LARRY R. HICKS, District Judge.
Before the Court is Defendant Hartford Life and Accident Insurance Company's ("Hartford") Motion for Summary Judgment. Doc. # 50.
This is an action for long term disability ("LTD") benefits pursuant to the Employee Retirement and Income Security Act of 1974 ("ERISA"), 29 U.S.C. § 1001 et seq., brought by Hertz against Hartford. The suit stems from Hartford's alleged wrongful termination of Hertz's LTD benefits. Hertz commenced this action on March 15, 2012, after exhausting all administrative remedies required under ERISA. Doc. # 1. On May 9, 2012, Hertz filed a First Amended Complaint ("FAC"). Doc. # 10. On June 27, 2013, Hartford filed the present Motion for Summary Judgment. Doc. # 50. On June 28, 2013, Hertz filed the present Motion for Judgment Under Federal Rule of Civil Procedure 52. Doc. #52.
"In bench trials, [Federal Rule of Civil Procedure] 52(a) requires a court to `find the facts specially and state separately its conclusions of law thereon.'" Vance v. American Hawaii Cruises, Inc., 789 F.2d 790, 792 (9th Cir.1986) (quoting F.R.C.P. 52(a)). The following constitutes the Court's findings of fact based on the Administrative Record ("AR"), the parties' uncontested admissions, and extrinsic evidence submitted with the Motions presently before the Court.
At all relevant times, Hertz was employed by Intuit, Inc. Doc. # 10, ¶ 5; Doc. #11, ¶ 5. As a result of her employment, Hertz was, and continues to be, a participant in The Group Long Term Disability Plan (the "Plan"), an employee welfare benefit plan regulated by ERISA. Doc. #10, ¶ 6; Doc. #11, ¶ 6; AR 000001-50. The Plan designates and names Hartford as the claims fiduciary for benefits provided under the policy. AR 000034, 37.
AR 000020. "Essential Duty" is defined as "a duty that: 1. is substantial, not incidental; 2. is fundamental or inherent to the occupation; and 3. can not be reasonably omitted or changed." AR 000021. The Plan applies a "Your Occupation" definition of "Disability" for the first 24 months. AR 000020. Thereafter, the more stringent "Any Occupation" definition of "Disability" applies. AR 000020. "Any Occupation" is defined as "an occupation for which you are qualified by education, training or experience, and that has an earning potential greater than an amount equal to the lesser of the product of your Indexed Pre-disability Earnings and the Benefit Percentage and the Maximum Monthly Benefit shown in the Schedule of Insurance." AR 000020.
On October 13, 2006, Hertz stopped working as a Customer Service Manager at Intuit, Inc. due to lumbar degenerative disc disease and cervical degenerative disc disease. AR 000069, 561. On March 14, 2007, Hartford approved Hertz's claim for LTD benefits. AR 000051-53. Hartford determined that Hertz's condition, limitations, and restrictions prevented her from performing the material duties of her own sedentary occupation. Doc. # 10, ¶ 29; Doc. #11, ¶ 29. Periodically thereafter, Hartford re-evaluated Hertz's claim and requested supplemental information from her physicians. AR 000494-552, 581, 582.
On June 18, 2007, Hartford informed Hertz that she would be required to apply for Social Security Disability ("SSD") benefits. AR 000055-56. Hertz applied for SSD benefits and the Social Security Administration ("SSA") determined that she was disabled as of October 16, 2006. AR 000057-60. On February 6, 2008, Hertz informed Hartford that she had been awarded SSD Benefits in the amount of $1,064 per month. AR 000541. On February 13, 2008, Hartford informed Hertz
On November 13, 2008, Hartford notified Hertz that the first twenty-four (24) months of her LTD benefits, during which time her "Disability" was evaluated by reference to "Your Occupation," was set to expire on April 21, 2009. AR 000575-576. Hartford further advised Hertz that it would be initiating an investigation to determine if she qualified for LTD benefits under the more stringent "Any Occupation" definition of "Disability." AR 000575-576. Finally, Hartford requested that Hertz and her treating physician complete and return several forms related to her disability. AR 000575-576. On April 10, 2009, Hartford sent a letter to Hertz advising her that she met the "Any Occupation" definition of "Disability" and would continue to qualify for benefits on or after April 21, 2009. AR 000565.
Regularly thereafter, Hartford re-evaluated Hertz's claim and requested supplemental information from her treating physicians. AR 000406-512, 563, 564. These re-evaluations included reports from Hertz's treating family physician Dr. Green, treating neurosurgeon Dr. Morgan, treating neurologist Dr. Quaglieri, treating neurosurgeon Dr. Bigley, and treating Advance Practice Nurse ("APN") Murphy. AR 000406-520. At least until November 2010, the record consistently reflects that Hertz's condition, including diagnoses of cervical degenerative disc disease and lumbar degenerative disc disease, as well as her restrictions and limitations, were medically supported. AR 000406-520. Additionally, in October 2010, Hertz filled out a claimant questionnaire wherein she indicated that she had cramping in both legs making it impossible to walk or stand up at times, and cramping in her arms and legs from sitting for periods of time. AR 000447. She also indicated that in the last eighteen (18) months, her headaches had gotten worse, she had fallen several times because her left leg would not lift up all the way, and that she was experiencing numbness in her hands at most times. AR 000447. Finally, she indicated that she can no longer manage daily walks or exercise due to pain and limited range of motion. AR 000447.
On November 9, 2010, a Hartford examiner called Hertz for an interview, and someone other than Hertz answered the phone, stating that the number was for a business called "Doggie Diner." AR 000512. Hertz was unavailable to speak to the Hartford examiner at that time. AR 000512. Hartford claims that the phone call "raised a reasonable question about whether Hertz was working" and "called into question Hertz's functional capacities." Doc. # 50, ¶¶ 9, 10. Additionally, a database inquiry revealed that Hertz had posted a new menu for "Jim's Old Fashion Doggie Diner" on her Facebook page, that she was listed as the Secretary of the Fallon Lions Club, and that she had a tow truck registered in her name.
On November 22, 2010, Hartford hired HUB Enterprises, Inc. ("HUB")
Because Hartford believed that the above surveillance revealed "inconsistencies" with respect to Hertz's stated level of function, Hertz's file was referred for a face-to-face interview. AR 000506. On February 28, 2011, Hartford Investigator Wayne Spencer conducted an in-person interview with Hertz at a restaurant. AR 000506. Investigator Spencer observed Hertz "to sit for 1 hour and 5 minutes" and "to ambulate with a noticeable limp." AR 000506. Hertz reported to Investigator Spencer the same functional limitations as had been previously documented. AR 000506. She also explained that the Diner "is solely her husbands and he does all of the work however she spends some time there to get out of the house." AR 000506. She further indicated that "her husband had another job and thus 4-5 hours a week [she] goes [sic] to ensure that the business is running properly." AR 000506.
At that time, Hartford also requested and received updated medical records from Dr. Quaglieri, Dr. Morgan, Dr. Green, and APN Murphy. AR 000506-507. On March 25, 2011, Hartford requested updated medical records from Dr. Quaglieri and Dr. Morgan. AR 000321; AR 000393. On April 19, 2011, Hartford requested updated medical records from Dr. Green and APN Murphy. AR 000390. Hartford Investigative Specialist Mari Gaston then referred Hertz's file to Medical Case Manager ("MCM"), Hartford Nurse Johanna Cobb, "to review medical records and investigative material as well as to help clarify [her] current level of function from her treating [physicians]." AR 000506-507. On May 20, 2011, Nurse Cobb performed an initial assessment, reviewing the surveillance video; Investigator Spencer's report from the unrecorded February 28, 2011 interview; medical records from Dr. Morgan through July 6, 2010; medical records from Dr. Quaglieri through July 10, 2010; medical records from APN Murphy through April 25, 2011; and historical Attending Physician Statements ("APS") from Dr. Morgan
On May 24, 2011, Nurse Cobb contacted Dr. Green, requesting clarification of Hertz's current maximum level of function in light of the December 2010 surveillance information and the February 28, 2011 interview. AR 000218. Specifically, she requested his medical opinion "from a Family Practice perspective" as to
AR 000218. On June 15, 2011, Dr. Green responded in the affirmative.
On June 29, 2011, citing medical records and video surveillance that notate a higher level of function, Investigative Specialist Gaston recommended terminating benefits effective July 2, 2011, "as [Hertz] no longer meets the definition of disability." AR 000496. On July 5, 2011, Hartford sent Hertz a letter terminating her LTD benefits, effective July 6, 2011. AR 000077-81. Hartford based its decision to terminate benefits on "all of the documents contained in [Hertz's] file," including but not limited to Hertz's claimant questionnaire, dated January 9, 2010; the aforementioned video surveillance, dated December 7, 8, 22, and 23, 2010; Hertz's "Continuing Statement
On July 10, 2011, Hertz notified Hartford of her intention to appeal Hartford's decision to terminate her LTD benefits. AR 000085-87. Therein, Hertz also contested Hartford's reasons for terminating her benefits. AR 000085-87. On August 26, 2011, Hertz sent another letter, addressed specifically to Investigative Specialist Gaston, informing Hartford of her official request for an appeal. AR 000186. The letter enclosed a Renown Rehabilitation Therapy Evaluation, dated July 18, 2011 (AR 000187-188); a letter from Dr. Green acknowledging his prior statement that Hertz "could have a sedentary job," but stating that upon review of her case, Hertz "is COMPLETELY unable to work in any type of work," dated July 29, 2011 (AR 000189); an office visit report from Dr. Green indicating that "although [Hertz] could do [a sedentary job] for a day or two she could never do this on a daily basis and she is unable to maintain any type of employment due to her disability," and further diagnosing chronic back pain, lumbar spinal stenosis cervical disc disease with myelopathy, lumbar disc disease, depression, neuropathy, and insomnia, dated July 29, 2011 (AR 000190-194); and an Outpatient Referral Form to Neurology (AR 000195). On August 31, 2011, the Appeal Unit at Hartford sent a letter to Hertz confirming receipt of her appeal and informing her that Hartford maintains a separate Appeal Unit for the consideration of claims that have been denied by the Claims Department, and that Appeal Specialist Joye Kelly would be reviewing her claim file and all documents relevant to it. AR 000066. On September 15, 2011, Hertz sent a fax to Investigative Specialist Gaston enclosing her most recent MRI and x-ray results taken on September 8, 2011. AR 000175-180.
On September 13, 2011, Hartford sent a referral to MLS Group of Companies, Inc. ("MLS") with the following instructions:
AR 000180-185. On October 7, 2011, board certified neurologist, Dr. Choon Rim, provided an "independent peer review"
AR 000160. Dr. Morgan, Dr. Green, and Dr. Quaglieri agreed that Hertz's complaints of pain were "mostly subjective in nature," "difficult to assess [in] degree or severity ... without objective findings to indicate any underlying disease process to cause pain," and without "neurologic explanation." AR 000157-159. Nevertheless, Dr. Morgan concluded that Hertz was "totally disabled," and recommended a Functional Capacity Evaluation ("FCE"). AR 000158. Dr. Morgan had last seen Hertz in November of 2010. AR 000153. Dr. Green concluded that Hertz suffered from "a radicular problem that probably makes [her] disabled." AR 000158. Dr. Green also concluded that "from the internal medicine point of view, [Hertz] is capable of doing sedentary work," but that Hertz "is considered unable to work." AR 000158. Dr. Green had last seen Hertz in July of 2011. Dr. Quaglieri did not comment on Hertz's functional capacity, noting that "he is not aware of [Hertz's] current status." AR 000159.
On October 31, 2011, Hartford sent a second referral to MLS specifically requesting additional documentation regarding functional restrictions or limitations and/or discussions with the treating physicians regarding functional restrictions caused by medications. AR 000148-149. On November 7, 2011, Dr. Rim sent an Addendum indicating that he had not spoken to either Dr. Morgan or Dr. Green specifically about functional impairment caused by medication, but that Dr. Quaglieri had indicated "no adverse reaction from medication." AR 000145-146.
On December 8, 2011, Hartford sent a third referral to MLS specifically requesting that Dr. Rim review the additional attached information and advise whether it would change his prior opinion of Ms. Hertz's ability to work. AR000115-116. On December 15, 2011, Dr. Rim sent an Addendum based on updated medical records from Dr. Morgan and Dr. Quaglieri. AR 000109-112. Specifically, Dr. Rim cited medical records from Hertz's October 21, 2011 visit to Dr. Morgan. AR 000110. Dr. Morgan opined that Hertz "could be active up to four hours a day with frequent breaks and she could sit for maximum of one hour, and walk for about 20 minutes, and she could do maybe two days' work out of a week." AR 000110. Dr. Rim also cited medical records from Hertz's October 27, 2011 visit to Dr. Quaglieri, at which
AR 000111. Finally, Dr. Rim maintained his opinion as to Hertz's functional capacity (i.e., her ability to work at a sedentary job on a full-time basis as of 7/01/11). AR 000111. Dr. Rim did not conduct a peer-to-peer review with either Dr. Morgan or Dr. Quaglieri at that time. AR 000109-112.
On January 10, 2012, Appeal Specialist Kelly notified Hertz of Hartford's decision to uphold the termination of her LTD benefits. AR 000069-72. The letter states:
AR 000071. The letter also provides:
AR 000070. The letter references the updated medical records and diagnoses from Dr. Quaglieri without detailing or crediting his clinical findings. AR 000070.
Again, the letter provides the standardized language that Hartford requires when terminating a claim after SSD benefits have been awarded. AR 000071. The letter further explains that, unlike the Social Security Administration ("SSA"), Hartford is not required to give special weight to the opinion(s) of a treating physician, and goes on to state that Hartford generally conducts follow-up disability reviews more frequently than the SSA. AR 000071. While the letter states that Hartford "carefully considered all relevant medical, vocational, and other evidence, including any SSA determinations or materials provided and received and requested at the appeal level," the letter is largely devoid of any specifics as to how or why it reached a different conclusion regarding Hertz's disability status. AR 000071-72. Hartford also advised Hertz that she had exhausted her administrative remedies under ERISA and that she was entitled to bring a civil action under Section 502(a) of ERISA. AR 000071. The present action ensued.
Where, as here, an ERISA plan confers discretion upon a plan administrator
However, it is undisputed in this case that, as an entity that both determines eligibility for benefits and pays benefit awards, Hartford operates under a "structural conflict of interest." See Abatie, 458 F.3d at 965 ("an insurer that acts as both the plan administrator and the funding source for benefits operates under what may be termed a structural conflict of interest"). Under these circumstances, "[s]imply construing the terms of the underlying plan and scanning the record for medical evidence supporting the plan administrator's decision is not enough, because a reviewing court must take into account the administrator's conflict of interest as a factor in the analysis." Montour v. Hartford Life & Acc. Ins. Co., 588 F.3d 623, 630 (9th Cir.2009). As such, the Court "must weigh the conflict as a factor in determining whether there is an abuse of discretion." Nolan, 551 F.3d at 1153 (quoting Metro. Life Ins. Co. v. Glenn, 554 U.S. 105, 111, 128 S.Ct. 2343, 171 L.Ed.2d 299 (2008)) (internal quotation marks omitted); but see Salomaa, 642 F.3d at 674 (explaining that while a conflict of interest must be weighed as a factor, it does not have the effect of converting abuse of discretion review into de novo review).
"[T]he extent to which a conflict of interest appears to have motivated an administrator's decision is one among potentially many relevant factors that must be considered." Montour, 588 F.3d at 630. "Other factors that frequently arise in the ERISA context include the quantity and quality of the medical evidence, whether the plan administrator subjected the claimant to an in-person medical evaluation or relied instead on a paper review of the claimant's existing medical records, whether the administrator provided its independent experts with all of the relevant evidence, and whether the administrator considered a contrary SSA disability determination, if any." Id. (internal quotation marks omitted). The weight assigned to the conflict factor, as well as "the level of skepticism with which it reviews a potentially biased plan administrator's explanation for its decision," depend on the facts and circumstances of each particular case. Id. at 630-31; see also Nolan, 551 F.3d at 1153 (in weighing a conflict of interest, the court may "consider evidence outside the administrative record to decide the conflict's nature, extent, and effect on the decisionmaking process") (internal quotation marks omitted). "If [the] facts and circumstances indicate the conflict may have tainted the entire administrative decision-making [sic] process, the court should review the administrator's stated bases for its decision with enhanced skepticism: this is functionally equivalent to
The Court is keenly aware of the conflicting standards under which the parties have brought their respective Motions. In an ERISA case, such as this, the Ninth Circuit has held that "a motion for summary judgment is merely the conduit to bring the legal question before the district court and the usual tests of summary judgment, such as whether a genuine dispute of material fact exists, do not apply." Bendixen v. Standard Ins. Co., 185 F.3d 939, 942 (9th Cir.1999). However, "Bendixen predated Abatie and its requirement that any conflict [of interest] always be considered[.]" Nolan, 551 F.3d at 1154. Rather, it "applied an abuse of discretion standard untempered in any way, and did not involve a case where the district court examined evidence outside of the administrative record." Id. Whereas here, a court must consider evidence outside of the administrative record, namely evidence related to an alleged conflict of interest, the traditional rules of summary judgment apply (e.g., the requirement that evidence be viewed in the light most favorable to the non-moving party). See id. (finding error where the district court weighed the documentary evidence of bias and ignored the protections that summary judgment usually affords the non-moving party, but also noting that the district court could have properly weighed such evidence after a bench trial). Because a bench trial will ensure that the Court has an opportunity to conduct a full conflict of interest inquiry and weigh such evidence in determining the precise contours of the abuse of discretion standard, the Court finds that judgment on the merits pursuant to Federal Rule of Civil Procedure 52 is the appropriate standard under which to review Hartford's decision to terminate Hertz' LTD benefits.
While Hartford acknowledges that there is structural conflict of interest, it disputes the extent to which the Court should consider it as a factor in determining whether it abused its discretion in denying Hertz's LTD benefits. Indeed, the weight given to a conflict of interest will be less important, "perhaps to the vanishing point," where the claims administrator "has taken active steps to reduce potential bias and to promote accuracy." Glenn, 554 U.S. at 117, 128 S.Ct. 2343. Such steps include separating claim examiners from those interested in the company's finances, evaluating employees without consideration of numbers of claims approved or denied, imposing management checks to penalize inaccurate decision making, providing each claimant with an individualized and independent review, and separating the appeals unit form those who make initial claims determinations. See id.
Hartford contends that because it took active steps to minimize its conflict, the conflict should not weigh heavily in the Court's analysis. In support thereof, Hartford submitted a Declaration by Bruce Luddy, Director of Litigation and
Here, Hartford's failure to disclose Luddy as a potential witness or as someone with relevant knowledge is neither harmless nor justified. See Langston v. N. Am. Asset Dev. Corp., No. C 08-02560 SI, 2009 WL 941763, at *6 (N.D.Cal. April 6, 2009) (disregarding Luddy's declaration in its analysis of Hartford's structural conflict where Hartford's failure to disclose Luddy as a potential witness was neither justified nor harmless). Hartford's contention that its failure to disclose Luddy was harmless and not prejudicial because it disclosed as a potential witness the "Person Most Knowledgeable at Hartford" is entirely unavailing. See Doc. # 58, p. 9. Had Hertz known that Hartford planned to introduce evidence of the measures it had taken to mitigate its structural conflict of interest, Hertz could have propounded discovery on that issue and could have deposed Luddy. Moreover, in light of Hartford's repeated reliance on an affidavit or declaration of Luddy to evidence the minimization of its conflict of interest in a number of cases since Glenn in 2008,
Nevertheless, even if the Court were to consider Luddy's declaration that "Hartford does not provide Investigative Specialists, Claims Specialists, or Appeals Specialists with incentives, remuneration, bonuses, awards, achievements or other recognition based in whole or in part upon the denial or termination of claims," the Court finds that there is significant evidence that undermines his claim. Hertz presented evidence that, even if Hartford does not explicitly tie administrators' remuneration to denial or termination of claims, its employees are acutely aware that Hartford evaluates them on that basis. Specifically, Hertz proffered evidence that Hartford evaluates its employees according to their ability to deny and terminate claims. See Doc. # 52, Ex. 8 (commending employee for "striving to eliminate non-standard claim files"). Additionally, Investigative Specialist Gaston, who terminated Hertz's claim, was specifically evaluated on her ability to close claims. See Doc. # 57, Ex. 3, p. 0001 (remarking that "[Gaston] maintained a very high case intake and closed a high number of total cases, while demonstrating a solid overall level of Case quality"). Hertz also proffered evidence that Hartford evaluates its employees on how frequently they make referrals to SIU. See
Likewise, even if the Court were to consider Luddy's declaration that "the individual responsible for the appeal does not discuss the merits of the claim with the Investigative Specialist who makes the initial benefits determination, or the Claim Specialist who approved the determination," Hertz presented evidence that Hartford's appeal unit is not entirely "walled off" from those individuals that made the initial claim determination. First, Kelly, the Appeal Specialist assigned to handle Hertz's appeal, works in the very same office as Gaston, the Investigative Specialist assigned to handle Hertz's initial claim determination. See e.g., AR 000068, 171 (documenting the fact that both Kelly and Gaston work in the Maitland, Florida Office). Second, Luddy is employed by Hartford in Connecticut, and thus has no personal knowledge as to whether the above-mentioned policy is faithfully observed. See Doc. # 50, Ex. A, ¶ 2. Thus, even if Hartford has such a policy in place, as Luddy declares, the Court is somewhat skeptical about the extent to which the said policy is implemented in practice. In light of the aforementioned evidence, the Court concludes that even if Hartford adopted policies and procedures to reduce the impact of its structural conflict of interest, they do not effectively eliminate the existence of the conflict. See Bender, 2011 WL 3566483, at *12 (concluding that even where Luddy's declaration demonstrates that Hartford has taken steps to reduce bias and promote accuracy, "such procedures do not serve to wholly eliminate the existence of conflict").
In Caplan v. CNA Financial Corporation, the district court looked not only to Hartford's conflict of interest, but also considered Hartford's reliance on vendors it knew benefitted financially from repeat business. 544 F.Supp.2d 984, 991-93 (N.D.Cal.2008). The court noted that Hartford knew that the vendors had "an incentive to provide it with reports that [would] increase the chances that Hartford [would] return to [them] in the future — in other words, reports upon which Hartford may rely in justifying its decision to deny benefits to a plan participant." Id. at 991-92. Similarly, here, the Court finds that Hartford relied on vendors — namely HUB and MLS — that it knew had an incentive to provide it with reports in favor of terminating Hertz's LTD benefits.
As to HUB, the Central District of California recently found that "HUB has strong financial ties" to Hartford. Kurth v. Hartford Life and Acc. Ins. Co., 845 F.Supp.2d 1087, 1097 (C.D.Cal.2012). Here, Hartford does not dispute that HUB has strong financial ties to Hartford. As such, the Court finds it at least plausible that these financial ties incentivized HUB to record those portions of Hertz's activity that most convincingly portrayed her as a
Likewise, the nature of Hartford's relationship with MLS and their reviewing physicians creates an incentive for MLS to reach results that are favorable to Hartford in order to foster and sustain their business relationship. Significantly, between January 2010 and November 6, 2012, MLS conducted 752 medical reviews for Hartford. See Doc. # 52, Ex. 2 at 4:15-20. In a sampling of 75 of those medical reviews, only four (4) were determined to be completely unable to work. Doc. # 52, Ex. 3 at 4:4-6. Accordingly, MLS found that approximately 95% of all claimants could perform some type of work. During that same time frame, Dr. Rim reviewed fourteen (14) claims for Hartford. Doc. # 52, Ex. 4 at 2:24-25. Significantly, of those fourteen (14) claims reviewed, Dr. Rim did not find that a single claimant was completely unable to perform any type of work. Doc. # 52, Ex. 4 at 3:20-22. Accordingly, Dr. Rim found that 100% of all claimants could perform some type of work. The Court finds these statistics strongly suggest that both MLS and Dr. Rim harbored a significant bias towards finding a claimant capable of performing some type of work. See Montour, 588 F.3d at 634 (noting relevance of statistics regarding Hartford's rate of claims denials or how frequently it contracts with the file reviewers it employed in that case to the issue of bias).
In sum, Hartford's own structural conflict of interest, as well as its reliance on biased vendors, persuade the Court to review Hartford's decision to terminate Hertz's LTD benefits with significant skepticism. Moreover, it can be reasonably inferred from the following circumstances that Hartford's bias infiltrated the entire administrative decision-making process.
Like the district court in Montour, the Court finds that throughout the
Also detrimental to Hartford's conclusion that Hertz's "observed activities of daily living [] provide[d] a picture of function in spite of any medical condition(s)" is the fact that the surveillance video does not in fact amount to a picture of function sufficient to support the conclusion that Hertz is capable of doing full-time sedentary work. Moreover, contrary to Hartford's assertion that the surveillance video depicted "inconsistencies with respect to [Hertz's] current level of function," the Court finds that the surveillance video evidences a level of function that is entirely consistent with Hertz's own self-reported limitations. See AR 000287-289 (Hertz admitting that she could independently and without the use of special equipment walk slowly for 15-20 minutes; stand for 15-20 minutes; perform all of her own shopping; lift and carry items weighing between 5 and 10 pounds; push and pull things that require slight resistance; reach to her front, sides, and below her waist; walk up and down stairs and steps using a handrail; write and type for 3-5 minutes; read without restriction; drive short distances in her community; sit for approximately 20-30 minutes at a time; and dress and perform her own personal hygiene). Moreover, the video surveillance is entirely consistent with Dr. Morgan's characterization of her level of function. See AR 000110 (opining that Hertz "could be active up to four hours a day with frequent breaks and she could sit for [a] maximum of one hour, and walk for about 20 minutes, and she could do maybe two days' work out of a week").
Furthermore, the Court finds that Hartford's over-reliance on the skewed surveillance video and accompanying report infiltrated the whole claims review process. First, Hartford Nurse Cobb, who did not evaluate Hertz in person, overstated the extent to which the surveillance video evidenced Hertz's level of function. Specifically, Nurse Cobb noted that "[s]he did not display any noticeable limitations or restrictions." AR 000502. Moreover, Nurse Cobb noted that "[Hertz] was observed up to 6 hours in 1 day at Doggie Diner." AR 000502. These "observations," however, are problematic because they mischaracterize the value of the surveillance. First, HUB only obtained one minute and thirteen seconds of video on that date. See AR 000304. Second, HUB's accompanying
Second, the Court finds that Hartford's initial attempt to obtain Dr. Green's family practice perspective as to Hertz's maximum level of function was "marred by this overstatement of the surveillance findings, as well as the apparent advocacy of the position that [Hertz] was not disabled." Montour, 588 F.3d at 633; AR 000218. In response to the letter, Dr. Green checked a box, agreeing that "from a Family Practice perspective" Hertz had the ability to engage in full-time sedentary work. AR 000218. First, the fact that Hartford couched its inquiry in terms of a "Family Practice perspective" indicates that Hartford did not want Dr. Green to consider Hertz's neurological condition in making his determination. Second, as a family physician, Dr. Green is apparently less familiar with Hertz's neurological condition and was perhaps more apt to be swayed by Hartford's slanted presentation of the facts via the surveillance video.
Finally, the fact that Dr. Rim relied on the surveillance video to assess Hertz's functionality instead of conducting an in-person evaluation is troubling. Given that he also only reviewed the eleven-minute video segment and HUB's accompanying report, the Court finds his assessment that Hertz engaged in "various activities ... quite normally" to be equally unpersuasive. See AR 000157 (reviewing the surveillance video and report provided by Hartford).
Although Hartford was not required to accord special weight to the opinions of Hertz's treating physicians, the Court finds that it was improper for Hartford to discredit Dr. Morgan, Dr. Green, and Dr. Quaglieri's opinions regarding Hertz's diagnoses and functional capacity in the absence of reliable evidence to the contrary. See Black & Decker Disability Plan v. Nord, 538 U.S. 822, 834, 123 S.Ct. 1965, 155 L.Ed.2d 1034 (2003) (holding that while "courts have no warrant to require administrators automatically to accord special weight to the opinions of a claimant's physician," "Plan administrators, of course, may not arbitrarily refuse to credit a claimant's reliable evidence, including the opinions of a treating physician"). Here, the record clearly demonstrates that Hartford and Dr. Rim gave only minimal consideration, if that, to Dr. Morgan, Dr. Green, and Dr. Quaglieri's medical opinions. Specifically, neither Hartford nor Dr. Rim ever indicated whether Dr. Green's diagnoses of chronic back pain, lumbar spinal stenosis, cervical disc disease with myelopathy, lumbar disc disease, depression, neuropathy, and insomnia, and Dr. Quaglieri's diagnoses of chronic pain syndrome and chronic bilateral radiculopathies were correct. Nor did they opine as to whether or to what extent those diagnoses would affect Hertz's functional limitations. Moreover, despite their brief mention in the appeal letter, Hartford appears not to have considered Dr. Quaglieri's updated records with objective findings of Hertz's impairment to any significant degree.
Rather, Dr. Rim simply concluded that Hertz was capable of performing full-time sedentary work because her pain symptoms could not be "objectively assessed except for regular chronic lumbosacral radiculopathy with minimal objective findings to support this." AR 000111. Similarly, Hartford cited the absence of "any
Here, Hartford's denial of benefits on appeal was based primarily on Dr. Rim's report, which found only minimal objective evidence to support Hertz's subjective complaints of pain. However, Hartford's apparent objective evidence requirement is inconsistent with the terms of the Plan, which never details such a requirement. See AR 000018 (stating only that Hartford "reserves the right to determine if your proof of loss is satisfactory"). Thus, contrary to Hartford's assertion in its Motion for Summary Judgment, a claimant is not required to give objective proof in order to prove disability. See Doc. # 50, p. 21 (arguing that "[i]n order to prove disability, a claimant must give objective proof that they are disabled, for `the very concept of proof connotes objectivity'") (quoting Maniatty v. UNUM Provident Corp., 218 F.Supp.2d 500, 504 (S.D.N.Y.2002)). In Mitchell v. Metropolitan Life Insurance Company, the district court found that an administrator cannot deny a claim based upon a lack of objective evidence where that standard was not expressly articulated in the Plan, even where the Plan conferred discretion upon the administrator to determine eligibility for benefits. 523 F.Supp.2d 1132, 1146 (C.D.Cal.2007) (citing Canseco v. Constr. Laborers Pension Trust for So. Cal., 93 F.3d 600, 608 (9th Cir.1996) (holding that administrators "may not construe a plan so as to impose an additional requirement for eligibility that clashes with the terms of the plan")). The Ninth Circuit agreed that the Plan administrator had abused is discretion in denying the claimant's disability claim "on the basis of `an unwritten and unexplained objective evidence requirement' not specified within its policy." Mitchell v. CB Richard Ellis Long Term Disability Plan, 611 F.3d 1192, 1199 (9th Cir.2010) (internal citations omitted). Because there is no explicit, or even implicit requirement that a claimant produce objective proof of his or her disability, the Court finds that it was improper for Hartford to base its denial of benefits on Dr. Rim's assessment that there was only minimal objective evidence to support Hertz's claims of chronic pain.
Even more problematic is the fact that Hartford's own Claims Manual further recognizes that "[s]ubjective complaints frequently contribute to an individual's functional status and we must also take these complaints into consideration when evaluating a claim for disability benefits." Doc. # 52, Ex. 1, p. 0001247, 1384. Likewise, the APS that Hartford sent to Hertz's treating physicians asked them specifically to identify "Current Subjective Symptoms." AR 000408. Thus, Hartford's obvious disregard for Hertz's subjective complaints of pain is contrary to its own internal policy. Finally, this is not a case in which Hertz's "significant subjective complaints" are "grossly disproportionate"
Hartford's insistence on objective evidence is also problematic because medical conditions such as chronic pain syndrome may not be amenable to objective verification. See, e.g., Saffon v. Wells Fargo & Co. Long Term Disability Plan, 522 F.3d 863, 872-73 (9th Cir.2008) (holding that "individual reactions to pain are subjective and not easily determined by reference to objective measurements"). Here, Hartford and Dr. Rim failed to discuss whether or to what extent Hertz's self-reported symptoms were disabling. Instead, Hartford and Dr. Rim discredited and dismissed Hertz's subjective evidence of pain without explanation. Dr. Rim noted some restrictions and limitations, but concluded that Hertz's "sitting is unrestricted." AR 000160. In the appeal letter, Hartford conceded that Hertz "may have ongoing chronic pain symptoms," but concluded that she did not "have any functional impairment that would preclude [her] from performing alternative sedentary work activity." AR 000071. However, these assessments are directly in conflict with Hertz's subjective complaints of pain and her physicians' functional assessment thereof.
If Hartford had serious doubts about the physical limitations imposed by Hertz's symptoms (i.e., doubts about Hertz's subjective reports of pain and her treating physicians' functional assessments), it should have sought an in-person medical evaluation (IME) or an independent functional capacity evaluation (FCE). The Court addresses Hartford's failure to obtain an IME or FCE in greater detail in the following section. Alternatively, if Hartford felt that the medical records were insufficient to verify Hertz's disability, it was incumbent upon Hartford to inform Hertz of the deficiency so that she might proffer any additional needed documentation. See Montour, 588 F.3d at 635 (finding that where the record is insufficient to make a disability determination, the plan administrator has a duty to inform the claimant of the deficient record and provide an opportunity to furnish the missing information). However, Hartford never offered any guidance as to what type of "objective" evidence would be sufficient to corroborate Hertz's subjective complaints of pain.
Finally, the Court disagrees with Dr. Rim's assessment that there was only minimal objective medical data to support Hertz's alleged pain levels. In Montour, the Ninth Circuit found that "[i]t would probably have been unreasonable for Hartford to require the claimant to produce objective proof of his pain level, per [his treating physician], or to reject his subjective claims of `excess pain' based solely on [his reviewing physician's] observation." 588 F.3d at 635. However, the Ninth Circuit went on to conclude that evidence of the claimant's relatively mild pain medication and lack of engagement in any pain treatment programs was sufficient "objective" evidence to support the conclusion that the claimant's pain did not rise to a level of disabling pain. Id. In contrast here, there is ample "objective" evidence in the record to substantiate Hertz's claims of disabling pain. See AR 000191-193 (Dr. Green listing current patient prescriptions, including Gabapentin up to 6 times per day for pain, Norco 4-5 times daily for pain and "occasionally she has had to take 1½ meds at a time," and Baclofen to minimize the number of severe spasms); see also AR 000190 (Dr. Green noting hospitalization for severe spasm episode, during which patient received "IV
Lastly, but of equal significance, is the fact that Hartford previously determined that Hertz was disabled and paid her LTD benefits until July 2010 on the basis of the same allegedly non-objective medical evidence. See Kurth, 845 F.Supp.2d at 1101 (finding abuse of discretion where administrator failed to explain why a treating physician's diagnosis was sufficient to grant benefits for a time but was completely unacceptable once the investigation began). Here, Hartford terminated Hertz's benefits without any showing that her condition had materially improved. Rather, the only change appears to be the extent to which Hartford credited Hertz's medical evidence. There is simply no indication as to why her treating physician diagnoses and functionality assessments were sufficient to grant her LTD benefits for a time, but were no longer acceptable once her case had been referred to SIU.
According to the unequivocal language in the Plan, Hartford may conduct an IME to determine disability. See AR 000018. Likewise, the Hartford Claims Manual specifically provides that "[i]f the claimant's [attending physician(s)] continue to support the claimant's disability status, an IME or FCE should be arranged." Doc. # 52, Ex. 1, Hartford 0000523. The Hartford Claims Manual also provides that an IME, FCE, or independent medical review of the records "must be done in order to make a claim determination ... [w]hen, the limitations noted by the attending physician remain inconsistent with diagnostic study results or medical records, and/or... to resolve legitimate conflicting opinions between the claimant's treating/examining physicians and our own MCM staff." Doc. # 52, Ex. 1, Hartford 0001248.
Here, instead of arranging for an FCE, as recommended by Dr. Morgan, or conducting an IME to ensure an accurate assessment of Hertz's functional capacity, Appeal Specialist Kelly relied on the eleven-minute surveillance video that supposedly depicted Hertz engaging in "activities of daily living which provide[d] a picture of function in spite of any medical condition(s)," and Dr. Rim's identical assessment of the same. AR 000072. Similarly, Dr. Rim did not examine or even speak to Hertz in rendering his opinions. Indeed, "the fact that a video surveillance was conducted in lieu of an IME raises legitimate questions concerning the thoroughness of the investigation." Kurth, 845 F.Supp.2d at 1097 (citing Calvert v. Firstar Fin., Inc., 409 F.3d 286, 295 (6th Cir. 2005) (holding that the failure to conduct a physical examination may, in some cases, raise questions about the thoroughness and accuracy of the benefits determination)). Here, the absence of an FCE or IME is even more troubling in light of the fact that both Dr. Morgan and Dr. Green, the only two physicians who had evaluated Hertz's functional capacity in person in the latter part of 2011, strongly opined that she was not capable of doing any type of full-time work due to chronic pain. While the Court recognizes that there is nothing procedurally improper about the use of surveillance, an FCE or IME certainly "would have yielded [] a more complete assessment of [Hertz's] capacity and limitations." Kurth, 845 F.Supp.2d at 1097; Salomaa, 642 F.3d at 674 (noting that "[a]n insurance company may choose to avoid an [IME] because of the risk that
Here, while Dr. Rim stated that "[a]ll records provided by The Hartford were reviewed[,]" there is no indication as to whether he was provided with or whether he reviewed the SSA's contrary disability determination. See Montour, 588 F.3d at 634 (Hartford's professional experts only mentioned the SSA's contrary conclusion, "not even to discount or disagree with it, which indicates that [they] may not even have been aware of it") (internal quotation marks omitted). Because the record is entirely devoid of any documentation related to the SSA's determination of disability, and because Dr. Rim did not specifically cite to any SSA records in his written review, the Court shall infer that he was not provided with such documentation.
Finally, the Court considers Hartford's failure to discuss the SSA's disability determination. The letter denying Hertz's appeal merely pays lip service to the existence of a contrary SSA disability determination and further explains two discrete differences between the SSA and Hartford's review process. However, it did not discuss, cite to, or weigh the findings by the SSA or differentiate those findings from Hartford's determination to deny benefits. "Ordinarily, a proper acknowledgment of a contrary SSA disability determination would entail comparing and contrasting not just the definitions employed but also the medical evidence upon which the decisionmakers relied." Id. at 636. As previously noted, the record does not contain the opinion of the SSA administrative law judge or the SSA administrative record, as was also the case in Montour. Accordingly, the Court finds that the record was insufficient to properly consider and discuss the SSA's differing disability determination. See id. (finding that where the record is insufficient to make a disability determination, the plan administrator has a duty to inform the claimant of the deficient record and provide an opportunity to furnish the missing information).
"While ERISA plan administrators are not bound by the SSA's determination, complete disregard for a contrary conclusion without so much as an explanation raises questions about whether an adverse benefits determination was `the product of a principled and deliberative reasoning process.'" Montour, 588 F.3d at 635 (citing Glenn v. MetLife, 461 F.3d 660, 674 (6th Cir.2006), aff'd by Glenn, 554 U.S. 105, 128 S.Ct. 2343). Here, there is certainly evidence that Hartford's adverse benefits determination was the product of a principled and deliberative reasoning process. Specifically, that Hartford did not distinguish between its own disability determination and that of the SSA is significant because the SSA employs a more stringent standard for determining disability than does the governing ERISA Plan. In Montour, the Ninth Circuit compared the very same definition of "disability" under the Plan at issue with the SSA's definition
Weighing all of the aforementioned factors together, the Court concludes that Hartford's conflict of interest improperly motivated its decision to terminate Hertz's LTD benefits. This constituted an abuse of its administrative discretion under ERISA. Accordingly, Hartford shall reinstate Hertz's LTD benefits in accordance with this Order and the terms of the Plan until such time as the administrator properly terminates said benefits according to the Plan's provisions. See Pannebecker v. Liberty Life Assur. Co. of Boston, 542 F.3d 1213, 1221 (9th Cir.2008) (ERISA benefits may be reinstated if the claimant would have continued receiving benefits absent the administrator's wrongful conduct). Additionally, Hartford shall pay Hertz back benefits equal to the amount she would have received had Hartford not improperly terminated her benefits on July 5, 2011.
IT IS THEREFORE ORDERED that Hertz's Motion for Judgment Under FRCP 52 (Doc. # 52) is GRANTED.
IT IS FURTHER ORDERED that Hartford's Motion for Summary Judgment (Doc. # 50) is DENIED.
IT IS FURTHER ORDERED that Hartford shall reinstate Hertz's LTD benefits in accordance with this Order and the terms of the Plan.
IT IS FURTHER ORDERED that Hartford shall pay Hertz back benefits from the date on which her LTD benefits were terminated, including pre- and post-judgment interest.
IT IS FURTHER ORDERED that Hertz shall seek an Order awarding attorney's fees and costs in accordance with Local Rule 54-16.
IT IS SO ORDERED.
