Jennings v. Hartford Life and Accident Insurance et al
Filing
36
MEMORANDUM DECISION AND ORDER: The court GRANTS 22 Defendant Hartford's Motion for Summary Judgment and DENIES 21 Jennings' Motion for Summary Judgment. Signed by Judge Robert J. Shelby on 3/29/18. (dla)
IN THE UNITED STATES DISTRICT COURT FOR
THE DISTRICT OF UTAH, CENTRAL DIVISION
SHAWNA JENNINGS,
Plaintiff,
MEMORANDUM
DECISION AND ORDER
v.
HARTFORD LIFE AND ACCIDENT
INSURANCE COMPANY and GROUP
SHORT TERM DISABILITY PLAN FOR
EMPLOYEES OF INTERMOUNTAIN
HEALTH CARE, INC.,
Case No. 2:15-cv-00683-RJS-EJF
Judge Robert J. Shelby
Magistrate Judge Evelyn J. Furse
Defendants.
Plaintiff Shawna Jennings brings this action under the Employee Retirement Income
Security Act, seeking to recover short-term disability benefits.1 Jennings challenges the decision
of Defendant Hartford Life and Accident Insurance Company to deny her claim. Hartford
contends its decision was reasonable and supported by substantial evidence in the administrative
record. Before the court are cross motions for summary judgment.2 For the reasons discussed
below, the court grants Hartford’s Motion and denies Jennings’ Motion.
BACKGROUND
Jennings is a former employee of Intermountain Health Care, Inc. (IHC), and a
participant in the Group Short Term Disability Plan for IHC employees (the Plan). According to
the Plan, short-term disability benefits are payable to an employee who is “totally disabled.”3 A
1
Dkt. 2 at 2.
2
Dkt. 21; dkt. 22.
3
R. at 000156.
1
claimant is “totally disabled” and thus eligible for benefits if she is prevented by injury, sickness,
mental illness, substance abuse, or pregnancy from performing “essential duties of [the]
occupation,” and is therefore earning “less than 20% of [her] Pre-disability earnings.”4 An
essential duty is one that “1) is substantial, not incidental; 2) is fundamental or inherent to the
occupation; and 3) cannot be reasonably omitted or changed.”5 Hartford is the Plan’s claims
administrator,6 and has discretionary authority to determine eligibility for coverage. 7
Jennings suffers from spastic diplegia, a degenerative condition that affects her lower
extremities and makes it difficult for her to walk. In her position as a nurse auditor, Jennings
was responsible for auditing medical charts and verifying medical codes.8 Finding it difficult to
perform her job, Jennings applied to IHC for a leave of absence. IHC approved the request in
January 2015 and forwarded Jennings’ documentation to Hartford for its review of her eligibility
for short-term disability benefits.9 After an investigation, Hartford determined Jennings was not
totally disabled and therefore denied the claim. Jennings appealed the denial through the
administrative appeal process, and Hartford upheld its decision.
4
R. at 000163.
5
R. at 000162.
R. at 000161 (“Claims Administrator means Hartford Comprehensive Employee Benefit Service
Company (HARTFORD CEBSCO).”).
6
R. at 000159 (“The Claims Administrator is delegated the duties of the Employer to: 1) determine
benefits payable according to the terms and conditions of The Plan; and 2) make payment for benefits
payable.”).
7
8
R. at 000146.
9
R. at 000090.
2
I.
The Administrative Recor
When both parties move for summary judgment in an ERISA denial-of-benefits case, the
“factual determination of eligibility for benefits is decided solely on the administrative record.”10
Following is a summary of the administrative record at the time of Hartford’s initial denial and
subsequent appeal determination.
A. Initial Denial
Jennings initiated her benefits claim on January 21, 2015.11 Hartford investigated the
claim by requesting information from Jennings’ treating physicians and interviewing Jennings by
telephone.12
Jennings’ treating neurologist, Dr. Joseph Watkins, provided medical records for
Jennings’ November 24, 2014 and January 28, 2015 office visits. 13 At the November visit, Dr.
Watkins noted his findings as spastic diplegia, pain, stiffness, and gait difficulty.14 Jennings
reported “the spasticity in her legs [was] getting worse . . . especially when walking, but also
when sitting and standing now.”15 Jennings also reported pain and stiffness in her legs, hips, and
lower back, especially in the morning and at the end of a work day.16 The notes indicate
Jennings had a “spastic scissor-type gait” and “ha[d] to concentrate quite a bit to walk well.”17
10
LaAsmar v. Phelps Dodge Corp. Life, Accidental Death & Dismemberment & Dependent Life Ins.
Plan, 605 F.3d 789, 796 (10th Cir. 2010) (quoting Bard v. Boston Shipping Ass’n, 471 F.3d 229, 235 (1st
Cir. 2006)).
11
R. at 000148.
12
R. at 000122-149.
13
R. at 000101-110.
14
R. at 000110.
15
R. at 000108.
16
R. at 000108.
17
R. at 000108.
3
Dr. Watkins recommended Jennings increase her dosage of the medication Baclofen from 10 to
15 milligrams.18
At the January 2015 visit, Jennings reported worsening spasticity and muscle cramping in
her legs, and Dr. Watkins noted Jennings’ gait had “worsened over the past two months.”19 Dr.
Watkins lowered Jennings’ Baclofen dosage back to 10 milligrams based on Jennings’ report
that the increased dosage caused daytime drowsiness and not much benefit. Dr. Watkins referred
Jennings to Dr. Michael Green for a consultation regarding Botox injections.20 He
recommended Jennings “continue off work for now due to increasing symptoms and new
medication trials.”21
Dr. Watkins also completed an Attending Physician’s Statement of Functionality (APS)
form, in which he confirmed Jennings’ diagnoses of spastic diplegia and gait difficulty.22 Dr.
Watkins stated Jennings “will be undergoing a series of treatments for her condition and will be
unable to work . . . [for an estimated] 30 days.”23 However, he struck out the portion of the form
relating to specific workplace restrictions and wrote “N/A” beside it.24 In response to the
question “does the patient have a psychiatric/cognitive impairment?” Dr. Watkins checked the
box “no.”25
On February 10, 2015, a Hartford Medical Clinical Case Manager (MCCM) assigned to
Jennings’ case faxed Dr. Watkins a letter, asking him to clarify Jennings’ capabilities and
18
R. at 000110.
19
R. at 000105, 106.
20
R. at 000105.
21
R. at 000107.
22
R. at 000120-121.
23
R. at 0000121.
24
R. at 000121.
25
R. at 000121.
4
functionality. The MCCM asked for medical evidence to support Jennings’ “inability to work
her sedentary occupation . . . as it was noted you have been treating her since 2010 for her spastic
dipleg[ia] of which she was able to work with her condition.”26 Dr. Watkins’s office called the
MCCM to respond, and indicated Jennings was taking time off to “get used to medications” and
receive Botox injections in her legs.27 Dr. Watkins’s office also told the MCCM “there are no
specific [restrictions/limitations] as to the exact time how long [Jennings] may sit, stand or
walk[,] just that [she] is unable to sit for long periods of time because of the cramping leg pain
she gets.”28
Hartford denied Jennings’ claim on February 26, 2015.29 In the denial letter, Hartford
wrote that the record showed “no change or worsening of symptoms” from the November and
January visits, and that “[t]he medical information provided does not show an impairment or
worsening or symptoms that would prevent you from performing your sedentary job duties.”30
B. Appeal Decision
Jennings appealed Hartford’s denial on May 1, 2015, and provided additional
documentation to support her claim.31 Hartford referred the file to its Appeal Unit for an
independent review and eligibility determination.32 Hartford also retained a neurologist, Dr.
Caroline M. Badeer, to conduct an independent medical review of Jennings’ file.33 Specifically,
Hartford asked Dr. Badeer to provide “an objective assessment of [Jennings’]
26
R. at 000014.
27
R. at 000140.
28
R. at 000140.
29
R. at 000011-12.
30
R. at 000012.
31
R. at 000092-93.
32
R. at 000003.
33
R. at 000033-34, R. at 000026-29.
5
restrictions/limitations based on your medical records review, your conversation(s) with the
attending physician(s), and the individual’s self-reported information.”34
Jennings provided two letters from Dr. Michael Green, both of which stated that she
would be unable to return to work until July 2015.35 Jennings also included two letters from Dr.
Watkins. The first excused Jennings from work until April 15, 2015 “due to her ongoing medical
condition.”36 In the second letter, Dr. Watkins wrote, “[i]n my opinion, Shawna Jennings is
unable to resume any type of gainful employment due to physical impairment. My expectation is
that Ms. Jennings will see a continued decline in function over time.”37
Jennings included with her appeal various medical records, including office notes from
visits with Dr. Watkins and Dr. Green, and several physical therapy visits.38 In his office notes,
Dr. Green indicated that Jennings was “ambulatory” but that he discussed with her the possibility
of using a wheelchair or other assistive device in order to prevent falls or injuries.39 Dr. Green
provided Jennings with Botox injections on April 2, 2015.40
In a written report provided to Hartford, Dr. Badeer summarized Jennings’ medical
records and the letters from Dr. Watkins and Dr. Green. Dr. Badeer tried unsuccessfully to speak
with both doctors on the phone. However, Dr. Green provided a written response to Dr.
Badeer’s questions. In response to the question, “Could [Jennings] work in a seated position
using the upper extremities only?” Dr. Green wrote:
34
R. at 000033.
35
R. at 000095, 96.
36
R. at 000098.
37
R. at 000098.
38
R. at 000036.
39
R. at 000042.
40
R. at 000046.
6
At this time, Shawna does not seem to have upper extremity involvement, yet
with her balance and gait difficulties it will be challenging for her to maintain a
job; when she need to go to the restroom, answer phones, etc. Modifications
could be provided which may give her the ability to return to work.41
Based on her review of the medical record and limited communication with Dr. Green,
Dr. Badeer found Jennings “[could not] work in any position requiring standing or walking.”
She further noted that Jennings was “totally restricted from balancing, climbing stairs, bending,
stooping, kneeling, squatting, and working at heights,” and could not “use . . . foot controls or
driv[e] due to the spasticity in her legs.”42 However, Dr. Badeer ultimately agreed with Dr.
Green’s assessment that “modifications could be provided to allow [Jennings] to go to work.”
Dr. Badeer concluded Jennings would be “able to work in a seated position full time, without any
restrictions in the upper extremities.”43
Hartford asked Dr. Badeer to opine whether Jennings’ “condition ha[d] changed
significantly” since January 19, 2015.44 Dr. Badeer wrote that the location of Jennings’
symptoms in the lower extremities had not changed, though the level of pain and cramping had
increased. She also noted that Jennings could not tolerate higher doses of medications due to
their sedating effects.
On June 24, 2015, Hartford upheld its denial of Jennings’ claim based on its review of
Dr. Badeer’s report and the “totality of the information presented.” Hartford informed Jennings
“the medical information in the claim file does not support that you are totally disabled.”
41
R. at 000032.
42
R. at 000028.
43
R. at 000028.
44
R. at 000028.
7
Hartford explained its finding that Jennings was “capable of performing in a sedentary
occupation with restrictions.” 45 Jennings filed this lawsuit on September 22, 2015.
ANALYSIS
I.
Standard of Review
In an ERISA case, “summary judgment is merely a vehicle for deciding the case; the
factual determination of eligibility for benefits is decided solely on the administrative record and
the non-moving party is not entitled to the usual inferences in its favor.”46
A denial of benefits is reviewed de novo, “unless the benefit plan gives the administrator
or fiduciary discretionary authority to determine eligibility for benefits or to construe the terms
of the plan.”47 Where a plan grants an administrator discretionary authority, the court employs a
“deferential standard of review, asking only whether the denial of benefits was arbitrary and
capricious.”48 Under that standard, a plan administrator’s decision will be upheld “so long as it
is predicated on a reasoned basis.”49 The basis relied upon need not be “the superlative one,” so
long as the decision “resides ‘somewhere on a continuum of reasonableness – even if on the low
end.’”50 On the other hand, “[a] lack of substantial evidence often indicates an arbitrary and
capricious decision;” substantial evidence is that “a reasonable mind could accept as sufficient to
support a conclusion.”51
45
R. at 000006.
46
LaAsmar, 605 F.3d at 796 (internal quotation omitted).
47
Firestone Tire and Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989).
48
LaAsmar, 605 F.3d at 796 (quoting Weber v. GE Grp. Life Assur. Co., 541 F.3d 1002, 1010 (10th Cir.
2008)).
49
Adamson v. Unum Life Ins. Co. of America, 455 F.3d 1209, 1212 (10th Cir. 2006).
50
Id. (quoting Kimber v. Thiokol Corp., 196 F.3d 1092, 1098 (10th Cir. 1999)).
51
Id.
8
Jennings and Hartford agree the denial of benefits should be reviewed under an arbitrary
and capricious standard.52 However, Jennings proposes a “diluted” version of that standard due
to the existence of a purported conflict of interest arising because the Plan grants IHC – the
payor – discretionary authority to make claims determinations.53
The Tenth Circuit uses a sliding scale approach when a conflict of interest exists in an
ERISA case.54 Reviewing courts are to “dial back [their] deference” to a plan administrator
operating under a conflict of interest “in proportion to the seriousness of the conflict.”55
Here, IHC explicitly delegates its discretionary authority to Hartford.56 Furthermore,
Hartford engaged an independent reviewer, Dr. Badeer, as part of its eligibility determination.
Thus, any conflict of interest arising out of IHC’s dual role has been effectively mitigated and
plays little to no role in the court’s analysis.57
II.
Abuse of Discretion Analysis
Jennings contends that Hartford’s decision to deny her short-term disability benefits was
arbitrary and capricious because Hartford: (1) disregarded medical documentation of Jennings’
limitations; (2) failed to identify and consider all of the essential elements of Jennings’
occupation; and (3) read into the Plan a condition that Jennings was not “totally disabled” if she
could work with accommodations. The court considers each of Jennings’ arguments in turn.
52
See dkt. 21 at 14; dkt. 22 at 5.
53
R. at 000167.
54
Weber, 541 F.3d at 1010.
55
Id. (internal quotation omitted).
56
R. at 000159.
See Metro. Life Ins. Co. v. Glenn, 554 U.S. 105, 126 (2008) (“[A conflict of interest] should prove less
important (perhaps to the vanishing point) where the administrator has taken active steps to reduce
potential bias and to promote accuracy.”).
57
9
A. Information in the Medical Records
Jennings first argues Hartford failed to appropriately credit her physicians’ opinions
concerning her ability to work. ERISA plan administrators “may not arbitrarily refuse to credit a
claimant's reliable evidence, including the opinions of a treating physician.”58 However,
administrators are also not required to accord “special weight” to those opinions, and reviewing
courts may not impose a “burden of explanation” on administrators who credit evidence which
conflicts with a physician’s conclusion.59
Jennings alleges Hartford arbitrarily disregarded the following information:
Dr. Watkins was unequivocal in saying that Shawna could not work. Dr.
Singleton verified that her symptoms were slowly progressing. Both Dr. Watkins
and Dr. Green commented on the sedating effect of her medications. Both Drs.
Watkins and Green provided letters extending Shawna’s return to work dates.
Shortly before the claim was submitted to MCMC, Dr. Watkins wrote a letter
stating that, in his opinion, Shawna was unable to resume any type of gainful
employment due to her physical impairments and that he expected to see a
“continued decline in function over time.” Dr. Green indicated that while Shawna
“may” have been able to return to work, it was only with accommodations that
addressed the realities of her restrictions and limitations.60
Jennings contends Hartford also ignored Dr. Badeer’s findings that Jennings could not work “in
any position requiring standing or walking” and would require modifications to return to work.
Hartford responds that it did not disregard any of this information, but rather considered
it against the whole of the record and in the context of Jennings’ sedentary position at work. The
court agrees the administrative record demonstrates Hartford gave reasonable consideration to
the medical evidence in the record, including the opinions of Jennings’ physicians.
58
Black & Decker Disability Plan v. Nord, 538 U.S. 822, 834 (2003).
59
Id.
60
Dkt. 21 at 16.
10
Hartford based the initial denial of Jennings’ claim on its finding that the medical
information did not support “an impairment or worsening or [sic] symptoms that would prevent
[Jennings] from performing [her] sedentary job duties.”61 Jennings argues that because evidence
in the administrative record, including statements by Dr. Singleton and Dr. Watkins, illustrates a
progressive worsening of her symptoms, Hartford’s denial on this basis was arbitrary and
capricious. But while the record shows deterioration in Jennings’ condition, that trend is not
incompatible with Hartford’s articulated basis for denial. In other words, it is possible that
Jennings’ symptoms continued to worsen, but had not yet progressed to the point that they
rendered Jennings unable to work.
In its appeal determination letter, Hartford referenced the letters from Dr. Watkins and
Dr. Green excusing Jennings from work. The fact that Hartford’s decision is not in line with the
conclusion drawn in those letters does not signify that it arbitrarily disregarded the physicians’
opinions. Rather, as Hartford outlined in its explanation, it considered the letters but found
insufficient medical evidence to support the conclusion that Jennings’ symptoms rendered her
unable to work in her occupation.62 The court finds substantial evidence to support this
conclusion. Dr. Green stated that Jennings could return to work with modifications, and Dr.
Badeer concurred. Both conclusions, and the medical documentation from which they are
drawn, provide a “reasoned basis” on which Hartford’s decision relies.
61
R. at 000012.
R. at 000006 (“[Y]ou have indicated that you are unable to work due to your physical conditions.
However . . . , the medical documentation in your file does not support a functional impairment that
would have precluded you from performing the duties of your occupation as a Nurse Auditor as of
1/19/15 forward.”).
62
11
B. Essential Elements of the Occupation
Jennings also contends Hartford acted arbitrarily and capriciously by failing to identify
and consider all of the essential elements of Jennings’ nurse auditor occupation. Jennings
essentially argues Hartford considered only the sedentary nature of her job, without regard to its
cognitive demands and the impact of her condition on her ability to meet those demands.
Jennings relies on Gaither v. Aetna Life Insurance Co for support.63 In Gaither, a plan
administrator failed to recognize the nature of the claimant’s narcotic-related disability, rejecting
his claim “without a substantial basis for doing so, without following up on obvious leads, and
apparently without specifically considering the claim at all.”64 The administrator failed to “come
to grips” with the fact that “being drug-free” was an essential element of the claimant’s
occupation.65 The Tenth Circuit found the denial was arbitrary and capricious.66
Jennings argues Harford similarly abused its discretion here, but the administrative record
does not support this argument. The cognitive demands Jennings identifies – concentration,
stamina, mental alertness, and an eye for detail – may very well be essential to the nurse auditor
occupation. However, unlike the administrator in Gaither, Hartford neither ignored the cognitive
components of the nurse auditor occupation67 nor failed to investigate whether Jennings was
unable to meet those responsibilities.68 The court finds Hartford did not act arbitrarily and
capriciously concerning Jennings’ ability to perform the essential functions of her job.
63
394 F.3d 792 (10th Cir. 2004).
64
Id. at 806.
65
Id. at 802.
66
Id. at 809.
R. at 000004 (“[Y]our occupation as a Nurse Auditor is a sedentary occupation which involves auditing
medical charts verifying the ICD.9 code and CPT codes.”).
67
Hartford specifically inquired as to what affect, if any, Jennings’ illness would have on her ability to
perform the cognitive demands of her job. In the APS form, Hartford asked Dr. Watkins whether
68
12
C. The “Modifications” Condition
Jennings argues that Hartford acted arbitrarily and capriciously when it determined she
was not totally disabled because she could return to work with modifications. Under ERISA,
“the imposition of new conditions that do not appear on the face of a plan constitutes arbitrary
and capricious conduct.”69 Jennings contends the Plan does not permit Hartford to consider
workplace accommodations or modifications in making its determination.
Jennings cites several cases for the proposition that an administrator may not arbitrarily
impose an “accommodations condition” into a plan’s definition of disability.70 In this case,
however, the Plan incorporates the concept of accommodations or modifications into the
disability analysis. Under the Plan’s terms, an essential duty is defined as one that: “1) is
substantial, not incidental; 2) is fundamental or inherent to the occupation; and 3) cannot be
reasonably omitted or changed.”71 Even assuming the ability to walk and drive unassisted are
essential duties of the nurse auditor occupation,72 those duties could reasonably be changed to
allow Jennings to use an assistive device such as a cane, walker, or wheelchair. For that reason,
Jennings had a “psychiatric/cognitive impairment” and whether he believed Jennings was “competent to
endorse checks and direct the use of the proceeds.” Dr. Watkins marked the boxes “no” and “yes,”
respectively. R. at 000121. See also R. at 000012 (“Our clinician was advised that you were reporting
complaints of daytime sedation and leg cramping however; there were no additional diagnostic findings
or examination findings provided.”).
69
Cirulis v. UNUM Corp., 321 F.3d 1010, 1013 (10th Cir. 2003).
70
See, e.g., Saffle v. Sierra Pacific Power Co. Bargaining United LTD Income Plan, 85 F.3d 455, 459460 (9th Cir. 1996).
71
R. at 000162 (emphasis added).
Hartford maintains that the ability to drive and “ambulate unassisted” are not essential duties of the
Nurse Auditor occupation. Dkt. 27 at 25. Jennings, on the other hand, argues that the ability to get to
work every day, enter the building, and “move around without assistance” are essential duties. Dkt. 32 at
6. Neither party cites legal authority for their respective positions. Because the court finds that it was not
an abuse of discretion for Hartford to condition its denial on the availability of modifications, it need not
determine whether the ability to drive and walk unassisted are essential duties.
72
13
it was not arbitrary and capricious for Hartford to deny Jennings’ claim based on its
determination that she could return to work “with modifications.”
The court finds Hartford did not act arbitrarily and capriciously in denying Jennings’
short-term benefits claim because its determination is based on substantial evidence in the
administrative record. Evidence in the record supports the conclusion that Jennings’ spastic
diplegia affected primarily her lower extremities, and did not preclude her from working in a
sedentary position. Both Dr. Green and Dr. Badeer found Jennings could return to work with
modifications such as a cane or walker to help her enter and leave the building, and to move
around as needed at work. Hartford also had a reasonable basis to conclude that Jennings was
capable of performing the cognitive demands of her occupation. Hartford’s decision need not be
“the superlative one” so long as it lies on the “continuum of reasonableness – even if on the low
end.” That standard is met here.
III.
Long-Term Benefits
In her Complaint, Jennings seeks instatement in the long-term disability benefits plan and
payment of past long-term benefits due.73 As Hartford points out, if Jennings applied for longterm benefits, that information is not part of the administrative record in this case. Therefore, the
court does not reach this issue.
73
Dkt. 2 at 8.
14
CONCLUSION
For the reasons discussed above, the court GRANTS Defendant Hartford’s Motion for
Summary Judgment74 and DENIES Jennings’ Motion for Summary Judgment.75
SO ORDERED this 29th day of March, 2018.
BY THE COURT:
________________________________________
ROBERT J. SHELBY
United States District Judge
74
Dkt. 22.
75
Dkt. 21.
15
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