In the present case, Brenna Mawa (“Mawa”) worked as a nurse, Branch Director, and Clinical Director; she was employed by LHC Group, Inc. (“LHC”). The company was insured by a Group Long Term Disability Plan for Employees issued by the Hartford Life & Accident Insurance Company. This plan defined a disability as whether a person can perform the duties related to his or her own occupation. After twenty-four months pass, the plan additionally tests whether that person can perform the duties of any occupation at all. The term “any occupation” is specifically defined as “any occupation for which you are qualified by education, training, or experience.”
Around 2015, Mawa began experiencing symptoms from peripartum cardiomyopathy and ceased work. She later applied for long term disability (LTD) benefits, which was approved by Hartford on June 5, 2015. The approval letter for the LTD benefits further stated that her “any occupation” test would be effective February 8, 2017. One of Hartford’s nurses, Roxann Koelln contacted Mawa on May 20, 2016, to check about her symptoms and status. Mawa stated that she had been experiencing several symptoms including fatigue and tiredness, feeling lightheaded or dizzy upon standing and bending, shortness of breath, and slight edema in the legs and feet. She stated that she had lost a significant amount of weight due to lap band surgery and did light exercise, including lifting her four-year-old child.
The nurse further inquired as to whether Mawa might be able to do sedentary work. Mawa stated, however, that she was likely unable to do so due to her use of coumadin. The nurse replied that employees taking coumadin are often allowed the freedom to move around, stand, and stretch as needed. Mawa’s final response was that she would consider returning to work when she was able to get her symptoms under better control.
Several months later, Nurse Koelln called to obtain an update from Mawa. She was informed that Mawa had an echocardiogram on June 15, 2016, and that she still experienced blood pressure and dizziness problems. The day after the call, the nurse sent a letter to Mawa’s treating physician to inquire about her ability to work. A month or so later, Assistant Nurse Practitioner Terri Hancock responded to the letter on Dr. Kristin Scott-Tillery’s behalf, alleging that Mawa would be able to work part-time in a sedentary capacity. The letter stated that Mawa had “significant limitations at this time” and cited pre-syncope episodes and hypertension.
Following that, Mawa saw Dr. Stehlik. He stated that she had no symptoms of fatigue, near-syncope, shortness of breath, muscle weakness, orthopnea, dyspnea on exertion, or claudication. However, he opined that she did have some lightheadedness. A few weeks after this visit, Nurse Koelln reached out to Dr. Scott-Tillery to see if Mawa would be able to perform full-time sedentary work. She was later informed that Dr. Scott-Tillery had moved away and that Mawa’s primary physician was Dr. Stehlik.
Hartford forwarded Mawa’s records to Dr. Mark Eaton for an independent physician peer review on October 6, 2016. After reviewing hundreds of pages, he opined that there was some inconsistency with the medical provider’s statements limiting Mawa’s work ability, even though she showed clear cardiac function improvements. He further concluded that Mawa “would be capable of full-time work capacity 8 hours daily and 40 hours weekly” and that she could maintain “a sedentary level occupation at this time – which is defined as involving lifting no more than 10 pounds at a time” and “sitting up to 6 hours out of an 8-hour work day with occasional walking and standing up to 2.4 hours out of the 8-hour work day.”
On November 14, 2016, Hartford began to determine Mawa’s current employability by utilizing an Occupational access System. The program ran Mawa’s work history and qualifications, as well as her work abilities and limitations. The analysis resulted in a finding of 6 close occupations at the closest level, 2 within the good level, 131 within the fair level, and 159 within the potential level.
Hartford’s Ability Agent contacted Mawa on November 22, 2016. Mawa stated that she was “[a]bout the same with some good days and some bad.” Further, “all [activities of daily living] performed independently, does require some assistance w[ith] deep cleaning and grocery shopping, but cares for home/daughter mostly as [her spouse] travels for business.” Later, on January 5, 2017, Hartford decided that Mawa was not limited from working “any occupation.” Therefore, as a result, her LTD benefits were ceased on February 7, 2017.
Mawa appealed and Hartford had a third-party conduct an independent medical consultant review. The third-party designated Dr. Robert Weber, Board Certified in Cardiology, to review her file. He opined that there was “no evidence to support the claimant is/was totally restricted from work activity as of February 8, 2017 through present.” Subsequently, Hartford issued a determination that Mawa could work full-time in a sedentary capacity.
The court utilized an arbitrary and capricious standard when reviewing this case. After several arguments by Hartford were agreed to by Mawa, the only remaining issue was whether or not Hartford should have conducted an additional employability analysis after Dr. Weber reviewed Mawa’s file. Originally, Dr. Eaton reviewed her records and provided recommended restrictions. The restrictions then determined the outcome of the Employability Analysis Report. Hartford argued that the occupation recommendations continued to be valid, even based on the restrictions that Dr. Weber subsequently suggested.
Mawa, at this point, did not explain why she believed that Dr. Weber’s recommendations warranted an additional Employability Analysis Report.
The court held that Dr. Weber’s recommended restrictions were so similar to Dr. Eaton’s that there did not need to be a second report. As a result, the court decided that it was reasonable for Hartford to decide that Mawa could conduct work in a sedentary capacity. This also meant that she did not meet the standard of being unable to perform “any occupation.” As such, the court ruled that Mawa’s claim was validly denied by 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.]Here is a PDF copy of the decision: