Filed: Jun. 08, 2007
Latest Update: Feb. 21, 2020
Summary: United States Court of Appeals Fifth Circuit F I L E D IN THE UNITED STATES COURT OF APPEALS June 8, 2007 FOR THE FIFTH CIRCUIT Charles R. Fulbruge III _ Clerk No. 06-60776 Summary Calendar _ JAMES MORGAN WILLIAMS, Plaintiff-Counter Defendant-Appellant, versus HARTFORD LIFE INSURANCE COMPANY, Defendant-Counter Claimant-Appellee. _ Appeal from the United States District Court for the Southern District of Mississippi (No. 3:05-CV-110) _ Before JOLLY, DENNIS, and CLEMENT, Circuit Judges. * PER CURI
Summary: United States Court of Appeals Fifth Circuit F I L E D IN THE UNITED STATES COURT OF APPEALS June 8, 2007 FOR THE FIFTH CIRCUIT Charles R. Fulbruge III _ Clerk No. 06-60776 Summary Calendar _ JAMES MORGAN WILLIAMS, Plaintiff-Counter Defendant-Appellant, versus HARTFORD LIFE INSURANCE COMPANY, Defendant-Counter Claimant-Appellee. _ Appeal from the United States District Court for the Southern District of Mississippi (No. 3:05-CV-110) _ Before JOLLY, DENNIS, and CLEMENT, Circuit Judges. * PER CURIA..
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United States Court of Appeals
Fifth Circuit
F I L E D
IN THE UNITED STATES COURT OF APPEALS
June 8, 2007
FOR THE FIFTH CIRCUIT
Charles R. Fulbruge III
__________________________ Clerk
No. 06-60776
Summary Calendar
__________________________
JAMES MORGAN WILLIAMS,
Plaintiff-Counter Defendant-Appellant,
versus
HARTFORD LIFE INSURANCE COMPANY,
Defendant-Counter Claimant-Appellee.
___________________________________________________
Appeal from the United States District Court
for the Southern District of Mississippi
(No. 3:05-CV-110)
___________________________________________________
Before JOLLY, DENNIS, and CLEMENT, Circuit Judges.
*
PER CURIAM:
James Williams appeals the district court’s grant of summary judgment in favor of
Hartford Life Insurance Company (“Hartford”) on Williams’s claim for wrongful
termination of his disability benefits and on Hartford’s counterclaim for a refund of
disability overpayments in the amount of $27,186.87. We affirm.
*
Pursuant to 5TH CIR. R. 47.5, the court has determined that this opinion should not
be published and is not precedent except under the limited circumstances set forth in 5TH
CIR. R. 47.5.4.
I. FACTS AND PROCEEDINGS
Williams was employed as an electrician with Helmerich & Payne, Inc.
(“Helmerich”). He injured his knee in June 1999 and thereafter applied for and received
disability benefits from Hartford, which administered Helmerich’s employee welfare
benefit plan. The plan is governed by ERISA, 29 U.S.C. § 1001 et seq. The Hartford policy
provides that, during the first twenty-four months of disability, the participant is entitled
to receive benefits if he is unable to perform one or more of the essential duties of his job.
Benefits continue only if the participant is unable to perform the essential duties of any job
for which he is qualified by education, training, or experience. In accordance with the
policy, Hartford notified Williams in June 2001 that his first 24 months of disability
benefits would soon expire and that Hartford had begun an investigation into whether
Williams was entitled to continuing benefits.
Hartford determined that Williams could perform sedentary work and discontinued
disability benefits in August 2002. Following an unsuccessful appeal of that decision with
Hartford, Williams commenced this action in July 2004. Hartford asserted a counterclaim
for overpaid disability benefits.
II. STANDARD OF REVIEW
This court reviews de novo the district court’s decision whether the plan
administrator abused its discretion in discontinuing disability benefits. Barhan v. Ry-Ron
Inc., 121 F.3d 198, 201 (5th Cir. 1997). Since the terms of the ERISA benefit plan give the
plan administrator discretionary authority to determine benefits, the district court reviews
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the denial of benefits for abuse of discretion. See id. “[I]f the administrator’s decision on
eligibility is supported by substantial evidence and is not erroneous as a matter of law, it
will be upheld.”
Id. Notwithstanding, because Hartford acts as both the insurer and the
claims administrator, it operates under a conflict of interest because it “potentially benefits
from every denied claim.” Vega v. Nat’l Life Ins. Servs., Inc.,
188 F.3d 287, 295 (5th Cir.
1999). As the district court did, this court therefore applies a “sliding scale standard” and
grants Hartford’s decision less than full deference. Gooden v. Provident Life & Acc. Ins.
Co.,
250 F.3d 329, 333 (5th Cir. 2001).
III. DISCUSSION
A. Benefits decision
Williams first challenges Hartford’s decision to discontinue disability benefits on
the basis that Hartford’s reviewing physician, Dr. Wagner, misconstrued a statement from
one of Williams’s physicians, Dr. Pasco. Pasco informed Wagner that Williams was capable
of functioning at a sedentary level. Based on his review of Williams’s medical records and
Pasco’s statement, Wagner concluded that Williams could perform work at a sedentary
level with lifting restrictions. Though Pasco later wrote a letter to Hartford to urge that he
did not mean his statements to Wagner “to imply that [Williams] was not disabled,”
Hartford did not abuse its discretion in discontinuing benefits. Pasco’s letter was sent three
years after Hartford’s discontinuance of Williams’s benefits, and Hartford did not rely on
Pasco’s statement alone. Hartford relied on Wagner’s opinion, Williams’s medical records,
and a report from a Hartford rehabilitation expert who concluded that Williams had
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sufficient skills that would allow him to be readily employable with earning equal to his
pre-disability wages. Williams has not demonstrated a genuine issue of fact as to whether
Hartford abused its discretion in discontinuing benefits. See Simoneaux v. Cont’l Cas. Co.,
101 F. App’x 11–12 (5th Cir. 2004) (rejecting a benefits determination challenge because the
determination was rationally connected to the facts in the administrative record).
Williams also argues that summary judgment was error because Hartford
considered neither Williams’s back problems nor a letter from a physician, Dr. Eicke, who
asserted that Williams was unable to perform sedentary work due to mental illness. As to
the back problems, though the evidence was submitted after the benefits discontinuance
decision, we conclude, as did the district court, that Hartford nonetheless considered the
evidence as part of Williams’s appeal with Hartford and determined that it was consistent
with other medical information that Hartford already had reviewed.
Dr. Eicke’s letter was not submitted to Hartford until after Williams’s appeal with
Hartford was denied. The letter, moreover, was not accompanied by any medical records,
and it presented a new basis for disability benefits—Williams originally applied for and
received disability benefits due to physical disability. Under these circumstances, we
cannot say that Hartford abused its discretion in discontinuing benefits. See Vega, 188 F.3d
at 298 (“There is no justifiable basis for placing the burden solely on the administrator to
generate evidence relevant to deciding the claim, which may or may not be available to it,
or which may be more readily available to the claimant.”); Simoneaux, 101 F. App’x at 12
(finding no abuse of discretion where the administrator declined to give overriding weight
4
to medical opinions not supported by objective medical findings).
We also find no merit in Williams’s argument that because a part of the medical
records reviewed by Wagner were illegible, the administrator must have abused his
discretion by discontinuing benefits. Williams’s argument misapprehends Hartford’s
burden. The existence of some unspecified quantity of illegible notes does not render
meaningless the legible medical records, Wagner’s investigation, including phone calls to
Williams’s treating physician, Wagner’s medical evaluation, and the employability
analysis performed by Hartford. There is substantial evidence supporting Hartford’s
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disability determination.
Considering the full record and the parties’ submissions, we hold that the district
court did not err in granting summary judgment in favor of Hartford on Williams’s claim
2
for improper discontinuance of disability benefits.
B. Williams’s requests for remand and additional discovery
1
Hartford declined to defer to the Social Security Administration’s determination
that Williams, an electrician by trade, had no skills transferable to sedentary work, but this
decision does not necessitate reversal. Hartford is not required to defer to a Social Security
ruling. See Horton v. Prudential Ins. Co., 51 F. App’x 928 (5th Cir. 2002) (“[W]hile an
ERISA plan administrator might find a social security disability determination relevant or
persuasive, the plan administrator is not bound by the social security determination.”
(citation omitted)). Hartford, moreover, conducted an employability analysis, the
substance of which Williams has challenged in only a conclusory fashion.
2
As to Hartford’s counterclaim, Williams does not dispute that he is contractually
obligated to refund overpayments. He instead argues that, since Hartford assigned the
collection of the overpayments to a collection agency, Hartford has no standing to pursue
the claim. However, the right to collect the payments and the right to the payments
themselves are distinct. The assignment of collection responsibility alone does not establish
that the right to the overpayments was also assigned.
5
Williams seeks a remand to Hartford for consideration of certain evidence,
including Dr. Pasco’s letter submitted three years after the benefits determination and Dr.
Eicke’s letter regarding Williams’s mental illness. Williams also seeks remand because
portions of the records were illegible and because Dr. Wagner never successfully contacted
two of Williams’s treating physicians, even though the medical records from Williams’s
treatment by those physicians was before Hartford either during Wagner’s initial
evaluation or during the Hartford appeal. We decline to remand on this basis. See Vega,
188 F.3d at 302 n.13 (“We decline to remand to the administrator to allow him to make a
more complete record on this point. We want to encourage each of the parties to make its
record before the case comes to federal court, and to allow . . . another opportunity to make
a record discourages this effort.”).
Williams also seeks review of the district court’s denial of his discovery requests.
Under ERISA, as a general rule, the district court is limited to a review of the
administrative record that existed when reviewed by the administrator. See Estate of
Bratton v. Nat’l Union Fire Ins. Co., 215 F.3d 516, 521 (5th Cir. 2000). There are limited
exceptions to the rule, including exceptions for evidence related to how an administrator
interpreted certain policy provisions and for evidence that assists the district court in
understanding medical terminology. See
id. Williams argues that he should have been
allowed to depose Hartford employees about the disability determination. At issue is a
factual determination of no disability by Hartford, not Hartford’s interpretation of plan
terms. Williams has not explained why his discovery requests fit into the limited
6
exceptions to the administrative record rule. We find no merit in his contentions.
IV. CONCLUSION
The judgment of the district court is AFFIRMED.
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