of its medical reviewers, inconsistencies in the reports of Ingravallo and her neurologist, observations derived from the surveillance video regarding her current functional capacities, and observations by an investigator who met with Ingravallo for several hours.
Ingravallo then sought judicial review of Hartford’s decision. On cross-motions for summary judgment on the administrative record, the District Court concluded that Hartford’s denial of coverage was arbitrary and capricious and granted Ingravallo’s motion for summary judgment and damages.
The District Court pointed, for support, to three perceived errors in Hartford’s determination: (1) that Hartford did not “provide a cogent reason for its disagreement with the [SSA],”; (2) that Hartford’s medical reviewers did not address “an important detail”: the “presence of ‘black holes’ on Ingravallo’s most recent MRIs,”; and (3) that, although “th[e] videos undoubtedly show Ingravallo doing things that she claimed not to be able to do,” the videos “d[id] not constitute substantial evidence that she is able to [work],”
On appeal, The Hartford contended that the District Court erred in the above conclusion, and the Second Circuit agreed.
The Hartford first challenged the District Court’s criticism that Hartford should have provided a more substantial explanation for its decision because it ran counter to the SSA’s (unchanged) disability determination.
The Second Circuit agreed:
Although we have “encourage[d] plan administrators, in denying benefits claims, to explain their reasons for determining that claimants are not disabled where the SSA arrived at the opposite conclusion,” Hobson, 574 F.3d at 92, administrators are not bound by an SSA’s award of benefits—as the District Court acknowledged. See, Black & Decker Disability Plan v. Nord, 538 U.S. 822, 833-34 (2003). Here, with respect to the SSA award, Ingravallo provided only a 2006 letter from the SSA informing her that it approved her application for disability benefits. Ingravallo presented no documents disclosing the basis for the SSA’s decision. In addition, the record does not reflect that the SSA conducted any reevaluation of Ingravallo’s condition after its initial award—with which Hartford agreed—in 2006. Unlike the District Court, we cannot fault Hartford for failing to discuss the SSA’s position more substantially in its decision.
The Hartford next attacked the proposition that Hartford’s reviewers did not adequately address the presence of the “black holes” on images of Ingravallo’s thoracic spine—objective findings noted by Ingravallo’s neurologist and characterized by him as “correlate[ing] well with the degree of a patient’s disability.”
The Second Circuit court pointed out:
Although an administrator “may not arbitrarily refuse to credit a claimant’s reliable evidence, including the opinions of a treating physician,” courts may not “impose on plan administrators a discrete burden of explanation when they credit reliable evidence that conflicts with a treating physician’s evaluation.” Black & Decker, 538 U.S. at 834. Here, although Ingravallo’s treating neurologist assigned some weight to the “black holes” observed, neither he nor Ingravallo identified any evidence suggesting that the lesions demonstrated Ingravallo lacked the capacity to work. Indeed, the significance of the treating physician’s statement—that the lesions’ presence “correlate[s] well with the degree of a patient’s disability”—was unclear. One of Hartford’s peer reviewers noted the lesions’ presence, but did not discuss them further. We cannot agree on this record that the failure of Hartford’s peer reviewers to account further for the lesions rendered Hartford’s decision arbitrary and capricious.
Further, although the treating neurologist offered his general opinion again in 2009 that Ingravallo was not capable of returning to work, the administrative record contains sufficient contrary medical evidence, inadequately rebutted by Ingravallo, to support Hartford’s decision. For example, one peer reviewer noted that Ingravallo’s “disease ha[d] been quiescent,” and that, despite some abnormalities regarding her gait, her “cognitive function was normal.” That reviewer concluded that Ingravallo was “reasonabl[y] capable of full time work at a sedentary level.” A second peer reviewer provided a similar, albeit more guarded, assessment. He acknowledged that Ingravallo “ha[d] restrictions,” and that she was “limited by fatigue due to weakness.” But “[d]ue to a lack of medical information to support an inability to work,” he also concluded that Ingravallo “should be able to work at the sedentary level.” These assessments constituted “more than a scintilla” of evidence that Ingravallo no longer qualified as disabled within the meaning of the Plan. Durakovic, 609 F.3d at 141. Again, we note that Ingravallo bore the burden of establishing, through objective medical evidence, her continued inability to work. See Critchlow, 378 F.3d at 256. The evidence cited by Ingravallo does not vitiate the contrary opinions offered by Hartford’s reviewers or render its decision arbitrary and capricious.
(internal citations omitted)
Conclusion: The Second Circuit reversed the District Court and ordered Judgment for The Hartford: “ORDERED, ADJUDGED, AND DECREED that the April 19, 2013 judgment of the District Court is REVERSED and the cause is REMANDED with directions to enter judgment for Hartford.”
Disclaimer: This was not a case handled by the disability attorneys at the Ortiz Law Firm. The court case is summarized here to give readers a better understanding of how Federal Courts decide long term disability ERISA claims.
Here is a copy of the decision in PDF: