TORO v. Hartford Life and Accident Insurance Company

Filing 25

ORDER denying 19 Motion for Summary Judgment; granting 20 Motion for Judgment. Signed by District Judge Arthur J. Tarnow. (MLan)

UNITED STATES DISTRICT COURT
EASTERN DISTRICT OF MICHIGAN
SOUTHERN DIVISION
ANGELA TORO,
Case No. 16-12951
Plaintiff,
SENIOR U.S. DISTRICT JUDGE
ARTHUR J. TARNOW

v.
HARTFORD LIFE AND ACCIDENT
INSURANCE COMPANY,

U.S. MAGISTRATE JUDGE
MONA K. MAJZOUB

Defendant.
/
ORDER DENYING PLAINTIFF’S CROSS MOTION TO REVERSE DEFENDANT’S
ERISA DETERMINATION AND MOTION FOR SUMMARY JUDGMENT [19] AND
GRANTING DEFENDANT’S MOTION FOR JUDGMENT ON THE ADMINISTRATIVE
RECORD [20]
Plaintiff Angela Toro is 45-years old and suffers from degenerative cervical
disc disease, lumbar spondyloses, and rheumatoid arthritis. She challenges the
decision by Defendant Hartford Life and Accident Insurance Company to deny her
claim for Long Term Disability (“LTD”) benefits issued under an ERISAgoverned employee benefit plan (“the Plan”) to her employer, ZF North America,
Inc. Plaintiff’s claim falls under 502(a)(1)(B) of ERISA, 29 U.S.C. §
1132(a)(1)(B).
For the reasons stated below, Plaintiff’s Cross Motion to Reverse
Defendant’s ERISA Determination and Motion for Summary Judgment [19] is

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DENIED. Defendant’s Motion for Judgment on the Administrative Record [20] is
GRANTED.
FACTUAL BACKGROUND
45-year old Angela Toro worked as a machinist from August 2011 to
October 2012 at ZF Lemforder. Through her employment, she participated in the
Plan, which was sponsored and administered by ZF Group North America, Inc.
Defendant Hartford Life and Accident Insurance Company is the Plan’s insurer.
Plaintiff has a long history of neck and back ailments. She had an MRI of
her thoracic spine and an MRI of her lumbar spine in January 2010. HA 685-86.
Plaintiff had a second MRI of her lumbar spine in September 2012. HA 345-48.
She stopped working on October 23, 2012 because she needed a procedure to
alleviate her back pain. HA 694. Dr. Salwa Mohamedahmed,1 Plaintiff’s treating
physician, indicated that Plaintiff was excused from work from October 29, 2012
to January 2, 2013. HA 681. Plaintiff applied for and received Short Term
Disability (“STD”) Benefits from approximately October 30, 2012 through April
22, 2013. HA 166.
On December 26, 2012, Dr. Mohamedahmed extended Plaintiff’s leave to
April 29, 2013. HA 679. On April 23, 2013, Dr. Rudram Muppuri extended

1

Plaintiff refers to Dr. Mohamedahmed in both her Motion and her Response Brief as a
male. Defendant claims that Plaintiff is mistaken. In his Review, Dr. Chandler refers to
Dr. Mohamedahmed as a female.

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Plaintiff’s leave time again, to May 22, 2013, due to uncontrolled chronic lower
back pain. HA 678. Plaintiff had another MRI of her thoracic spine on April 25,
2013 and an MRI of her lumbar spine in August 2014. HA 339-40, 343-44, 39394.
I.

The Terms of the Insurance Policy
ZF Group North America, Inc. sponsored and administered the Insurance

Policy at issue for the benefit of its employees. The Policy provides disability
benefits if a participant becomes disabled while insured under the policy, remains
disabled during and after the elimination period, and submits proof of loss. HA
725. To receive coverage, an individual’s disability must result from accidental
bodily injury, sickness, mental illness, substance abuse, or pregnancy. HA 734. An
individual is considered disabled under the Policy if she is prevented from
performing one or more of the essential duties of:
1) Your occupation during the elimination period;
2) Your occupation for the 24 month(s) following the elimination period,
and as a result your current monthly earnings are less than 80% of your
indexed pre-disability earnings; and
3) After that, any occupation.
HA 734.
“Your occupation” refers to “your occupation as it is recognized in the
general workplace,” rather than “the specific job you are performing for a specific
employer or at a specific location.” HA 737. “Any occupation” means:

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Any occupation for which you are qualified by education, training or
experience, and that has an earnings potential greater than the lesser of:
1) The product of your Indexed Pre-Disability Earnings and the Benefit
Percentage; or
2) The maximum monthly benefit.
HA 733.
An “Essential Duty” is one that “is substantial, not incidental; is
fundamental or inherent to the occupation; and cannot be reasonably omitted or
changed.” HA 734. A participant’s ability to work the number of hours in a
regularly scheduled work week qualifies as an Essential Duty. HA 734. Benefit
payments will stop when the participant is no longer disabled. HA 726.
II.

Plaintiff’s claim for Long Term Disability Benefits
In July 2013, Defendant informed Plaintiff that her STD benefits were set to

expire. If Plaintiff wished to continue receiving benefits, she would have to apply
for Long Term Disability (“LTD”) Benefits and provide Defendant with updated
medical information supporting her disability. HA 166. Toro applied for LTD
Benefits on July 7, 2013 and Defendant approved her claim under a “Your
Occupation” standard on July 22, 2013. HA 562-65, HA 160. The total of Toro’s
Gross Monthly LTD Benefits was $1,404. HA 165.
On October 31, 2014, Defendant asked Plaintiff via letter to submit
information and documentation supporting her continued need for LTD Benefits.
HA 130-31. The letter indicated that after receiving LTD Benefits for 24 months

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under the Policy’s “Your Occupation” Disability/Disabled standard, Plaintiff
would have to qualify as disabled under the Policy’s “Any Occupation” standard to
continue receiving benefits. HA 130. Plaintiff’s LTD Benefits began April 23,
2013; accordingly, she would have to qualify under the “Any Occupation”
standard beginning on April 23, 2015. HA 131. Dr. Mohamedahmed provided
medical records to Defendant between November 2014 and March 2015. HA 10406, 108-13, 117-18, 121-26. One of the records from April 1, 2014 indicates that
Plaintiff told Dr. Mohamedahmed that she exercises regularly. HA 519.
In the January 20, 2015 Attending Physician’s Statement of Continued
Functionality, Dr. Mohamedahmed confirmed diagnoses of lumbar spondylosis,
facet arthropathy, chronic pain syndrome, and degenerative disc disease. HA 202.
She noted that Plaintiff suffered from neck pain, thoracic and lumbar back pain,
tenderness in her thoracic spine, and numbness. HA 202. She found that Plaintiff
could:






Walk for 10 minutes at one time and for one hour total per day;
Stand for 15 minutes at one time and for 2 hours total per day;
Sit for 30 minutes at one time and for 3 hours total per day;
Not bend, kneel, crouch, drive, or lift any amount over one pound;
Occasionally reach above the shoulder with her right arm, but never
with her left arm;
 Occasionally reach below her shoulder with her left arm, but never
with her right arm; and
 Frequently finger/handle with her right hand and occasionally with
her left hand.

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HA 203.
Notwithstanding Defendant’s repeated requests for additional information
regarding Plaintiff’s capabilities, medical condition, and restrictions, Dr.
Mohamedahmed failed to explain the medical rationale to support the above-listed
restrictions. HA 212-14. The doctor also confirmed on May 5, 2015 that Plaintiff
was occasionally able to lift/carry up to five pounds. HA 212.
To determine Plaintiff’s employability, Defendant commissioned an
Employability Analysis Report on May 8, 2015. HA 240. The results of the Report
were generated by cross-referencing Plaintiff’s functional capabilities, education,
and work history with nearly 13,000 occupations as classified by the U.S.
Department of Labor, using the Occupational Access System (“OASYS”) job
matching system. The OASYS search, adjusted to match Plaintiff’s functional
capabilities per her doctor’s opinions, returned two occupations that best suited
Plaintiff’s training and experience. HA 241. Although one occupation was
eliminated, the other, surveillance-system monitor, qualified as a viable
employment match that fit Plaintiff’s needs. A surveillance-system monitor is an
entry-level position that requires no extensive training, no prior experience, “and
can be performed with short term on the job training.” HA 242. It is not a
physically demanding position and the functions of the job fit Plaintiff’s abilities
and limitations. Plaintiff would earn approximately $1,563.29 per month, which

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exceeds the “Any Occupation” definition’s $1,459.29 monthly requirement. HA
242, 245.
After a review of the available administrative record, Defendant determined
that Toro was not prevented from performing the essential duties of any
occupation. Accordingly, she no longer qualified as Disabled under an “Any
Occupation” standard, and LTD Benefits were no longer payable. HA 89. In
making its determination, Defendant gave particular consideration to the following
documents:
 Dr. Mohamedahmed’s January 2015 Attending Physician’s Statement;
 Dr. Mohamedahmed’s May 2015 explanation of Plaintiff’s
restrictions;
 Dr. Mohamedahmed’s office notes from August 2014 through January
2015;
 Plaintiff’s January 2015 Work and Educational History form; and
 The May 2015 Employability Analysis Report.
III.

The appeal process and independent physician review

Plaintiff, through counsel, appealed Defendant’s denial of LTD benefits on
November 17, 2015. HA 236. Plaintiff’s counsel provided to Defendant an August
18, 2015 MRI study that noted a disc protrusion at L4-5 with degenerative discs at
T11-12 and T12-L1. HA 237-38. Plaintiff also gave to Defendant medical records
that post-dated the original denial and records Defendant had already reviewed.
HA 84-85, 204, 216.

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Defendant engaged Professional Disability Associates (“PDA”) to facilitate
an independent physician review of Plaintiff’s case. Dr. Leon Chandler, who is
board-certified in physical medicine and rehabilitation, provided the independent
review. HA 85. Dr. Chandler spoke with Dr. Mohamedahmed and analyzed
Plaintiff’s available medical records. MRIs of Plaintiff’s lumbar and thoracic spine
from 2012 and 2013 indicated that most of Plaintiff’s vertebrae and spinal
segments were intact and showed no significant abnormalities, with only some
“mild facet degenerative changes” and “mild disc bulging.” HA 339-45. Dr.
Chandler noted that Dr. Mohamedahmed “has consistently documented Ms. Toro
to have a normal gait, posture, normal strength in upper and lower limbs and
tenderness to palpitation of the spine.” HA 85. He also highlighted the fact that in
April 2014, Plaintiff self-reported leading an active lifestyle and exercising
regularly. HA 187, 519. On June 8, 2014, Plaintiff “was documented to be
independent with activities of daily living and having no limitations on mobility.”
HA 187. Lastly, despite Plaintiff’s absence from work since October 2012, Dr.
Chandler found no documented range of motion, strength, sensory, or balance
deficits. HA 187. Dr. Chandler opined that it was not credible that a 43-year-old
woman “who is documented to have full age appropriate strength would not have
the capability of lifting/carrying/pushing/pulling 10 lbs. at least occasionally or a
negligible amount of weight frequently.” HA 188.

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In December 2015, Defendant commissioned a second Employability
Analysis Report following Dr. Chandler’s evaluation. The OASYS search
ultimately identified two occupations suited to Plaintiff’s needs; surveillancesystem monitor and lens inserter. HA 177. Both are unskilled, entry level positions
that require no protracted training or prior experience. “These occupations also use
worker traits and habits that Ms. Toro possesses and were acquired in her work
experiences.” HA 177.
Defendant affirmed its denial of Plaintiff’s LTD Benefits on December 15,
2015. It determined that Plaintiff was not disabled from performing any occupation
as defined in the Insurance Policy. Plaintiff filed her Complaint [1] on August 12,
2016.
LEGAL STANDARD
The parties agree that because the benefit plan at issue here does not confer
discretionary authority upon the administrator, the Court should conduct a de novo
review of Defendant’s denial of Plaintiff’s benefits. Mellian v. Hartford Life and
Accident Insurance Company, 161 F.Supp. 3d 545, 555 (E.D. Mich. 2016).
Therefore, the Court’s review is confined to the administrative record. The Court
must “determine whether the plan administrator made ‘a correct decision’ without
according the administrator any deference or presumption of correctness.” Lipker

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v. AK Steel Corp., 698 F.3d 923, 928 (6th Cir. 2012) (quoting Shelby County
Health Care Corp. v. Majestic Star Casino, 581 F.3d 355, 367-68 (6th Cir. 2009)).
ANALYSIS
In her Motion to Reverse and for Summary Judgment, Plaintiff argues that
Defendant failed to conduct an independent medical evaluation and erroneously
relied on the opinions of Dr. Chandler. Plaintiff also claims that there are questions
regarding Dr. Chandler’s motivation for finding Plaintiff capable of performing
any occupation.
I.

Defendant properly evaluated Plaintiff’s medical records in denying
her application for LTD benefits.
The Insurance Policy at issue is clear: after receiving LTD benefits under the

“Your Occupation” standard for 24 months, Plaintiff had to qualify as disabled
under the “Any Occupation” standard to continue receiving benefits. The “Any
Occupation” standard obligates the plan administrator “to make a reasonable
inquiry into the types of skills [a claimant] possesses and [determine] whether
those skills may be used at another job that can pay her the same salary range as
[her pre-disability earnings].” McDonald v. Western-Southern Life Insurance Co.,
347 F.3d 161, 172 (6th Cir. 2003). “Just as a plan administrator must make some
inquiry into the nature and transferability of a claimant’s job skills, a plan
administrator must make some inquiry into whether the jobs selected are ones that
the claimant can reasonably perform in light of specific disabilities.” Brooking v.
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Hartford Life and Accident Ins. Co., 167 F. App’x 544, 549 (6th Cir. 2006).
However, the plan administrator has no obligation to conduct “a full-blown
vocational evaluation” on the claimant’s behalf. McDonald, 347 F.3d at 172.
Defendant does not contest that Plaintiff has suffered from back pain and
that she is functionally limited in certain respects. Contrary to Plaintiff’s
arguments, however, the record shows that Defendant conducted a meaningful
review of Plaintiff’s medical history and that its denial of benefits was “the result
of a deliberate, principled reasoning process.” DeLisle v. Sun Life Assur. Co. of
Canada, 558 F.3d 440, 444 (6th Cir. 2009). Defendant examined Plaintiff’s Work
& Education History Form, the Attending Physician Statement of Continued
Disability completed by Dr. Salwa Mohamedahmed, Plaintiff’s medical records,
and Dr. Mohamedahmed’s office notes from as far back as June 2013. In the
Attending Physician’s Statement, Dr. Mohamedahmed notes Plaintiff’s thoracic
and lumbar back pain, spinal tenderness, and neck pain, and indicates Plaintiff’s
various functional restrictions. Defendant used Dr. Mohamedahmed’s Attending
Physician Statement, Plaintiff’s LTD benefits application, and Plaintiff’s &
Education History Form to generate the May 2015 Employability Analysis Report.
The OASYS search – which was also based on the information provided by

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Plaintiff and her treating doctor – yielded one occupation that satisfied Plaintiff’s
limitations.2
In her Motion to Reverse Defendant’s ERISA determination and her
Response to Defendant’s Motion for Judgment on the Administrative Record,
Plaintiff does not provide specific arguments as to why Defendant’s initial denial
of her benefits was erroneous. She provides a laundry list of the pain she suffered
and the various treatments and procedures she has undergone, but does not explain,
for example, how she is unqualified for the positions identified by the OASYS
search or how she is functionally limited from performing those jobs. In fact, she
addresses neither the accuracy of the Employability Analysis Report nor the
OASYS search. Plaintiff’s conclusory allegations are insufficient for the Court to
reverse Defendant’s benefits determination.
II.

On appeal, Defendant considered the opinions of the reviewing
physician and Plaintiff’s treating physician.
Plaintiff’s central argument concerns the weight given to the opinions of her

treating doctor and Dr. Chandler. She claims that Defendant gave special deference
to Dr. Chandler and did not meaningfully consider the opinions of Dr.
Mohamedahmed.
2

The initial OASYS search, which occurred in May 2015 before the denial of LTD
benefits, ultimately yielded one occupation, surveillance-system monitor, as a viable
employment match that fit Plaintiff’s needs. The second OASYS search, which occurred
in December 2015 after Plaintiff appealed the denial of LTD benefits, yielded two
occupations that Plaintiff could perform (surveillance-system monitor and lens inserter).

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With respect to the weight given to the opinions of different doctors, the
Supreme Court has stated:
Courts have no warrant to require administrators automatically to accord
special weight to the opinions of the plaintiff’s physician; nor may courts
impose on plan administrators a discrete burden of explanation when they
credit reliable evidence that conflicts with a treating physician’s evaluation.
Black & Decker Disability Plan v. Nord, 538 U.S. 822, 825, 834 (2003).
Similarly, the Sixth Circuit has held that there is “nothing inherently
objectionable about a file review by a qualified physician in the context of a
benefits determination.” Calvert v. Firstar Fin. Inc., 409 F.3d 286, 296 (6th Cir.
2005). Although the plan administrator “may not arbitrarily refuse to credit a
claimant’s reliable evidence, including the opinions of a treating physician,” Nord,
538 U.S. at 834, it also “need not defer to the opinions of treating physicians.”
Fant v. Hartford Life and Acc. Ins. Co., No. 09-12468, 2010 WL 3324974, at *8
(E.D. Mich. Aug. 20, 2010) (internal citation omitted).
In forming his opinion, Dr. Chandler analyzed, among other things,
diagnostic imaging reports from September 20, 2012 through August 8, 2015;
communication between Plaintiff and Defendant; clinical notes from Dr.
Mohamedahmed from April 1, 2014 through November 3, 2015; and clinical notes
from Doctors Rudram Muppuri and Shushovan Chakrabortty from March 8, 2013
through December 4, 2014. He also spoke with Dr. Mohamedahmed for
approximately 30 minutes, during which she frequently referred to her notes. Dr.
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Mohamedahmed told Dr. Chandler that Plaintiff was osteoporotic and had sporadic
pain; Plaintiff could sit for one hour at a time; and Plaintiff seemed fine when she
walked into the clinic, sat comfortably, and did not use an assistive device. HA
186.
It is Plaintiff’s position that Dr. Chandler’s conversation with Dr.
Mohamedahmed should be considered suspect because Defendant did not pay Dr.
Mohamedahmed for her opinions and because the conversation was not recorded.
Plaintiff provides no support for this assertion, nor does she point to specific parts
of the record that she feels are untruthful or inaccurate. Dr. Mohamedahmed
explained Plaintiff’s diagnoses and her treatment regimen and was able to discuss
with Dr. Chandler the degree to which impairment was likely. There is simply no
support in the record to suggest that Dr. Mohamedahmed was incompetent to
discuss Plaintiff or her condition.
Defendant commissioned a second Employability Analysis Report in
December 2015, relying on Dr. Chandler’s analysis, Plaintiff’s application for LTD
benefits, and Plaintiff’s Work & Education History Form. The OASYS search
indicated that given her limitations, Plaintiff could work as a surveillance-system
monitor and a lens inserter. Dr. Chandler found – again, based on the restrictions
imposed by Dr. Mohamedahmed – that these occupations were “flexible and allow
for a combination of sitting and standing and walking.” HA 177.

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It is very clear that Defendant properly evaluated Plaintiff’s claim – both in
its initial review and on appeal – and its decision that Plaintiff is not prevented
from working in any occupation is supported by substantial evidence in the record.
“Hartford fulfilled its obligation to inquire into [Plaintiff’s] skill set, and the
transferability of those skills, and to assess her functional capabilities to perform
the jobs that it identified.” Fant, 2010 WL 3324974 at *10.
CONCLUSION
For the reasons stated above,
IT IS ORDERED that Plaintiff’s Cross Motion to Reverse Defendant’s
ERISA Determination and Motion for Summary Judgment [19] is DENIED.
Defendant’s Motion for Judgment on the Administrative Record [20] is
GRANTED.
SO ORDERED.

Dated: August 21, 2017

s/Arthur J. Tarnow
Arthur J. Tarnow
Senior United States District Judge

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