Harrison v. UnitedHealth Group et al
Filing
20
MEMORANDUM OPINION AND ORDER granting 14 MOTION by Standard Insurance Company for Summary Judgment; denying 13 MOTION by Suzette Harrison for Judgment on the Pleadings; and dismissing this case from the docket of the Court. Signed by Judge Thomas E. Johnston on 3/28/2018. (cc: counsel of record; any unrepresented party) (taq)
IN THE UNITED STATES DISTRICT COURT
FOR THE SOUTHERN DISTRICT OF WEST VIRGINIA
CHARLESTON DIVISION
SUZETTE HARRISON,
Plaintiff,
v.
CIVIL ACTION NO. 2:16-cv-11406
UNITEDHEALTH GROUP, et al,
Defendants.
MEMORANDUM OPINION AND ORDER
Pending before the Court is Plaintiff Suzette Harrison’s Motion for Judgment on
Administrative Record, (ECF No. 13), and Defendant Standard Insurance Company’s Motion for
Summary Judgment, (ECF No. 14). For the reasons discussed herein, the Court GRANTS the
Motion for Summary Judgment, DENIES the Motion for Judgment on Administrative Record,
and DISMISSES this case from the docket of the Court.
I.
BACKGROUND
Plaintiff Suzette Harrison (“Ms. Harrison”), a former registered nurse, was formerly
employed as a medical case manager for UnitedHealth Group (“UHG”). (ECF No. 1-1 at 5.)
Ms. Harrison participated in an employee welfare benefit plan (“the Plan”) established by UHG.
Administrative Record at * 00793 (hereinafter “AR ___”).
UHG, through the Plan, is the
policyholder of a group long-term disability insurance policy (“the policy”) purchased from
Defendant Standard Insurance Company (“Standard”). (AR 00012.) Standard is both the insurer
1
responsible for paying claims made by Plan participants and the plan administrator who determines
which participants are eligible for benefits. (AR 00033–00034.) The policy, as a component of
the Plan, is subject to the regulatory provisions of the Employee Retirement Income Security Act
of 1974, 29 U.S.C. § 1001 et seq. (“ERISA”).
It is uncontested that Ms. Harrison was a qualified participant in the Plan and was covered
by the policy beginning in October 2013 when she was forced to cease working due to complaints
of low back and leg pain. (ECF No. 15 at 3–4; AR 00112–00116, 00121–00123.) Following the
cessation of working, Ms. Harrison received short-term disability benefits from October 8, 2013
to April 5, 2014, which Standard approved and paid for under the Plan while she underwent
treatment.
(AR 00628–00634.)
In April 2014, Ms. Harrison had a spinal cord stimulator
implanted to relieve her pain. (AR 00638–00642, 00651–00655.) In May 2014, after Ms.
Harrison’s short-term benefits expired, Standard awarded her long-term disability benefits, which
lasted until December 2015 when Standard terminated the benefits. (AR 00709–00712, 01089–
01093.)
Standard contends that following Ms. Harrison’s medical procedure, Ms. Harrison
progressed to the point where a current medical evaluation of Ms. Harrison’s abilities showed that
there was insufficient medical evidence to demonstrate that she lacked the functional capacity to
perform the Material Duties of her Own Occupation within the scope of her license, and was
therefore no longer eligible for payments of Plan benefits. (AR 01090–01092.) Following the
termination decision by Standard, Ms. Harrison submitted an administrative appeal of the decision
to close her claim. (AR 01135–01150.) Upon review, Standard determined that the medical
evidence did not support a conclusion that would find Ms. Harrison’s condition severe enough to
2
prevent her from working in her Own Occupation, and as such, resulted in Standard upholding its
prior decision. (AR 01219–01231.) Ms. Harrison contests Standard’s findings, and alleges that
Standard’s review process was flawed and tainted by a structural conflict of interest. (See ECF
No. 13 at 2.)
Having exhausted all of her administrative remedies, Ms. Harrison appealed Standard’s
decision and filed the instant Complaint in the Circuit Court of Kanawha County, West Virginia,
which Standard removed to this Court. Ms. Harrison asks this Court to order payment by
Standard of long-term disability benefits, or to enter judgment for benefits wrongfully denied.
(ECF No. 13.) Standard asks this Court to affirm its decision that Ms. Harrison is no longer
qualified as disabled, and to confirm its decision to stop providing long-term benefits. (ECF No.
14.)
Ms. Harrison filed a Motion for Judgment on Administrative Record on May 30, 2017.
(ECF No. 13.) Standard filed a response on June 13, 2017, (ECF No. 17), to which Ms. Harrison
replied on June 20, 2017, (ECF No. 18.) Standard filed its Motion for Summary Judgment on
May 30, 2017. (ECF No. 14.) Ms. Harrison filed a response on June 13, 2017, (ECF No. 16), to
which Standard replied on June 20, 2017, (ECF No. 19). As such, the parties’ cross-motions are
ripe for review by this Court.
II.
LEGAL STANDARD
A plaintiffs’ § 1132 claim challenging a denial of benefits is analogous to a
claim arising under the common law of trusts. See Firestone Tire & Rubber Co. v.
Bruch, 489 U.S. 101, 113, 109 S. Ct. 948, 103 L. Ed. 2d 80 (1989). Accordingly, a
jury trial is inappropriate, and such claims are properly decided through crossmotions for summary judgment on the basis of the administrative record that
was relied upon by the plan administrator who denied the benefits claim. See Berry
v. Ciba-Geigy Corp., 761 F.2d 1003, 1007 (4th Cir. 1985), In re Vorpahl, 695 F.2d
318, 320 (8th Cir. 1982).
3
Caldwell v. Std. Ins. Co., No. 2:14-cv-25242, 2015 U.S. Dist. LEXIS 112122, at *4–5 (S.D. W.
Va. August 25, 2015).
Rule 56 of the Federal Rules of Civil Procedure governs motions for summary judgment.
That rule provides that a court should grant summary judgment if “there is no genuine issue as to
any material fact and the movant is entitled to judgment as a matter of law.” Fed. R. Civ. P. 56(a).
Summary judgment is inappropriate, however, if there exist factual issues that reasonably may be
resolved in favor of either party. Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 250 (1986).
“Facts are ‘material’ when they might affect the outcome of the case, and a ‘genuine issue’ exists
when the evidence would allow a reasonable jury to return a verdict for the nonmoving party.”
The News & Observer Publ’g Co. v. Raleigh-Durham Airport Auth., 597 F.3d 570, 576 (4th Cir.
2010). When construing such factual issues, the Court must view the evidence “in the light most
favorable to” the party opposing summary judgment. Adickes v. S.H. Kress & Co., 398 U.S. 144,
157 (1970); see also Liberty Lobby, 477 U.S. at 255 (“The evidence of the non-movant is to be
believed, and all justifiable inferences are to be drawn in his favor.” (citation omitted)).
The moving party may meet its burden of showing that no genuine issue of fact exists by
use of “depositions, answers to interrogatories, answers to requests for admission, and various
documents submitted under request for production.” Barwick v. Celotex Corp., 736 F.2d 946,
958 (4th Cir. 1984). Once the moving party has met its burden, the burden shifts to the nonmoving
party to “make a showing sufficient to establish the existence of an element essential to that party’s
case, and on which that party will bear the burden of proof at trial.” Celotex Corp. v. Catrett, 477
U.S. 317, 322 (1986). If a party fails to make a sufficient showing on one element of that party’s
case, the failure of proof “necessarily renders all other facts immaterial.” Id. at 323.
4
“[A] party opposing a properly supported motion for summary judgment may not rest upon
mere allegation or denials of his pleading, but must set forth specific facts showing that there is a
genuine issue for trial.” Liberty Lobby, 477 U.S. at 256. “The mere existence of a scintilla of
evidence” in support of the nonmoving party is not enough to withstand summary judgment; the
judge must ask whether “the jury could reasonably find for the plaintiff.” Id. at 252.
III.
DISCUSSION
ERISA is a comprehensive statutory scheme that regulates qualifying
employee pension and welfare-benefits plans, including those that provide
disability insurance. See generally Metropolitan Life Ins. Co. v. Massachusetts, 471
U.S. 724, 105 S. Ct. 2380, 85 L. Ed. 2d 728 (1985). ERISA “establishes various
uniform procedural standards concerning reporting, disclosure, and fiduciary
responsibility” for such plans, but “does not regulate the[ir] substantive content.”
Id. at 732.
“[E]mployers have large leeway to design disability and other welfare plans
as they see fit.” Black & Decker Disability Plan v. Nord, 538 U.S. 822, 833, 123 S.
Ct. 1965, 155 L. Ed. 2d 1034 (2003). “The plan, in short, is at the center of ERISA.”
US Airways, Inc. v. McCutchen, 133 S. Ct. 1537, 1548, 185 L. Ed. 2d 654 (2013).
Unsurprisingly, given this focus on the individualized nature of each ERISA plan,
“the validity of a claim to benefits under an ERISA plan is likely to turn on the
interpretation of terms in the plan at issue.” Firestone Tire, 489 U.S. at 115.
Caldwell, 2015 U.S. Dist. LEXIS 112122, at *5 (S.D. W. Va. August 25, 2015).
a. Level of Deference
Before the Court addresses the merits of the parties’ arguments, the Court must determine
what level of deference should be applied to Standard’s decision to terminate Ms. Harrison’s
benefits.
An ERISA plan administrator’s decision to deny 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.” Firestone Tire, 489 U.S. at 115 (1989). If the plan
5
administrator is conferred discretion by the terms of the plan, the proper standard of review is
abuse of discretion. See Metro. Life Ins. Co. v. Glenn, 554 U.S. 105, 111 (2008).
Here, the policy contains an “allocation of authority” provision, which clearly grants
Standard discretion to determine if a Plan participant is eligible for benefits. (AR 00033–34.)
Both parties agree, and this Court finds, that the Plan confers discretionary authority on the
administrator in the exercise of its power, thus this Court should apply an abuse of discretion
standard. (See ECF Nos. 13 at 2; 15 at 13–15.) However, Ms. Harrison argues that Standard was
placed in a structural conflict of interest to which it succumbed. (ECF No. 13 at 2, 16.) Due to
the alleged tainted decision, Ms. Harrison argues that this Court should grant little deference
because the administrator acted under a conflict of interest. (Id.) On this basis, the Court will
first determine if there was a conflict of interest and what type of deference should be accorded.
The presence of a plan administrator’s conflict of interest does not modify the abuse of
discretion standard; instead, a conflict of interest is one factor to be considered when “reviewing
the reasonableness of a plan administrator’s discretionary decision.” Williams v. Metro. Life Ins.
Co., 609 F.3d 622, 630–31 (4th Cir. 2010) (citing Metropolitan Life Insurance Co. v. Glenn, 554
U.S. 105 (2008)). The Court may assess a conflict of interest “as one of the factors considered in
determining [the] reasonableness” of a plan administrator’s decision. Champion v. Black &
Decker (U.S.) Inc., 550 F.3d 353, 359 (4th Cir. 2008).
If a factor “suggests [that] a plan
administrator did not act reasonably and thereby abused its discretion, it must be weighed against
other indicators that the administrator ‘was not inherently biased.’” Caldwell, 2015 U.S. Dist.
LEXIS 112122, at *5 (S.D. W. Va. August 25, 2015) (quoting Williams, 609 F.3d at 632). A
structural conflict of interest should not have a significant role in the analysis when the insurer’s
6
conduct demonstrates a lack of bias.
Williams, 609 F.3d at 632.
The court in Williams
determined that lack of bias was shown when the insurer initially determined that the plaintiff
seeking benefits was disabled, paid long-term disability benefits to that plaintiff for almost two
years, and based its decision to stop paying benefits on a review of the plaintiff’s medical records
conducted by two independent doctors. Id.
Here, Standard approved Ms. Harrison’s application for short-term benefits and paid Ms.
Harrison’s short-term benefits through expiration. (AR 00643, 00709.) Upon the expiration of
the short-term benefits and following Ms. Harrison’s surgery to reduce pain in her back, Standard
approved Ms. Harrison’s long-term benefits but noted that her claim would be reviewed
“periodically to confirm [her] continued disability and eligibility for benefits.” (AR 00711,
00719.) Standard paid Ms. Harrison long-term benefits for over one year and seven months.
(AR 709–712, 01089–01093.) Following Ms. Harrison’s surgery in April 2014, she reported
significant improvement in her conditions, and the medical records reflected the same. (AR
00753, 00777, 00784, 00786, 00792.) In September 2014, Ms. Harrison indicated that she was
“doing well,” and she had “no lower extremity weakness” observed on examination. (AR 00832.)
Following this report, Standard consulted physician Akhil M. Chhatre, M.D., a board
certified physician in Physical Medicine and Rehabilitation with expertise in pain medicine, to
evaluate Ms. Harrison’s condition. (AR 00837–00843.) For the next year and two months, Dr.
Chhatre evaluated regularly updated medical records regarding Ms. Harrison’s progress, and
consulted with, although sometimes not the extent he preferred, Dr. Timothy R. Deer, who
conducted the spinal implant surgery and was Ms. Harrison’s pain management physician. (AR
00837–00843, 00899–00901, 01018–01020, 01055–01058.) Standard also consulted with Dr.
7
Deer on its own. (AR 01008–01010, 01037–01038, 01052.) Based on Dr. Chhatre’s medical
evaluation in November 2015, which showed Ms. Harrison’s progress regarding her low back and
that her shoulder did not require any limitations, Standard had a vocational evaluation of Ms.
Harrison’s ability to work conducted.
(AR 01028–01032, 01040–01044, 01055–01058.)
Standard consulted Certified Rehabilitation Counselor, Judith Levy, MS, CRC, to evaluate Ms.
Harrison’s ability to work in her Own Occupation within the scope of her license as a Registered
Nurse with the functional limitations and restrictions identified by Dr. Chhatre. (AR 01082–
01086.) Ms. Levy concluded that Ms. Harrison had the functional capacity to work within the
scope of her license as a Nurse Case Manager and Utilization Review Nurse. (AR 01084–01085.)
Upon this information, Standard terminated Ms. Harrison’s long-term benefits. (AR 01089–
01093, 01099.)
On appeal, Standard consulted physician Mark Shih, M.D., a board certified physician in
Physical Medicine and Rehabilitation, who conducted an independent review of the medical
records and determined that the evidence showed that Mr. Harrison continued to improve. (AR
01201–01206.) Concerned by Dr. Deer’s note that indicated “a flare or worsening of [Ms.
Harrison’s] condition,” Dr. Shih conducted a second report based upon updated medical records
and found that there was no indication of a flare up which would change the prognosis. (AR
01205, 01215.) Therefore, Standard upheld the original decision. (AR 01219–01231.)
Thus, Standard initially determined that Ms. Harrison was disabled and paid long-term
benefits for over one year and seven months, and only terminated her benefits after engaging in an
independent review of her medicals records, based upon consistent improvements. The decision
by Standard is similar to that of the insurer in Williams, which was upheld by the Fourth Circuit,
8
and as such, this Court finds that it must conclude the same. Therefore, the Court does not find
that there is an indication of bias, and will review Standard’s decision that Ms. Harrison was no
longer eligible for long-term benefits for abuse of discretion.
b. Review of Standard’s Decision
When applying the abuse of discretion standard, the administrator’s decision “will not be
disturbed if reasonable, even if the court would have reached a different conclusion.” Booth v.
Wal-Mart Stores, Inc. Associates Health & Welfare Plan, 201 F.3d 335, 341 (4th Cir. 2000). A
court may consider, but is not limited to, the following factors when determining reasonableness:
(1) the language of the plan; (2) the purposes and goals of the plan; (3) the adequacy
of the materials considered to make the decision and the degree to which they
support it; (4) whether the fiduciary’s interpretation was consistent with other
provisions in the plan and with earlier interpretations of the plan; (5) whether the
decisionmaking process was reasoned and principled; (6) whether the decision was
consistent with the procedural and substantive requirements of ERISA; (7) any
external standard relevant to the exercise of discretion; and (8) the fiduciary’s
motives and any conflict of interest it may have.
Booth, 201 F.3d at 342–43 (4th Cir. 2000). With consideration given to these factors, particularly
the first, third, and fifth factors, this Court will turn to the administrative record and evaluate
Standard’s decision to terminate Ms. Harrison’s benefits based upon reasonableness under an
abuse of discretion standard.
As noted above, Ms. Harrison ceased working due to her pain, was initially awarded shortterm benefits, and upon expiration of the short-term benefits was awarded long-term benefits.
(AR 00112–00116, 00121–00123, 00628–00634, 00709–00712, 01089–01093.)
Under the
policy’s Own Occupation Definition of Disability that applies during the initial 24-month Own
Occupation period, a participant must be “unable to perform with reasonable continuity the
9
Material Duties of [their] Own Occupation.” 1 (AR 00004, 00009, 00021.) Under the policy,
“[i]f your Own Occupation involves the rendering of professional services and you are required to
have a professional or occupational license in order to work, your Own Occupation is as broad as
the scope of your license.” (AR 00004.) The parties do not dispute that Ms. Harrison satisfied
the policy’s requirements for disability under the Own Occupation provision. (ECF Nos. 13 at 4;
15 at 3–4.) Furthermore, it is uncontested that Standard maintained the right to periodically
review Ms. Harrison’s disability status.
As noted above, in April 2014, Ms. Harrison had a spinal cord stimulator implanted to
relieve the pain that rendered her disabled. (AR 00638–00642, 00651–00655.) Following the
implant, Ms. Harrison reported that the stimulator “has really helped a lot” to reduce pains levels,
and her medical records showed significant improvement as well. (AR 00753, 00777, 00784,
00786, 00792.) Over the next five months, Ms. Harrison continued to report that she was doing
well and that her pain decreased from a 10, on a scale of 1-10, pre-surgery to a 1. (AR 000528,
00753, 00777, 00784, 00792, 00832) Based on all of the success, Standard consulted Dr. Chhatre
to evaluate Ms. Harrison’s condition. (AR 00837–00843.) Over the course of one year and two
months, Dr. Chhatre completed four written reports regarding Ms. Harrison, each completed based
upon current, updated medical records. (AR 00832, 00837–00843, 00899–00901, 01018–01020,
01055–01058.)
As discussed above, Dr. Chhatre found that Ms. Harrison was continually
improving. During this time, Dr. Chhatre attempted to consult with Dr. Deer; however, he had
difficulty consulting with him.
(AR 000834, 00899, 01018.)
Standard requested updated
medical records from Dr. Deer and that Dr. Deer conduct a Physician’s Report – Musculoskeletal
1
The policy defines “Own Occupation” and “Material Duties” at AR 00021.
10
regarding Ms. Harrison’s functional limitations. (AR 00931, 00956, 00971–00975.) Dr. Deer
did not complete the report, noting that he did not conduct functional limitation exams, but
provided additional medical records. (AR 01008–01010.) Standard continued its attempt to
receive an update regarding Ms. Harrison’s functional limitations and work restrictions to no avail,
with only updated medical records provided.
(AR 01037–01038, 01052.)
Relying on Dr.
Chhatre’s opinion and Dr. Deer’s limited input, Standard had Ms. Levy evaluate Ms. Harrison’s
ability to work in her Own Occupation within the scope of her license as a Registered Nurse with
the functional limitations and restrictions identified by Dr. Chhatre. (AR 01082–01086.) Ms.
Levy concluded that Ms. Harrison had the functional capacity to work within the scope of her
license as a Nurse Case Manager and Utilization Review Nurse. (AR 01084–01085.) Based on
Ms. Levy’s conclusion and the aggregated medical records and reviews, Standard made its
decision that Ms. Harrison was no longer entitled to disability benefits under the qualifications of
the Plan regarding her Own Occupation; however, she could request an administrative review of
the decision. (AR 01089–01093, 01099.)
On appeal, Ms. Harrison included a letter from Dr. Deer in which he noted that her
condition had improved and that she could continue to improve, but that she remained permanently
and totally disabled and would not improve enough for her to rejoin the work force. (AR 01127–
01128.) Furthermore, Dr. Deer noted that she had a recent flare-up of a new area of pain, which
could require more surgery and render her more disabled. (Id.) Standard consulted Dr. Shih to
review the medical records on appeal. (AR 01207–01208.) Dr. Shih completed two written
reports, and ultimately concluded that the updated medical records do not show evidence of a
worsening of her conditions, only improvements.
11
Therefore, Dr. Shih concluded that Ms.
Harrison would have limitations, but none of them would prevent her from returning to work, and
on that basis, Standard upheld its decision. (AR 01204–01205, 01215, 01219–01231.) Standard
mailed Ms. Harrison a detailed letter explaining its decision, and that Ms. Harrison had the right
to file suit under ERISA. (AR 01219–01231.)
When applying the abuse-of-discretion standard in an ERISA case, a district
court plays a “secondary rather than primary role in determining a claimant’s right
to benefits.” Evans v. Eaton Corp. Long Term Disability Plan, 514 F.3d 315, 323
(4th Cir. 2008). That is, if the plan administrator acts reasonably, it is inappropriate
to “substitute [the court’s] judgment in place of the judgment of the plan
administrator.” Id. A plan administrator’s decision is reasonable “if it is the result
of a deliberate, principled reasoning process and if it is supported by substantial
evidence.” Id. at 322. Substantial evidence has been held to be “more than a
scintilla, but less than a preponderance” and that “which a reasoning mind would
accept as sufficient to support a particular conclusion.” Clark v. Nationwide Mut.
Ins. Co., 933 F. Supp. 2d 862, 880 (S.D.W. Va. 2013)(internal quotations omitted).
Caldwell, 2015 U.S. Dist. LEXIS 112122, at *30 (S.D. W. Va. August 25, 2015).
Here, Standard reasonably relied on the opinions of two board certified physicians, who
performed six medical reviews, and considered the limited opinions of Ms. Harrison’s treating
physician. Furthermore, Standard relied on the evaluation of a vocational expert. Contrary to
Ms. Harrison’s contentions, it was not unreasonable for Standard to rely on the opinions of nontreating physicians when making its decision. See Childers v. United of Omaha Life Ins. Co., No.
3:12-0077, 2013 U.S. Dist. LEXIS 24897, at * 83 (S.D. W. Va. Feb 22, 2013).
“Plan
administrators are not obliged to accord special deference to the opinions of treating physicians”
and are not commanded “to credit the opinions of treating physicians over other evidence relevant
to the claimant’s medical condition.” Black & Decker Disability Plan v. Nord, 538 U.S. 822, 825
(2003). Additionally, when conflicting medical results are presented, it is the administrator’s
obligation to resolve the conflict based on its discretion, and as long as the administrator bases its
12
decision on reliable medical evidence, the administrator is not required to distinguish contrary
medical evidence. Id. at 834; Mullins v. AT&T Corp., 424 F. App’x 217, 223 (4th Cir. 2011).
Based on the evidence presented, it appears to the Court that Standard engaged in a
reasoned and principled decision-making process that took into account all of the evidence
presented by Ms. Harrison, relied on the judgment of independent consulting physicians, and
reached a conclusion logically consistent with the language of the relevant provisions of the policy.
Furthermore, Standard considered all of the evidence in its possession and continually sought
updated medical records and fresh medical reports for its consulting physicians.
While it might be possible for a court analyzing the record de novo to disagree with the
conclusion reached by Standard, that is not the inquiry that precedent dictates this Court undertake
in this case. Instead, it is the duty of this Court to determine if Standard’s decision was an abuse
of discretion. Having found that Standard’s decision-making process was reasoned, principled,
and based on substantial evidence, the Court finds that Standard did not abuse its discretion when
it determined that Ms. Harrison did not qualify as disabled under the “Own Occupation” definition
of disability, and was therefore no longer eligible for long term benefits.
IV.
CONCLUSION
For the reasons set forth above, the Court GRANTS Defendant Standard Insurance
Company’s Motion for Summary Judgment, (ECF No. 14), DENIES Plaintiff Suzette Harrison’s
Motion for Judgment on Administrative Record, (ECF No. 13), and DISMISSES this case from
the docket of the Court.
13
IT IS SO ORDERED.
The Court DIRECTS the Clerk to send a copy of this Order to counsel of record and any
unrepresented party.
ENTER:
14
March 28, 2018
Disclaimer: Justia Dockets & Filings provides public litigation records from the federal appellate and district courts. These filings and docket sheets should not be considered findings of fact or liability, nor do they necessarily reflect the view of Justia.
Why Is My Information Online?