McDonel v. Hartford Life and Accident Insurance Company
Filing
32
MEMORANDUM OPINION AND ORDER denying without prejudice defendant's 12 Motion for Summary Judgment; denying without prrejudice plaintiff's 17 Motion for Summary Judgment. Plaintiff's long-ter m disability benefits claim is remanded to Defendant for further administrative review consistent with this opinion.This action is stayed pending a final decision by Defendant. Within thirty (30) days of a final decision by Defendant, either party may move to lift the stay and renew their dispositive motions based on the administrative record. (Written Opinion). Signed by Judge John R. Tunheim on June 25, 2012. (DML)
UNITED STATES DISTRICT COURT
DISTRICT OF MINNESOTA
CAROL A. MCDONEL,
Civil No. 10-4510 (JRT/JJK)
Plaintiff,
v.
HARTFORD LIFE AND ACCIDENT
INSURANCE COMPANY,
Defendant.
MEMORANDUM OPINION AND
ORDER DENYING MOTIONS FOR
SUMMARY JUDGMENT
Alesia R. Strand and Thomas J. Beedem, III, BEEDEM LAW OFFICE,
200 South 6th Street, Suite 1450, Minneapolis, MN 55402, for plaintiff.
Eric C. Tostrud and Scott Moriarty, LOCKRIDGE GRINDAL NAUEN
PLLP, 100 Washington Ave South, Suite 2200, Minneapolis, MN 55401,
for defendant.
Plaintiff Carol A. McDonel brings this action under the Employee Retirement
Insurance Income Security Act of 1974 (“ERISA”), seeking long-term disability (“LTD”)
benefits under Defendant Hartford Life and Accident Insurance Company’s
(“Hartford’s”) insurance policy. McDonel suffers from back and knee injuries that she
claims prohibit her from performing her occupation.
judgment regarding McDonel’s entitlement to benefits.
Both parties seek summary
Because Hartford gathered
inadequate information and thereby abused its discretion in denying McDonel LTD
benefits, the Court remands this case to Hartford for further proceedings in accordance
with this opinion.
23
BACKGROUND
I.
McDonel’s Work and Health History
McDonel began working at Andersen Corporation (“Andersen”) in 1983. (LTD
Insurance Claim File, Pl.’s Ex. 1, Docket No. 19, at HART1.) She was employed there
as a “Value Stream I Associate.” (HART160.) As a Value Stream I Associate, she
assisted with window assembly in a manufacturing shop. (HART109-11, 160.)
In 2001, McDonel suffered a low back injury that led to a lumbar fusion surgery at
L4-5 and L5-S1.1
The hardware from this surgery was removed in July 2006.
(HART105-06; 160-62.) McDonel has a long history of back problems due to her injury.
(See HART9.)
The record indicates that Andersen may have provided adjustments to McDonel’s
job for fifteen years because of her back injury. (HART3, 9.) There is no evidence,
however, as to the nature of these adjustments. The record also indicates that McDonel
worked “regular duty,” but this term is not defined. (HART142, 160.)
McDonel received permanent job-related restrictions in 2007, imposed by
Dr. Thomas Rieser, because of her back problems. (HART80-81, 113.) Dr. Rieser stated
that McDonel should work only on “light duty” with “no frequent bending, lifting, or
twisting.” He also stated that she should “stretch/change position every 30 minutes,” that
she could lift/carry up to twenty-five pounds, and that she was capable of sitting,
standing, and walking for six hours per day. (Id.) It is unclear if these restrictions
1
The record indicates that McDonel may have also suffered a back injury in 1991.
(HART9.)
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required adjustments in McDonel’s job. (See HART5, 18.) McDonel worked with her
2007 restrictions until August 2009.
II.
Andersen’s Threat of Termination
On August 25, 2009, Andersen Corporation sent McDonel a letter threatening to
terminate her employment because of her physical restrictions. The letter stated:
Your permanent restrictions prevent you from performing the essential
functions of the Value Stream I position, with or without reasonable
accommodation. Andersen’s efforts to place you into a regular job within
your permanent restrictions have been exhausted. At the current time, there
are no positions available that accommodate[] your restrictions . . . It is
your responsibility to find another position with Andersen . . . [I]f you are
unable to find a regular position within 60 days from the date of this letter
your employment will end.
(HART134.) The letter further stated that Andersen would place McDonel on a sixty day
leave. (Id.) The last day that McDonel worked at Andersen was August 26, 2009. (See
HART161.) McDonel was thereafter approved for leave under the Family Medical
Leave Act through January 13, 2010. (HART154.)
Hartford’s notes indicated that Andersen sent this letter to McDonel because
“there were changes in” Andersen and Andersen “was no longer able to accommodate
[McDonel’s] permanent [work] restrictions” due to her physical limitations. (HART9.)
McDonel apparently told Hartford that the “new rotating jobs at work” were “not within
her permanent restrictions.” (HART10.) Nothing in the record explained this alleged
new rotating system, however. Andersen’s August 25 letter stated nothing about a new
“rotating” system and discussed only McDonel’s inability to perform the Value Stream I
position. (HART134.)
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III.
McDonel’s Worsening Symptoms
Shortly after Andersen placed McDonel on leave, on September 11, 2009,
McDonel visited Steven J. Lawson, PA-C,2 and Dr. Rieser. (HART95.) Lawson and
Dr. Rieser noted the following:
[McDonel] has done well until recently. She has had an increase in her
symptoms. Her back pain is quite debilitating now. She can barely
function at home let alone at work . . . Two views of the lumbar spine were
obtained . . . She does have significant degeneration at L3-4 which has
progressed since her last films which were reviewed today from 2006.
Diagnosis: Progression of L3-4 disc degeneration with significant endplate
sclerosis and kyphosis at this level.
(Id.) Lawson and Dr. Rieser recommended an MRI and epidural steroid injections, and
instructed McDonel to remain completely off work from September 11, 2009 until
January 13, 2010. (HART87-89.)
McDonel’s MRI in November 2009 indicated a loss of intervertebral disc space
height, as well as significant disc space narrowing, bulging, and bone-on-bone and
stenosis producing low back and radiating hip, buttock, and leg pain. (HART90, 106-07,
124.) McDonel reported that she “ache[d] all the time” in her back and thigh and was
“unable to work” due to the pain. (HART3, 93.) She received an epidural steroid
injection that provided her with no relief. (HART124.) Dr. Rieser stated that a surgery at
the L3-4 level might help. (See id.)
Although Dr. Rieser recommended back surgery, McDonel declined because, she
claims, she had been advised to forego surgery until her knee improved. (HART7, 10.)
2
Lawson is a physician’s assistant.
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McDonel visited a different physician, Dr. Nicholas G. Weiss, for problems with her left
knee. (HART8, 133.)
IV.
McDonel’s New Work Restrictions
On January 13, 2010, Dr. Rieser indicated that McDonel was ready to return to
work but imposed numerous new restrictions on McDonel: no static positions; no more
than one to three hours per day of bending, twisting, turning, kneeling, squatting, or
overhead reaching; no operating of forklift or vibrating tools; a maximum of fifty pounds
pushing or pulling, and the weight must be on a cart with wheels; only occasional driving
and stair climbing; and avoidance of ladders. (HART85-86, 125.) Dr. Rieser also
reiterated the same permanent restrictions that had been in place in 2007. (HART92,
125.)
V.
McDonel’s Application for LTD Benefits
Hartford insured McDonel under Group Long Term Disability Insurance Policy
No. GLT-675805. On February 23, 2010, McDonel submitted an application for longterm disability benefits under this policy. (HART160-63.) In her application for LTD
benefits, McDonel stated that she was applying for benefits because a “permanent weight
restriction” prevented her from doing her job. (HART11, 161.)
A.
Critical Terms of LTD Policy
Hartford’s LTD policy possessed the following critical terms:
Disability or Disabled means You are prevented from performing one or
more of the Essential Duties of . . . Your Occupation . . . .
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***
Your Occupation means Your Occupation as it is recognized in the
general workplace. Your Occupation does not mean the specific job You
are performing for a specific employer or at a specific location.
***
Essential Duty means a duty that
(1)
is substantial, not incidental;
(2)
is fundamental or inherent to the occupation; and
(3)
cannot be reasonably omitted or changed.
Your ability to work the number of hours in Your regularly scheduled work week
is an Essential Duty.
(HART43-47.)
B.
Information Hartford Obtained about McDonel
Ann Simpson, Ability Analyst with Hartford, initially handled McDonel’s claim.
(HART156-57.) Simpson requested some of McDonel’s medical records as part of her
investigation, including Dr. Rieser’s work restrictions from 2007 and 2010. There is no
evidence that Simpson requested Dr. Weiss’ records to obtain more information about
McDonel’s knee or that she consulted with other physicians.
On March 1, 2010, Simpson sent an e-mail to Andersen requesting the following
information: a job description for McDonel, a Physical Demands Analysis (“PDA”)3 for
McDonel, a list of accommodations made to McDonel’s job, and information on when
3
The record does not define a PDA, but a PDA likely would have included a description
of the physical demands associated with McDonel’s job.
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Andersen implemented these accommodations.
(HART159.)
Andersen informed
Simpson that a PDA existed for McDonel’s occupation. (HART7.)
On March 11, 2010, Simpson sent another e-mail to Andersen indicating that she
had found a short job description for McDonel.
(HART109.)
It is unclear where
Simpson obtained this description and if Andersen viewed it as an accurate and complete
description of McDonel’s job duties. The description stated that: McDonel assembled
window models on a waist-high work table, McDonel was required to extend her elbow
greater than 4-6 inches from her body at or below chest height “occasionally,” McDonel
was required to use battery operated drills and glue guns “on a frequent basis” and did not
need to reach over her head to obtain these tools, and McDonel would “rarely” pick
supplies from shelving behind her work table at a maximum of 56” height. (Id.) The
description also identified the presence of a rolling cart with window models measuring
55” inches high, but did not explain what task McDonel performed in relationship to the
cart. (See id.) Simpson admitted in this same e-mail that an “actual PDA [for McDonel]
was never completed.” (Id.) Simpson also admitted that she did not know the amount of
weight requirement for “Lift/Carry/Push/Pull” applicable to McDonel’s position – a
critical piece of information, because McDonel had stated that a “permanent weight
restriction” associated with her job was at least one reason she could no longer perform it.
(See HART11, 161, 109.)
Simpson further obtained a two-page document describing duties associated with
the “Corner Section Line” at Andersen. (HART110-11.) It is unclear from the face of
the document what it purports to describe. (See id.) At oral argument, Hartford indicated
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that this document provided one example of a task that a window assembler performs,
and that this task was likely a representative example of one of McDonel’s duties.
C.
Denial of Benefits
On April 13, 2010, Hartford informed McDonel that it had denied her claim for
LTD benefits. (HART79-82.) In its denial letter, Hartford stated that McDonel was not
disabled because she could perform the essential duties of her occupation. (HART79,
81.) Hartford determined that nothing had changed to prevent McDonel from performing
the same occupation that she had performed, with restrictions, for the previous fifteen
years.
Specifically, the letter stated, “The Report of Workability signed by Dr. Thomas
Rieser on January 18, 2010, indicated that you were released to return to work on
January 13, 2010 with the same restrictions and limitations as outlined on the April 7,
2007 [Report] of Workability.” (Id.) (emphasis added). (See also HART5.) Because
McDonel had been working full time with the Dr. Rieser’s restrictions from 2007 “for at
least the past 15 years,” “this job would be considered Your Occupation.” (HART81.)
On April 16, 2010, McDonel informed Simpson that she was completely removed
from work due to her knee problems.4 (HART4.) There is no evidence that Simpson
requested records confirming this fact.
4
The record contains almost no information about McDonel’s knee problems or how the
knee problems would affect her occupation.
-8-
D.
Appeal
On April 19, 2010, McDonel appealed the denial of her LTD benefits. (HART67.)
In doing so, she stated:
I am appealing your decision due to the fact that my permanent restrictions
from April 7, 2007 and the new restrictions as of 1/18/2010 from
Dr. Thomas Rieser are not the same and that he has add[ed] additional
restriction[s] in the Comments found on my Workability Form: Push/Pull
50lb, Maximum, Cart with Wheels, Occasional Stair Climbing, Avoid
Ladders. I will be faxing you this letter along with a copy of my
Workability Form Dated 01/18/10 by Dr. Thomas Dr. Rieser.
(Id.)
Angie Ager, Appeal Specialist with Hartford, handled McDonel’s appeal.
(HART64.) Ager sent a letter denying McDonel’s appeal on May 11, 2010, twelve days
after the appeal was filed. (HART63-64.) The letter stated, in part, the following:
The information in your claim file indicates that your back condition has
required work restrictions for several years. As such, your modified
position is considered Your Occupation as it pertains to the review of
your eligibility for LTD benefits. According to the information in the
claim file, you ceased working as of August 26, 2009 because your
Employer determined that they could no longer accommodate your
restrictions and not because you were medically precluded from performing
Your Occupation. In order to be eligible for LTD benefits, it must be
shown that you were unable to perform the Essential Duties of Your
Occupation as of the date you ceased working and throughout and beyond
the policy’s Elimination Period. The medical information in our claim file
shows that there has been no significant change or worsening of your
condition which would have prevented you from performing the Essential
Duties of Your Occupation. While you reported an increase in back pain
for which your received an epidural injection, you also chose not to
pursue additional treatment and it does not appear that your medications
have required adjustment despite your reported increase in pain.
Although you assert that the restrictions outlined by Dr. Rieser in January
2010 are different from those provided in April 2007, a 50 lb. push/pull
restriction is consistent with a 25 lb. lifting restriction, or a light level
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occupation, and further, there is no indication that Your Occupation
requires pushing or pulling greater than 50 lbs. In addition, driving and
climbing are not considered essential functions of Your Occupation.
Therefore, the additional restrictions outlined by Dr. Rieser would not
have prevented you from performing the Essential Duties of Your
Occupation.
(Id. (emphases added); see also HART3-4.) Hartford informed McDonel that she had
exhausted her administrative remedies and also advised her of the right bring a claim in
court under ERISA. (HART63-64). There is no evidence that Ager conducted additional
factual investigation after McDonel filed her appeal.
ANALYSIS
I.
SUMMARY JUDGMENT STANDARD OF REVIEW
Summary judgment is appropriate where there are no genuine issues of material
fact and the moving party can demonstrate that it is entitled to judgment as a matter of
law. Fed. R. Civ. P. 56(a). A fact is material if it might affect the outcome of the suit,
and a dispute is genuine if the evidence is such that it could lead a reasonable jury to
return a verdict for either party. Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 248
(1986). A court considering a motion for summary judgment must view the facts in the
light most favorable to the non-moving party and give that party the benefit of all
reasonable inferences that can be drawn from those facts. Matsushita Elec. Indus. Co.,
Ltd. v. Zenith Radio Corp., 475 U.S. 574, 587 (1986).
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II.
EXHAUSTION OF ADMINISTRATIVE REMEDIES
A.
Issue Exhaustion
The Court must first determine if McDonel has adequately preserved the legal
issues that she raises in this action. ERISA possesses a judicially-created exhaustion
requirement. “‘Where a claimant fails to pursue and exhaust administrative remedies that
are clearly required under a particular ERISA plan, his claim for relief is barred.’”
Chorosevic v. MetLife Choices, 600 F.3d 934, 941 (8th Cir. 2010) (quoting Layes v. Mead
Corp., 132 F.3d 1246, 1252 (8th Cir. 1998)). An exhaustion requirement applies “so long
as the employee has notice of the [administrative appeal] procedure, even if the plan,
insurance contract, and denial letters do not explicitly describe the review procedure as
mandatory or as a prerequisite to suit.” Wert v. Liberty Life Assurance Co. of Boston,
Inc., 447 F.3d 1060, 1063 (8th Cir. 2006).
In her administrative appeal, McDonel raised the most important issues relevant to
this action. Her appeal explicitly disputed whether Hartford had adequately considered
her new permanent restrictions imposed in 2010. (See HART67.) In doing so, she also
implicitly addressed whether Hartford had failed to compare these restrictions to the
duties involved in her occupation.5 (See id.)
The issues that McDonel did not raise in her administrative appeal are also not
waived, however, because ERISA does not require issue exhaustion. The Eighth Circuit
has suggested that ERISA “does not require either issue or theory exhaustion; it requires
5
Because McDonel adequately raised these issues, she has established that Hartford
abused its discretion even if all of her other arguments are waived. See Part III, infra.
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only claim exhaustion.” Chorosevic, 600 F.3d at 942 (quoting Wolf v. Nat’l Shopmen
Pension Fund, 728 F.2d 182, 186-87 (3d Cir. 1984)) (emphasis original). This indication
is consistent with ERISA regulations requiring plan administrators to provide a “full and
fair review of the claim and the adverse benefit determination” in the event of an appeal,
regardless of the issues raised. See 29 CFR § 2560.503-1(h)(1) (emphasis added). Policy
considerations also weigh against requiring issue exhaustion because policyholders often
cannot fully respond to succinct benefit denials. See Khoury v. Grp. Health Plan, Inc.,
615 F.3d 946, 952 (8th Cir. 2010) (noting that initial denial letters from insurance
companies are often “succinct” and that more information is required for a “complete
record” of the administrator’s decision). Accordingly, the Court finds that McDonel was
not required to exhaust all legal issues in her administrative appeal. The Court will next
explain why, even if Hartford could have imposed an issue exhaustion requirement on
McDonel, it did not provide her with sufficient notice to do so.
B.
Lack of Adequate Notice
In this action, McDonel explicitly raised for the first time that Hartford did not
gather enough information to define her occupation and that Hartford inappropriately
considered Andersen’s modifications to her job. She also now raises Hartford’s failure to
investigate her knee condition. The Court finds that McDonel did not waive these issues
because Hartford provided inadequate notice of (1) the reasons why it denied McDonel’s
claims and (2) the existence of an issue exhaustion requirement.
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First, Hartford did not provide McDonel with sufficient notice of the reasons for
her claim denial. ERISA states that every employee benefit plan shall:
(1) provide adequate notice in writing to any participant or beneficiary
whose claim for benefits under the plan has been denied, setting forth the
specific reasons for such denial, written in a manner calculated to be
understood by the participant, and
(2) afford a reasonable opportunity to any participant whose claim for
benefits has been denied for a full and fair review by the appropriate named
fiduciary of the decision denying the claim.
29 U.S.C. § 1133.6 Despite these requirements, Hartford’s denial letter did not include a
description of McDonel’s occupation or the essential duties that McDonel could perform.
(See HART81.) Hartford also did not state the specific modifications that it used to
define McDonel’s occupation.7
These omissions deprived McDonel of sufficient
information to dispute Hartford’s analysis of her occupation and her ability to perform its
essential duties. Because Hartford did not provide “adequate notice” of the “specific
reasons” for its denial of coverage, Hartford may not now require McDonel to have
exhausted all issues. See 29 U.S.C. § 1133.
Second, Hartford’s LTD policy did not demand that McDonel raise all of the
issues she wished to appeal. The policy states that an applicant “may submit written
6
See also Booton v. Lockheed Med. Benefit Plan, 110 F.3d 1461, 1463 (9th Cir. 1997)
(“In simple English, what this regulation calls for is a meaningful dialogue between ERISA plan
administrators and their beneficiaries. If benefits are denied in whole or in part, the reason for
the denial must be stated in reasonably clear language, with specific reference to the plan
provisions that form the basis for the denial; if the plan administrators believe that more
information is needed to make a reasoned decision, they must ask for it.”)
7
The denial letter stated that, because McDonel had been working full time with the
Dr. Rieser’s restrictions from 2007 “for at least the past 15 years,” “this job would be considered
Your Occupation.” (HART81.) It noted no specific modifications that Hartford had considered,
however.
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comments, documents, records, or other information related to [her] claim” when
appealing a benefit denial. (HART41, 81-82) (emphasis added).8 Given this permissive
language, it would be unfair to require issue exhaustion before a “full and fair review” of
McDonel’s appeal. See 29 CFR § 2560.503-1(h)(1). Accordingly, the Court finds that
McDonel has not waived any of the issues that she raises in this action.
III.
ABUSE OF DISCRETION
A.
Standard of Review
To decide if either party is entitled to summary judgment, the Court must
determine if Hartford abused its discretion in denying McDonel’s claim. “[A] denial of
benefits challenged under § 1132(a)(1)(B) is to be reviewed under a de novo standard
unless the benefit plan gives the administrator . . . discretionary authority to determine
eligibility for benefits or to construe the terms of the plan.” Firestone Tire & Rubber Co.
v. Bruch, 489 U.S. 101, 115 (1989).
If the plan confers discretion on the plan
administrator, a deferential abuse-of-discretion standard of review applies. Bounds v.
Bell Atl. Enters. Flexible Long-Term Disability Plan, 32 F.3d 337, 339 (8th Cir. 1994)
(citing Firestone, 489 U.S. at 111-113). Courts apply the abuse-of-discretion standard
only if the plan contains “explicit discretion-granting language.” Id.
In this case, there is no dispute that the administrator has discretion to interpret the
provisions of the Hartford’s LTD policy.
The policy states that Hartford has “full
8
See also 29 CFR § 2560.503-1(h)(ii) (stating that employee benefit plans must
“[p]rovide claimants the opportunity to submit written comments, documents, records, and
other information relating to the claim for benefits”) (emphasis added).
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discretion and authority to determine eligibility and benefits and to construe and interpret
all terms and provisions of the policy.” (HART43.) Accordingly, the Court will review
Hartford’s denial of benefits under an abuse of discretion standard.
B.
Interpretation of the Plan
1.
Standard
Under an abuse of discretion standard, the proper inquiry is whether the decision
by the plan administrator to deny benefits is reasonable. King v. Hartford Life and
Accident Ins. Co., 414 F.3d 994, 998-99 (8th Cir. 2005). The reasonableness of the
administrator’s interpretation is assessed by whether the decision to deny benefits is
supported by substantial evidence, id. at 999, that is, “more than a scintilla but less than a
preponderance” of the evidence.9 Smith v. Unum Life Ins. Co. of Am., 305 F.3d 789, 794
(8th Cir. 2002). During this inquiry, the Court “consider[s] only the evidence before the
plan administrator when the claim was denied.” Shelton v. ContiGroup Cos., Inc., 285
F.3d 640, 642 (8th Cir. 2002).
When the plan administrator is also the insurer, it has an inherent conflict of
interest. Darvell v. Life Ins. Co. of N. Am., 597 F.3d 929, 934 (8th Cir. 2010). “Where an
9
The Eighth Circuit has identified factors for use in determining whether a plan
administrator’s interpretation of the policy is reasonable including: (1) whether the interpretation
is consistent with the goals of the plan; (2) whether the interpretation renders any language in the
plan meaningless or internally inconsistent; (3) whether the interpretation conflicts with the
substantive or procedural requirements of the ERISA statute; (4) whether the plan administrator
has interpreted the provisions at issue consistently; and (5) whether the interpretation is contrary
to the clear language of the plan. King, 414 F.3d at 999; Finley v. Special Agents Mut. Benefit
Ass’n, 957 F.2d 617 (8th Cir.1992). Though each factor is relevant, the Eighth Circuit has
observed that “significant weight should be given to . . . a misinterpretation of unambiguous
language in a plan.” Lickteig v. Bus. Men’s Assurance Co. of Am., 61 F.3d 579, 585 (8th Cir.
1995).
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insurer has a history of biased claims administration, the conflict may be given
substantial weight, but where the insurer has taken steps to reduce the risk that the
conflict will affect eligibility determinations, the conflict should be given much less
weight.” Id. A court gives the conflict “some weight” if there is little evidence about an
insurance company’s claims administration or its efforts to reduce potential bias created
by a conflict. Id. (citing Metro Life Ins. Co. v. Glenn, 554 U.S. 105 (2008)).
In this action, the investigator and the appeal specialist both worked for Hartford,
creating a conflict.10
Hartford has produced no evidence regarding its claims
administration history or its attempts to alleviate any bias produced by the conflict.
Accordingly, the Court will give the conflict “some weight,” although this factor is not
determinative. See Darvell, 597 F.3d at 934.
2.
Hartford’s Abuse of Discretion
Using the above standard, the Court must determine if Hartford abused its
discretion. A plan administrator abuses its discretion if it fails to identify and request
additional information needed to make a reasoned decision.11 Administrators may not
rely on “slivers of information” from a record, but must instead “evaluate the available
evidence in its entirety before reaching a determination.”
10
Willcox v. Liberty Life
The investigator making the initial eligibility determination was located in the same
Minneapolis Disability Claim Office as the appeal specialist performing the review, further
demonstrating a conflict. (See HART000063, 64, 79-82.)
11
See 29 C.F.R. § 2560.503-1(g)(iii) (requiring administrators to notify the claimant 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”); Chorosevic, 600 F.3d at 944.
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Assurance Co. of Boston, 552 F.3d 693, 702 (8th Cir. 2009) (internal quotation marks
omitted).
Hartford primarily based its denial of McDonel’s application on a short
description of the “Value Stream I Associate” position, contained in Simpson’s e-mail,
and on the job restrictions imposed by Dr. Rieser. Using this information, Hartford
determined that McDonel’s job restrictions did not meaningfully affect the essential
duties of the “Value Stream I Associate” occupation. The Court finds that this decision
was a flagrant abuse of discretion for two reasons.
a.
Lack of Information about McDonel’s Occupation
First, Hartford did not possess an adequate description of McDonel’s occupation
and her essential duties. The description of the “Value Stream I Associate” position in
the record is from an unknown source and has relatively little information in it.12 It
leaves uncertain, for example, whether McDonel’s position required her to frequently
turn and twist, to reach into a large bin to retrieve materials, or to pull, lift, carry, or push
significant weight. (See HART109.) Furthermore, Hartford did not identify whether
Andersen had implemented a new “rotating system” that changed McDonel’s position by
August 2009 and, if so, how this rotation may have affected her occupation. The Court
finds no basis for Hartford to reliably infer the essential duties of McDonel’s position.
12
An employee’s ability to perform some, but not all, of her occupation’s essential duties
is an insufficient basis for an administrator to deny benefits. Seitz v. Metro. Life Ins. Co., 433
F.3d 647, 651 (8th Cir. 2006).
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There is also no evidence that Hartford identified, as required under the LTD
policy, McDonel’s “occupation as it is recognized in the general workplace.”
(See
HART43-47.) The only job descriptions in the record are (1) a list of certain duties
McDonel performed, contained in Simpson’s e-mail, and (2) what appears to be an
example of one task that Andersen’s window assemblers perform. (See HART109-11.)
The Court finds no basis to conclude that these descriptions defined the essential duties of
window assemblers at Andersen, much less the essential duties of window assemblers in
the general workplace.
Hartford’s failure to investigate the “general workplace” duties of McDonel’s
occupation is further demonstrated by its statement to McDonel that “your modified
position is considered Your Occupation.”
(See HART63-64.)
Hartford claims that
Andersen accommodated McDonel’s disabilities for many years, and that Hartford
considered these accommodations when defining McDonel’s occupation. Yet the record
does not indicate what accommodations Andersen provided to McDonel, other than an
assertion that Andersen accommodated her 2007 restrictions in some way.
(See
HART81.) The record also does not show whether Andersen’s accommodations were
legally required or whether they would have been regularly or reasonably provided in the
general workplace. The Court finds that, without this information, it was impossible for
Hartford to determine whether the McDonel’s “modified position” was consistent with
her “occupation as it is recognized in the general workplace.” See Love v. Nat’l City
Corp. Welfare Benefits Plan, 574 F.3d 392, 397 (7th Cir. 2009) (noting “bare conclusions
are not a rationale” sufficient to satisfy ERISA) (internal quotation marks omitted).
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b.
Lack of Information about McDonel’s Restrictions
Second, Hartford did not adequately investigate or consider McDonel’s workrelated restrictions. Hartford discounted the new restrictions imposed by Dr. Rieser in
2010, declaring that they were “the same restrictions and limitations” as those from 2007.
(HART5, 79.) The restrictions, however, were not the same. Aside from conclusory
statements, it has provided no explanation for why any administrator could view these
restrictions as the same. Furthermore, no physician – or non-physician, for that matter –
has reviewed a comprehensive description of McDonel’s occupation and determined that
she can fulfill its essential duties with her limitations.13 Indeed, the most reliable record
evidence, the opinion of McDonel’s employer, indicates that McDonel could not perform
her occupation.
(See HART134) (“Your permanent restrictions prevent you from
performing the essential functions of the Value Stream I position, with or without
reasonable accommodation.”).
There is not enough evidence for any reasonable
administrator to have determined that McDonel’s 2010 restrictions did not affect her
occupation’s essential duties.
Hartford’s inadequate investigation is particularly evident because McDonel
indicated that a “permanent weight restriction” prevented her from doing her job.
13
See 29 CFR § 2560.503-1(h)(3)(iii) (“[I]n deciding an appeal of any adverse benefit
determination that is based in whole or in part on a medical judgment . . . the appropriate named
fiduciary shall consult with a health care professional who has appropriate training and
experience in the field of medicine involved in the medical judgment[.]”); (HART56) (“Any
adverse benefit determination will be in writing and include . . . if denial is based on a medical
judgment, either (i) an explanation of the scientific or clinical judgment for the determination . . .
or (ii) a statement that such explanation will be provided to you free of charge upon request.”).
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(HART109.) Hartford claims that “there is no indication that [McDonel’s] Occupation
requires pushing or pulling greater than 50 lbs.,” but Hartford also possesses no reliable
evidence that her occupation did not include pushing or pulling this amount.
(See
HART3-4, 63-64.)
The lack of evidence supporting Hartford’s decision is further demonstrated by its
discounting of McDonel’s 2010 restrictions because she “chose not to pursue additional
treatment” for her back. (See HART64.) Hartford never investigated if McDonel’s knee
problems prohibited her from seeking surgery. (See HART8.) Further, Hartford cannot
deny McDonel benefits because she continued to work for some years with a back injury
or because Andersen provided some kind of accommodations to her during this time. See
Seitz, 433 F.3d at 651 (stating that courts should not “unfairly punish individuals who test
their limitations and attempt to keep working before seeking benefits”).
In sum, the record is replete with relevant information that Hartford did not know.
It did not know the essential functions of McDonel’s job; it did not know about her
occupation in the general workplace; it did not know if her occupation had changed; it
did not know how Andersen had accommodated her; it did not know the limitations
imposed by her knee condition; and it did not know how her medically-recommended
restrictions affected her occupation. Hartford may have had “little incentive to come to
grips with” McDonel’s claims, but it had the obligation to do so. See Booton, 110 F.3d at
1463 n.6.
The Court finds that Hartford made its decision “blindfolded” and,
accordingly, abused its discretion. See id. at 1463.
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IV.
REMEDY
Although the Court has determined that Hartford abused its discretion, there is not
enough evidence in the record to determine if McDonel is entitled to LTD benefits. The
record does not adequately demonstrate the functional limitations associated with
McDonel’s injuries or the essential duties of her occupation. The Court may not gather
additional evidence outside of the claim file. Brown v. Seitz Foods, Inc., 140 F.3d 1198,
1200 (8th Cir. 1998). Accordingly, the Court will remand this case to Hartford for further
administrative review consistent with this opinion. See, e.g., Shelby Cnty. Health Care
Corp. v. Majestic Star Casino, 581 F.3d 355, 373 (6th Cir. 2009) (“[A]n incomplete
factual record provides a basis to remand the case to the plan administrator.”). Because
the Court will issue a remand, it reserves judgment on attorney’s fees, costs, expenses,
and prejudgment interest.
ORDER
Based on the foregoing, and all the files, records, and proceedings herein, IT IS
HEREBY ORDERED that:
1.
Plaintiff’s long-term disability benefits claim is REMANDED to
Defendant for further administrative review consistent with this opinion.
2.
This action is STAYED pending a final decision by Defendant. Within
thirty (30) days of a final decision by Defendant, either party may move to lift the stay
and renew their dispositive motions based on the administrative record.
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3.
Defendant’s Motion for Summary Judgment [Docket No. 12] is DENIED
without prejudice.
4.
Plaintiff’s Motion for Summary Judgment [Docket No. 17] is DENIED
without prejudice.
5.
Both parties shall be under an obligation to notify this Court by written
correspondence within thirty (30) days after Defendant reaches a final decision regarding
Plaintiff’s long-term disability benefits claim.
DATED: June 25, 2012
at Minneapolis, Minnesota.
____s/
____
JOHN R. TUNHEIM
United States District Judge
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