Estrella v. Hartford Life and Accident Insurance Company et al

Filing 54

Judge Rya W. Zobel: ORDER entered. MEMORANDUM of Decision; Hartford's decision to deny Estrella long term disability benefits was not arbitrary or capricious, and therefore Hartford's motion for summary judgment on the administrative record (#34) is ALLOWED.(Urso, Lisa)

UNITED STATES DISTRICT COURT
DISTRICT OF MASSACHUSETTS
CIVIL ACTION NO. 09-11824-RWZ
PATRICIA ESTRELLA
v.
HARTFORD LIFE AND ACCIDENT
INSURANCE COMPANY et al.

MEMORANDUM OF DECISION
September 6, 2011
ZOBEL, D.J.
Plaintiff Patricia Estrella (“Estrella”) seeks review of the denial of her disability
claim by defendant Hartford Life and Accident Insurance Company (“Hartford”). For the
reasons discussed below, I find that Hartford’s denial of benefits was not arbitrary and
capricious and therefore allow defendant’s motion for summary judgment and deny
plaintiff’s corresponding motion.
I.

Background and Procedural History
In 2007, Estrella, then employed as a network engineer for Sprint United

Management Company (“Sprint”), sought disability benefits due to a degenerative
nerve condition, as well as carpal tunnel syndrome and fibromyalgia. She received
salary continuation benefits for the period between September 12, 2007 and March 12,
2008. On March 24, 2008, Sprint submitted a long-term disability claim packet to
Hartford. On June 10, 2008, Hartford determined that Estrella had full work capacity
and denied her application for long-term disability benefits. The claim was also denied

on appeal. Defendant Hartford is the claims administrator under the plan.
On December 23, 2009, plaintiff challenged Hartford’s denial in a
four-count complaint brought against Sprint, Hartford, and Dr. Peter Mosbach alleging
that: (1) the denial of benefits was arbitrary and capricious in violation of the Employee
Retirement Income Security Act of 1974 (“ERISA”), Pub. L. No. 93-406, 88 Stat. 829, as
amended, 29 U.S.C. § 1132(a)(1)(B) (Count I); (2) Dr. Mosbach had a conflict of
interest when rendering his opinion and thereby interfered with plaintiff’s rights
protected by the Americans With Disabilities Act, 42 U.S.C. §§ 12101 et seq. (“ADA”)
(Count II); (3) Dr. Mosbach’s conflict constitutes tortious interference with contractual or
advantageous relations (Count III). Plaintiff seeks damages, past and future benefits,
and in a separate count (Count IV), attorneys’ fees and costs under 29 U.S.C. §
1132(g). On February 8, 2010, plaintiff voluntarily dismissed her claims against Dr.
Mosbach. (Docket # 25). Consequently, Counts II and III are dismissed.
Defendant moved for summary judgment (Docket # 34), and plaintiff sought
discovery as to the extent of the alleged conflict. On November 23, 2010, this court
granted leave for plaintiff’s motion to take limited discovery pertaining to an alleged
conflict of interest on the part of defendant’s reviewing physician, Dr. Mosbach.
(Docket # 42). As that discovery has been completed, defendant’s motion for summary
judgment is now ripe.
II.

Legal Standard
A.

Standard of Review

A district court generally reviews an ERISA plan administrator’s benefits
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determinations de novo. Gross v. Federal Exp. Corp. Long Term Disability Plan, 707 F.
Supp.2d 67, 71 (D. Mass. 2010). However, where, as here, the ERISA plan grants the
plan administrator discretionary authority in the determination of eligibility for benefits,
the administrator’s decision must be upheld unless it is “arbitrary, capricious, or an
abuse of discretion.” Cusson v. Liberty Life Assur. Co. of Boston, 592 F.3d 215, 224
(1st Cir. 2010) (citing Gannon, 360 F.3d at 213 (1st Cir. 2001)). A decision to deny
benefits to a beneficiary will be upheld under the “arbitrary and capricious” standard if
the administrator’s decision “[was] reasoned and supported by substantial evidence.”
Medina v. Metropolitan Life Ins. Co., 588 F.3d 41, 45 (1st Cir. 2009). Substantial
evidence does not require that there be no contradictory evidence, only that the
evidence is sufficient to reasonably support the administrator’s conclusion. Doyle v.
Paul Revere Life Ins. Co., 144 F.3d 181, 184 (1st Cir. 1998).
B.

Summary Judgment

A challenge of the denial of employee benefits arises under Section 502(a) of
ERISA, 29 U.S.C. § 1132(a)(1)(B). In ERISA cases, “where review is based only on the
administrative record before the plan administrator and there is an ultimate conclusion
as to disability to be drawn from the facts, summary judgment is simply a vehicle for
deciding the issue.” Orndorf v. Paul Revere Life Ins. Co., 404 F.3d 510, 517 (1st Cir.
2005). The court’s role is to make a determination “whether the administrator's action
on the record before him was unreasonable.” Liston v. Unum Corp. Officer Severance
Plan, 330 F.3d 19, 24 (1st Cir. 2003). Doubts are resolved in favor of the administrator,
and “no special inferences are to be drawn in favor of the plaintiff resisting in summary
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judgment.” Id.; see also Orndorf, 404 F.3d at 517 (where summary judgment is simply a
vehicle for deciding the issue, “the nonmoving party is not entitled to the usual
inferences in its favor.”).
III.

Factual Background
A.

Plaintiff’s Employment and Disability

Estrella worked at Sprint from September 8, 1997 to August 14, 2007. She was
responsible for “working on 911 switch translations,” which required keyboard use with
continuous sitting and only occasional reaching. The job required her both to talk on
the phone and type at the computer. Sprint paid her a base salary of $96,230.51 per
year and she managed a team of 15 employees.
She left work on August 14, 2007, complaining of pain and fatigue. She was
later diagnosed with, among other ailments, rheumatoid arthritis, left upper extremity
myofacial pain, fibromyalgia, intervertebral disc disorder with myelopathy lumbar and
cervical radiculopathy.
B.

The Long Term Disability Plan

Sprint’s Basic and Supplemental Long Term Disability policy provides that
participants who become disabled while insured under the plan will be paid a monthly
benefit. See Sprint/United Management Company Group Benefit Plan effective January
1, 2007 (A.R. 386-418). She was covered under both a short-term disability plan (“STD
Plan”) and a long-term disability plan (“LTD Plan”). Hartford is both the administrator of
and payer of benefits under the LTD Plan. Under the terms of the insurance policy (“the
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Policy”) for the LTD Plan, the definition of “Disability” or “Disabled” for LTD purposes
varies over time with the duration of the disability. For the initial 24-month period after
a claimant switches into the LTD Plan from the STD Plan, a person is considered
“disabled” if she has a listed injury and is unable to perform “one or more of the
[e]ssential [d]uties of [her] occupation.” (A.R. 404-405 at ¶¶1-2.) However, after 24
months, a person is considered “disabled” if she is “prevented from performing one or
more of the [e]ssential [d]uties of [a]ny occupation.” Id. at ¶ 3. Qualifying injuries
include bodily injury, sickness, and mental illness, among others. The policy places the
burden of providing proof of disability on the claimant. Id.
C.

Disability Claim

Estrella submitted her disability claim to Hartford on March 24, 2008. (A.R. 366384.) Her complaints included “neck pain, head & shoulder arm tingling, tiredness,
aching constant.” Id. She included a medical report from Dr. Joseph J. Doerr
(psychiatrist). Hartford conducted a telephonic interview with claimant on March 31,
2008, and later requested further records from Dr. Matthew Messina (pulmonologist),
Dr. Michael W. Egan (rheumatologist), and Dr. Jean Peeler (chiropractor).
Hartford received reports from Dr. Doerr describing a diagnosis of chronic pain
syndrome with left upper extremity myofacial component. She was seen for headaches
and prescribed Ultram and Zanalflex. (A.R. 191.) The medical records from Dr.
Messina show that Estrella was seen for asthma, rhinitis, excema, osteopenia,
fibromyalgia, and chronic fatigue. Dr. Eagan diagnosed Estrella with fibromyalgia, left

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cervical radiculopathy, fatigue and weakness. Finally, the medical reports submitted by
Dr. Peeler revealed a diagnosis of intervertebral disc disorder with myelopathy lumbar,
head and occipitocervical region subluxation, pelvic, hip and public region subluxation.
She received multiple adjustments, hot packs, cross friction massages and trigger point
therapy.
On May 30, 2008, Hartford Medical Case Manager Italialee Bright, R.N.,
performed a functional assessment based on the records received to date. She
concluded that “[t]he medical evidence submitted and reviewed does not support
[Estrella’s] inability to function at her previous level of primarily sedentary function.”
She further reported that while “it is reasonable that [Estrella]would have intermittent
discomfort, ... this should not preclude her from performing at her previous level of
function.” (A.R. 10.)
D.

Denial

In a written decision dated June 10, 2008, Hartford denied Estrella’s claim on the
ground that the information submitted did not support her claim of total disability. (A.R.
189-192). Hartford concluded that her medical condition should not prevent her from
performing her previous work at a sedentary level.
After considering the medical information submitted by the several doctors
previously identified, Hartford concluded that plaintiff’s medical condition would result
in “intermittent discomfort” but such discomfort “should not prevent [her] from
performing sedentary work related activities with the opportunity to alternate sitting and

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standing as needed.” (A.R. 191.)
E.

Appeal

By letter dated February 27, 2009, Estrella appealed Hartford’s decision. On
appeal, Estrella submitted “additional medical information,” including two additional
medical reports, in support of her claim, one from Dr. Thomas Lichauco (a family
practice physician; board certified in both family medicine and occupational health
medicine) and the other from Dr. Stone (a neuropsychologist). In its response dated
March 19, 2009, Hartford requested review of the new information presented by an
outside medical vendor, MES Solutions (MES). MES provided a peer review report by
Dr. Mark Burns, a rheumatologist and Dr. Peter Mosbach, a neuropsychologist.
Dr. Burns concluded that “no impairment is supported from a rheumatological
standpoint...Fibromyalgia is a waxing and waning condition and people are normally
able to work.” He further noted that there was no medical documentation, as Estrella
went untreated for the last year. Dr. Mosbach separately concluded that there was no
basis for any cognitive impairment. He concluded that the records did not “show
evidence of functional restrictions or limitations from a cognitive or mental/nervous
perspective that would be supported as of [August 15, 2007] to the present.” (A.R. at
64.)
On April 14, 2009, Hartford denied her appeal. (A.R. 23-26.)
IV.

Analysis
A.

Conflict of Interest
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1.

Effect on Standard of Review

In ERISA cases, the entity that administers the plan often both determines
whether an employee is eligible for benefits and pays benefits out of its own pocket.
Metro Life Ins. Co. v. Glenn, 554 U.S. 105, 128 (2008). The U.S. Supreme Court has
held that this dual role creates a structural conflict of interest. Id. The existence of this
conflict of interest does not change the standard of review; rather, it “should be
weighed as a factor in determining whether there is an abuse of discretion.”1 Id. at 115.
See also Cusson v. Liberty Life Assurance Co. of Boston, 592 F.3d 215, 224 (1st Cir.
2010).
2.

Effect on the Merits

Under some circumstances, however, the structural conflict will be “accorded
extra weight in the court’s analysis.” Cusson, 592 F.3d at 224. For example, the
conflict “should prove more important (perhaps of great importance) where
circumstances suggest a higher likelihood that it affected the benefits decision.” Metro
Life Ins. Co., 554 U.S. at 117. By contrast, where the administrator has taken “active
steps to reduce potential bias and to promote accuracy,” the conflict will be held to be
“less important (perhaps to the vanishing point).” Id. The First Circuit instructed in
Denmark v. Liberty Life Assur. Co. of Boston, 566 F.3d 1, 9 (1st Cir. 2009), that courts
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The argument that the existence of a structural conflict of interest changes the
standard of review from arbitrary and capricious to the “combination of factors” test was
rejected by the First Circuit in Cusson v. Liberty Life Assur., 592 F.3d 215, 224 (1st Cir.
2010) (disagreeing with plaintiff’s argument that the Supreme Court’s decision in Glenn
changed the standard of review from an abuse of discretion standard to a ‘combination
of factors’ standard in cases where there was a structural conflict of interest.”).
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are “duty-bound to inquire into what steps a plan administrator has taken to insulate the
decisionmaking process against the potentially pernicious effects of structural
conflicts.” The claimant bears the burden of proving that the conflict influenced the
administrator’s decision.
Here, plaintiff notes that in 2008, Hartford had revenue of $4.3 billion yet
suffered an operating loss of $6 million. Nevertheless, Hartford paid bonuses to its
employees in the appeals unit.
Without more, the fact that Hartford suffered operating losses yet paid bonuses
to employees in the appeals unit does not demonstrate that the conflict influenced the
administrator’s decision. Moreover, Hartford points to several active steps it took to
eliminate any potential conflict from impacting claims decisions. Specifically, it (1)
provided for a second person to review and sign off on initial claims decisions (in the
case, Ms. Rodriguez); (2) maintained a separate unit to consider appeals of denied
claims, and provided for appeal review by an employee, Ms. Kelly, who had no role in
the initial decision and no communications with the employees who handled the initial
claim; (3) “walled off” its ability analysts by ensuring their compensation is not tied in
any way to claims denials; and (4) retained independent third-party medical vendors
such as MES to supply reviews by appropriately credentialed physicians. In light of
these steps, this court cannot conclude that the structural conflict in fact influenced the
administrator’s decision.
B.

Substantial Evidence

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Plaintiff contends that Hartford’s denial was arbitrary and capricious on
both procedural and substantive grounds. First, she contends that substantial
evidence demonstrates that she suffers from intractable pain that prevents her from
working. Second, she lists several objections to Hartford’s denial, each of which is
addressed in turn below.
A claimant seeking benefits under an ERISA plan bears the burden of
demonstrating entitlement thereto. Morales–Alejandro v. Med. Card Sys., Inc., 486
F.3d 693, 700 (1st Cir. 2007). Substantial evidence is “evidence reasonably sufficient
to support a conclusion.” Gannon v. Metropolitan Life Ins. Co., 360 F.3d 211, 213 (1st
Cir.2004). Sufficiency does not disappear “merely by reason of contradictory
evidence.” Doyle v. Paul Revere Life Ins. Co., 144 F.3d 181, 184 (1st Cir. 1998).
Here, the medical records clearly support Estrella’s claims of chronic pain.
However, Hartford does not contest Estrella’s claims of chronic pain; rather, it disputes
the effect of that pain on her ability to work.
Estrella’s job required her to work at a computer 50% of the time and talk on the
phone 50% of the time, which required her to be seated continuously. Even crediting
her condition, Hartford’s conclusion that she is nonetheless able to work is supported
by substantial evidence. None of Estrella’s four treating practitioners concluded that
she was unable to work. Moreover, none addressed whether she would be precluded
from performing a job involving alternating sitting and standing.
The lone doctor to conclude that she could not work, Dr. Lichauco, concluded

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that “[Estrella’s] pain behavior is appropriate and compatible with her history. She
cannot sit still. She moves slowly, with a guarded gait.” (A.R. 132.) In a brief
statement, he concluded that even though Estrella’s physical condition alone did not
impair her from working she nonetheless had been “disabled from her previous
occupation since early 2007" by a combination of physical and mental complaints.
(A.R. at 141.)
Hartford’s medical experts, Drs. Burns and Mosbach, disagreed with Dr.
Lichauco. Although plaintiff attacks both their method and their conclusion, the primary
point of contention was Drs. Burns’ and Mosbach’s disagreement with Dr. Lichauco’s
statement that Dr. Stone’s evaluation in 2009 provided evidence that Estrella had been
impaired by a combination of physical and psychological symptoms in early 2007. Dr.
Stone’s evaluation revealed no cognitive decline. Even if it had, it did not bear on
Estrella’s condition during the pertinent time period. Moreover, treatment records
during the pertinent time period said nothing about psychological symptoms.
C.

Specific Objections
1.

Procedural Violation

Section 503 of ERISA sets forth certain procedural safeguards to ensure that
claimants have adequate information regarding their claim and/or its denial. That
section requires that an adverse determination letter shall set forth “a description of any
additional material or information necessary for the claimant to perfect the claim and an
explanation of why such material or information is necessary.” 29 U.S.C. § 1133; 29

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CFR § 2560-503.1(g)(1)(iii).
Estrella contends that Hartford’s denial was based, in part, upon the failure of
four of Estrella’s treating doctors to respond to requests for information from Hartford.
Estrella notes that this justification was not set forth in Hartford’s adverse benefit
decision letter of June 10, 2008. While the regulation requires the administrator to
provide a description of material or information necessary for the claimant to “perfect
the claim,” 29 CFR § 2560-503.1(g)(1)(iii), Hartford has never taken the position that
Estrella’s claim was not perfected. See Wolfe v. J.C. Penney Co. Inc., 710 F.2d 388,
393 (7th Cir. 1983), rev’d on other grounds by Casey v. Uddeholm Corp., 32 F.3d 1094,
1099 n. 4 (7th Cir.1994) (where administrator requested additional “medical
information,” administrator had an obligation to “specify with some detail what type of
information” was necessary). Nor has Hartford suggested that her claim was denied
because her doctors failed to submit required forms. Rather, her claim was rejected
because the information they did submit simply did not support her claim.
2.

Substantive Violations2
a.

Hartford Relied on So-Called “Hired Guns”

Estrella objects that Hartford improperly relied upon so-called “hired guns” —
crediting the opinions of a non-examining physician and a non-examining psychologist

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Estrella included one additional objection regarding her receipt of short-term
disability payments during the elimination period. However, she has acknowledged
that the payments she received were salary continuation benefits, and not short-term
disability payments. See Letter from Jonathan M. Feigenbaum, counsel to Estrella
dated April 22, 2011 (Docket # 53). Therefore, this court need not address the issue.
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over her examining physician and examining neuropsychologist. The First Circuit has
consistently rejected the argument that the opinions of independent and non-examining
medical records reviewers are not “substantial evidence” because they receive
payment for their work, because they did not physically examine the claimant, or
because they disagree with treating physicians. See, e.g., Cusson, 592 F.3d at 215
(1st Cir. 2010) (affirming grant of summary judgment affirming decision denying claim
and noting that a nonexamining physician’s review of a claimant’s file may be reliable
medical evidence). See also Tsoulas v. Liberty Life Assur. Co., 454 F.3d 68, 81 (1st
Cir. 2006) (rejecting critiques of non-examining physician and holding that “it is not for
a court to determine how much weight [a non-examining medical consultant] should
have accorded “a particular piece of evidence].”).
b.

Hartford’s Conclusion That Estrella Could Perform
Sedentary Work

Next, Estrella objects that the denial unfairly “concluded that Estrella had the
type of sedentary occupation that afforded her the flexibility to sit and stand at will.”
Hartford’s denial did not draw such a conclusion. Rather, Hartford concluded that she
was able to perform a job which allowed her to alternatively sit and stand.
c.

Failure to Consider the Constellation of Estrella’s
Ailments

Third, Estrella argues that the denial was erroneous inasmuch as it failed to
consider the impact of the constellation of her ailments on her work. See McDonald v.
Secretary of Health and Human Services, 795 F.2d 1118, 1120 (1st Cir. 1986)
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(applying regulation applicable to social security disability cases, 20 CFR § 404.1523,
requiring SSA to consider “the combined effect of all your impairments without regard to
whether any such impairment, if considered separately, would be of sufficient
severity”). This argument is belied by the record. Hartford did consider the
constellation of her ailments along with their aggregate or cumulative effect. See A.R.
191 (noting that claimant was seen for, among other ailments: chronic pain syndrome,
with left upper extremity myofacial component, headaches, asthma, rhinitis, excema,
osteopenia and fibromyalgia/chronic fatigue). Hartford noted that “[w]e considered all
of the evidence in your claim file in making our decision...[t]he combined information in
your file does not show that you are unable to perform the Essential Functions of Your
Occupation....” (A.R. 192.)
d.

Failure to Consider the Non-Physical Aspects of
Estrella’s Job

Fourth, Estrella contends that the claims administrator erred in failing to consider
any factor other than the physical aspects of her occupation as a network engineer and
failing to obtain an accurate job description. This argument is without merit. Hartford
investigated Estrella’s occupational duties by asking Sprint to provide information
regarding those duties and then reviewing the information submitted. Moreover,
Hartford considered, and rejected, the conclusion that non-physical aspects of her job,
(i.e., those that would affect her mental health), compelled the conclusion that she is
disabled. See Report of Dr. Mosbach (concluding that the records did not “show
evidence of functional restrictions or limitations from a cognitive or mental/nervous
perspective that would be supported as of [August 15, 2007] to the present”). (A.R.
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64.)
e.

Hartford’s Alleged History of Unfair Claims
Determinations

Finally, Estrella contends that the structural conflict issue should be given
“additional weight” because Hartford has a history of unfair claims determinations. In
support of her contention, Estrella states that Hartford has “created a culture of claim
denial,” whereby employees are rewarded when they deny claims and penalized when
they allow claims. As evidence, plaintiff points to the performance appraisal of one
Hartford case manager which stated that the number of cases the employee had closed
where the claimant returned to work represented 32% of her caseload, “realiz[ing] a
cost savings of approximately $4[.1 million] for the team.” Docket # 1-2, Complaint
Exhibit E.
Estrella’s conclusion that there is a “culture of claim denial” does not follow from
this one example. Plaintiff conceded that Hartford does not provide direct financial
incentives to promote claim denials and terminations. There is no evidence of a
“culture of claim denial,” nor is such fairly inferred from the isolated performance
evaluation in which remarks were made praising the employee’s return to work, not
denial, percentage. The employee in question is a rehabilitation case manager whose
primary function is not to make decisions on claims, but rather to assist people in
returning to work. Plaintiff’s argument is without merit.
V.

Conclusion
Hartford’s decision to deny Estrella long term disability benefits was not arbitrary
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or capricious, and therefore Hartford’s motion for summary judgment on the
administrative record (Docket # 34) is ALLOWED.

/s/Rya W. Zobel

September 6, 2011
DATE

RYA W. ZOBEL
UNITED STATES DISTRICT JUDGE

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