Carr v. John Hancock Life Insurance Company (USA)
ORDER granting 30 --motion for summary judgment; directing the clerk to ENTER JUDGMENT for John Hancock Life and against Carr, to TERMINATE any pending motion, and to CLOSE the case. Signed by Judge Steven D. Merryday on 10/17/2016. (BK)
UNITED STATES DISTRICT COURT
MIDDLE DISTRICT OF FLORIDA
CASE NO. 8:14-cv-2867-T-23AEP
JOHN HANCOCK LIFE INSURANCE
Under the Employee Retirement Income Security Act of 1974 (ERISA), David
Carr sues (Doc. 5) John Hancock Life Insurance Company for wrongfully denying a
claim for long-term disability benefits. John Hancock Life moves (Doc. 30) for
1. The Plan and the Policy
Carr worked for Shell Oil Company and participates in Shell’s pension and
welfare-benefits plan, which is governed by ERISA. Under Shell’s plan, John
Hancock Life issued to Shell a policy of “Group Long-Term Care Insurance,” and
Carr is insured under the policy. (Doc. 30 at 2) If an insured is eligible for benefits,
the policy requires John Hancock Life to pay the cost of the insured’s long-term care.
Under the policy’s “benefit trigger” (Doc. 30-5 at 9), an insured can become
eligible for benefits in two ways. First, an insured becomes eligible if the insured
requires “substantial supervision” to protect the insured “from threats to health and
safety” resulting from a “severe cognitive impairment.”1 (Doc. 30-5 at 9) The policy
defines “severe cognitive impairment” as a “loss or deterioration in intellectual
capacity” that is “comparable to . . . Alzheimer’s disease and similar forms of
irreversible dementia” and that is “measured by clinical evidence and standardized
tests.” (Doc. 30-5 at 14)
Second, the insured becomes eligible for benefits if, “due to a loss of functional
capacity,” the insured cannot “without substantial assistance from another
individual” perform at least two “activities of daily living for a period of at least
[ninety] days.”2 (Doc. 30-5 at 9) The policy lists six activities of daily living:
Bathing means washing oneself in either a tub or shower, including the
task of getting into or out of the tub or shower.
Continence means the ability to maintain control of bowel and bladder
function; or, when unable to maintain control of bowel or bladder
function, the ability to perform associated personal hygiene (including
caring for catheter or colostomy bag).
Dressing means putting on and taking off all items of clothing and any
necessary braces, fasteners or artificial limbs.
This order describes the policy’s first method for establishing eligibility as the
This order describes the policy’s second method for establishing eligibility as the
Eating means feeding oneself by getting food into the body from a
receptacle (such as a plate, cup or table) or by a feeding tube or
Toileting means getting to and from the toilet, getting on and off the
toilet, and performing associated personal hygiene.
Transferring means moving into or out of a bed, chair or wheelchair,
or moving from place to place either via walking or wheelchair or
(Doc. 30-5 at 8) Notably, the policy fails to list “housework” or “housekeeping” as
an activity of daily living. (Doc. 30-5 at 8)
“Substantial assistance” means either “hands-on assistance” or “standby
assistance” by “another person needed to perform” the activity of daily living. (Doc.
30-5 at 14) The policy defines “hands-on assistance” and “standby assistance”:
Hands-on assistance means the physical assistance of another person
without which You would be unable to perform the Activity of Daily
Living. You will be considered unable to perform an Activity of Daily
Living if You are not able to participate in that activity or You are able
to contribute in only a minor way.
Standby assistance means the presence of another person within arm’s
reach of You that is necessary to prevent, by physical intervention,
injury to You while You are performing the Activity of Daily Living.
(Doc. 30-5 at 14)
An insured must submit a written “proof of claim” that is “satisfactory” to
John Hancock Life and that “confirms” that the insured “continue[s] to meet all
eligibility requirements.” (Doc. 30-5 at 19)
2. Claim Approval
In May 2011, Carr submitted to John Hancock Life a claim under the policy.
(Doc. 36 at 7) Carr was diagnosed with anemia, anxiety, depression, hypertension,
legal blindness, and prostate cancer.3 (Doc. 36 at 7) After reviewing Carr’s medical
records, John Hancock Life determined that Carr was eligible for benefits because
Carr needed assistance with bathing, dressing, eating, toileting, and transferring. As
a result, John Hancock Life approved Carr’s claim. (Doc. 30 at 5)
In February 2012, Carr submitted to John Hancock Life a claim seeking
payment for the cost of a home healthcare service. To determine whether Carr
remained eligible under the policy, John Hancock Life ordered an “independent
external care assessment” in which third-party Univita Healthcare Solutions, LLC,
evaluated Carr’s cognitive health and functional ability. (Doc. 34-2 at 1–3; Doc. 69-1
at 1–30) During the assessment, Carr was intoxicated and debilitated; Carr explained
to the Univita nurse that he “had been drinking for [three] weeks and had not bathed
in [three] weeks.” (Doc. 69-1 at 1) The evaluation of Carr’s functional ability
concluded that Carr needed hands-on assistance with bathing, dressing, and bladder
continence care, and standby assistance with transferring, toileting, and bowel
continence care. (Doc. 69-1 at 1) Accordingly, John Hancock Life approved Carr’s
A 2011 psychological evaluation, which notes that Carr was “diagnosed in the past” with
Lewy body dementia, was included in the records submitted to John Hancock Life. (Doc. 69-1
Beginning in April 2012, a nurse employed by Maxim Health Care Agency
assisted Carr with his daily activity, and John Hancock Life paid for the service.
According to “weekly notes”4 completed by Maxim between April 2012 and
February 2013, the nurse typically assisted Carr with housekeeping and two activities
of daily living — bathing and transferring. (See Doc. 35-2 at 185, 212, 235) In
February 2013, John Hancock ordered another assessment by Univita. (Doc. 34-2
at 8; Doc. 69-1 at 34–59) The cognitive screening of Carr revealed no evidence of a
cognitive impairment. (Doc 69-1 at 38–41) However, the evaluation of Carr’s
functional ability showed that Carr needed hands-on assistance with
bowel-continence care and standby assistance with bathing, toileting, and
transferring.5 (Doc. 69-1 at 45–50) John Hancock Life again approved Carr’s claim.
After the February 2013 assessment, Carr’s functional ability improved.
According to weekly notes from May to mid-June 2013, the Maxim nurse typically
assisted Carr with only housekeeping and bathing. (See Doc. 35-2 at 264, 267, 275)
According to “independent care provider bills”6 from mid-June to mid-August 2013,
John Hancock Life required Maxim to complete a weekly note describing the particular
services Maxim’s nurse provided to Carr, and the nurse and Carr reviewed and signed each note.
(See, e.g., Doc. 34-4 at 52) For instance, if the nurse assisted Carr by emptying Carr’s catheter bag
and by cleaning Carr’s kitchen, the nurse marked the weekly note’s boxes entitled “empty catheter
bag” and “clean kitchen.” (See Doc. 34-4 at 52)
The Univita nurse noted Carr’s improving functional ability. For instance, a report from
the February 2013 assessment observes that, although Carr struggled with his balance, Carr had
gained strength and could use a walker. (Doc. 69-1 at 46–48)
In mid-June 2013, the nurse assisting Carr stopped working for Maxim and began
submitting to John Hancock Life an “independent care provider service bill,” which summarizes the
the nurse assisted Carr neither with bathing nor with any other activity of daily
living. (Doc. 34-4 at 53–68) As a result, in July 2013, John Hancock ordered
another assessment by Univita. (Doc. 34-2 at 11; Doc. 69-1 at 60–78) Like the
cognitive screening completed in February 2013, the July 2013 cognitive screening
revealed no evidence of a cognitive impairment. (Doc. 69-1 at 63–66) Further, the
evaluation of Carr’s functional ability confirmed that Carr required no assistance
with any activity of daily living. (Doc. 69-1 at 67–73, 75)
3. Claim Denial
Because the weekly notes, the provider bills, and the July 2013 assessment
showed that in July 2013 Carr no longer needed assistance, John Hancock Life
denied Carr’s claim.7 (Doc. 34-3 at 24) After John Hancock Life explained that Carr
could “submit any additional information [to] help clarify matters” (Doc. 34-3 at 25),
Carr requested reconsideration and sent to John Hancock Life medical records
purportedly supporting Carr’s claim. (Doc. 34-3 at 26–27, 29–30) After reviewing
the medical records, in January 2014 John Hancock Life upheld the denial of Carr’s
claim. (Doc. 34-3 at 28–30) Carr twice appealed to John Hancock Life’s appeals
committee and submitted new records to support his claim. (See Doc. 34-3 at 31, 43)
nurse’s weekly activity and verifies whether the nurse assisted Carr with an activity of daily living.
(See, e.g., Doc. 34-4 at 53) After reviewing a provider bill, both Carr and the nurse signed the bill
certifying “that the information provided [in the bill] is a complete and accurate representation of the
care provided and received.” (See, e.g., Doc. 34-4 at 54)
An August 2013 letter states that the denial was “effective July 18, 2013.” (Doc. 34-3 at 24)
The new records included a May 2014 statement by a neurologist and an
August 2014 statement by a urologist certifying that Carr is a “chronically disabled
individual.” (See Doc. 34-3 at 41–42, 43; Doc. 69-3 at 2) After reviewing the
administrative record, including the new records, the appeals committee upheld John
Hancock Life’s decision.8 (Doc. 34-3 at 40–43)
After exhausting his administrative appeals, Carr sues (Doc. 5) John Hancock
Life for wrongfully denying Carr’s claim for long-term disability benefits. Moving
(Doc. 30) for summary judgment, John Hancock Life argues that the decision to
deny Carr’s claim was correct.
1. Standard of Review
“ERISA itself provides no standard” for reviewing a benefits decision by a
plan administrator. Blankenship v. Metro. Life Ins. Co., 644 F.3d 1350, 1354 (11th Cir.
2011). Accordingly, based on guidance from Firestone Tire & Rubber Co. v. Bruch,
489 U.S. 101 (1989), and from Metropolitan Life Insurance Co. v. Glenn, 554 U.S. 105
(2008), the Eleventh Circuit established a “multi-step framework” for reviewing an
administrator’s benefits decision:
(1) Apply the de novo standard to determine whether the claim
administrator’s benefits-denial decision is “wrong” (i.e., the court
The appeals committee denied Carr’s first appeal in June 2014 and Carr’s second appeal in
October 2014. (Doc. 34-3 at 40–43)
disagrees with the administrator’s decision); if it is not, then end the
inquiry and affirm the decision.
(2) If the administrator’s decision in fact 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.
Blankenship, 644 F.3d at 1355 (citing Capone v. Aetna Life Ins. Co., 592 F.3d 1189, 1195
(11th Cir. 2010)). The review of the administrator’s benefits decision considers only
“the material available to the administrator at the time” of the administrator’s
decision. Blankenship, 644 F.3d at 1354.
2. De Novo Review
A review of the administrative record reveals that John Hancock Life correctly
denied Carr’s claim. First, no document in the administrative record suggests, and
Carr fails to argue, that in July 2013 Carr qualified for benefits under the policy’s
cognitive-impairment provision. (See Doc. 30-5 at 9, 14) Screenings in
February 2013 and in July 2013 uncovered no evidence of a cognitive impairment.
(Doc. 69-1 at 39–41, 63–66) Although a psychiatric evaluation in 2011 notes that
Carr was “diagnosed in the past” with Lewy body dementia (Doc. 69-1 at 98), no
other document in the administrative record, including notes from Carr’s neurologist,
corroborates this purported diagnosis or describes any treatment of Carr for dementia
or another cognitive impairment.
Second, John Hancock correctly denied Carr’s claim because Carr failed to
prove that in July 2013 Carr qualified for benefits under the functional-disability
provision. Carr incorrectly argues that John Hancock Life failed to show “that any
of [Carr’s] medical problems resolved to the extent that [Carr] became fully
independent” in the activities of daily living. (Doc. 36 at 18) Carr ignores that Carr
“bears the burden to prove that [he] is disabled.” See Glazer v. Reliance Standard Life
Ins. Co., 524 F.3d 1241, 1247 (11th Cir. 2008). (Doc. 30-5 at 19 (stating that under
the policy Carr must submit a “proof of claim” that is “satisfactory” to John Hancock
Life and that confirms that Carr continues “to meet all eligibility requirements”)
Thus, Carr must prove that, without either hands-on assistance or standby assistance,
Carr could not perform at least two activities of daily living. (See Doc. 30-5 at 8, 9,
14, 19) Carr failed to meet his burden.
During the February 2013 assessment, an evaluation of Carr’s functional
ability demonstrated that Carr required assistance with bathing, continence care,
toileting, and transferring. However, Carr’s functional ability improved, and during
the July 2013 assessment Carr performed without assistance all six activities of daily
living. (Doc. 69-1 at 67–73, 75) The nurse who assessed Carr observed that, at a
slow pace, Carr could walk with a “steady gait” and an “erect posture,” and Carr
admitted that he was “very pleased with his gains made recently with gait stability
[and] balance.” (Doc. 69-1 at 68, 75) Carr argues that John Hancock Life failed to
consider Carr’s comments about “his continued need for assistance” (Doc. 36 at 19),
but Carr ignores that at the assessment Carr explained to the Univita nurse that he
routinely ate, bathed, defecated, dressed, transferred, and urinated without
assistance. (Doc. 69-1 at 67–73)
The weekly notes and provider bills confirm that by July 2013 Carr no longer
met the functional-disability provision’s requirements for eligibility. The weekly
notes, signed by Carr and his nurse, show that from May to mid-June 2013 Carr
received assistance only with a single activity of daily living — bathing.
(See Doc. 35-2 at 264, 267, 275) And the provider bills, which Carr and his nurse
signed and certified, show that from mid-June 2013 to mid-August 2013 the nurse
assisted Carr with no activity of daily living. (Doc. 34-4 at 53–68) Carr alleges that
the weekly notes and the provider bills were “deficient” and argues that John
Hancock Life allowed Carr no opportunity to “amend the paperwork.” (Doc. 36
at 20) This argument fails because John Hancock Life denied Carr’s second appeal
more than fourteen months after initially denying Carr’s claim, and during those
fourteen months John Hancock Life encouraged Carr to “submit any additional
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information that you feel may help clarify matters.” (Doc. 34-3 at 25) Despite ample
opportunity, Carr failed to correct the purported deficiency.
The other documents in the administrative record fail to undermine John
Hancock Life’s conclusion that in July 2013 Carr no longer remained functionally
disabled. A May 2014 statement from Carr’s neurologist certifies that Carr lacked
ability to perform five activities of daily living. (Doc. 69-3 at 2) However, the
neurologist’s certification is inconsistent not only with the July 2013 assessment, the
weekly notes, and the provider bills, but also with the neurologist’s own notes. In a
section of the neurologist’s April 2014 notes entitled “functional status assessment,”
the neurologist observes that Carr “can eat, bathe, use the toilet, dress, and get up
from the chair or bed.” (Doc. 69-5 at 151) Thus, John Hancock Life correctly
assigned little weight to the neurologist’s certification. See Blankenship, 644 F.3d
at 1356 (holding that a plan administrator “may give different weight” to a treating
physician’s opinion especially if evidence in the record “could have led [the
administrator], with reason, to doubt” the opinion); cf. Townsend v. Delta Family-Care
Disability & Survivorship Plan, 295 Fed. Appx. 971, 977 (11th Cir. 2008) (per curiam)
(“To the extent other evidence in the record suggests that a claimant is disabled, a
plan administrator is entitled to weigh the evidence and resolve conflicting evidence
about the claimant’s disability.”).
Also, the “relevant time for assessment of [Carr’s] condition” is July 2013, the
effective date of the denial of Carr’s claim. Ramdeen v. Prudential Ins. Co. of Am.,
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163 F. Supp. 3d 1218, 1225 (M.D. Fla. 2016) (Antoon II, J.). The neurologist’s
statement in May 2014, a similar statement from a urologist in August 2014, and the
medical records from 2012 and earlier fail to rebut the other evidence demonstrating
that in July 2013 Carr needed no assistance with any activity of daily living.9
Because a review of the administrative record reveals that John Hancock Life
correctly denied Carr’s claim, John Hancock Life’s motion (Doc. 30) for summary
judgment is GRANTED. See Nolley v. Bellsouth Long Term Disability Plan For
Non-Salaried Employees, 610 Fed. Appx. 841, 843 (11th Cir. 2015) (per curiam) (“If we
would have reached the same decision as the administrator, the judicial inquiry ends,
and judgment in favor of the administrator is appropriate.”). The clerk is directed
(1) to enter judgment for John Hancock Life and against Carr, (2) to terminate any
pending motion, and (3) to close the case.
ORDERED in Tampa, Florida, on October 17, 2016.
Many if not most of the medical records submitted by Carr are irrelevant because the
records fail to discuss Carr’s functional ability. (See, e.g., Doc. 69-3 at 17–20)
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