JOSE E. MARTINEZ, District Judge.
THIS CAUSE came before the Court upon Plaintiffs Motion for Summary Judgment (D.E. No. 85) and Defendant's Motion for Summary Judgment (D.E. No. 77). Plaintiff Ramses Vivas ("Vivas" or "Plaintiff") participated in an employee benefit plan funded by a group insurance policy (the "Policy") that Defendant Hartford Life and Accident Insurance Company ("Hartford" or "Defendant") issued to his employer, Kendall Imports. (D.E. No. 77 at 111; D.E. No. 84 at 111). Plaintiff seeks to overturn Defendant's decision to discontinue payment of his long-term disability ("LTD") benefits, and moves for summary judgment on the basis that Defendant's decision to uphold termination of Plaintiff's LTD benefits was de novo wrong and manifestly unreasonable. Defendant asserts that the complete administrative record
This is an action to recover LTD benefits under the Employee Retirement Income Security Act of 1974, 29 U.S.C. § 1101, et seq. ("ERISA"). Plaintiff was employed as the director of information technology for Kendall Imports at all material times (D.E. No. 86 at ¶ 1), and he participated in an employee benefit plan funded by a group insurance policy that Hartford issued to his employer. (D.E. No. 77 at ¶ 1; D.E. No. 84 at ¶ 1). Plaintiff ceased working for Kendall Imports in February 2007. (D.E. No. 77 at ¶ 5; D.E. No. 86 at ¶ 15). Shortly thereafter, on March 9, 2007, he received a separation agreement confirming his release from employment. (AR at H555; D.E. No. 86 at ¶ 15). In February 2007, Plaintiff applied for short-term disability benefits ("STD") (D.E. No. 77 at ¶ 5), which Hartford initially denied. (AR at H382-83; D.E. No. 86 at ¶ 15). In connection with his STD claim, Plaintiff submitted a letter to Hartford on April 25, 2007, stating that he suffers from severe osteoporosis and is "unable to perform [his] job ... [because] the pain is constant." (AR at H343). Also on April 25, 2007, Plaintiff's physician, Jose J. Aldrich, M.D. ("Dr. Aldrich"), a rheumatologist, submitted a letter stating that he has treated Plaintiff for a "severe case of osteoporosis since August 2005" and that his condition has worsened to the point that he recommends Plaintiff "stop working because of the possibility of bone fracture." (AR at H345; D.E. No. 86 at ¶ 16). Plaintiff appealed Hartford's denial of STD benefits (AR at H298-99; D.E. No. 86 at ¶ 17) and, on July 31, 2007, Hartford reversed its initial decision, finding Vivas totally disabled for the period of February 28, 2007 through the duration of his eligibility for STD benefits. (AR at H278). On August 2, 2007, Hartford confirmed that Plaintiff's STD benefits would last through September 4, 2007.
In August 2007, Vivas submitted a claim for LTD benefits. (AR at H213-16; D.E. No. 77 at ¶ 5; D.E. No. 84 at ¶ 5). In support of this claim, Dr. Aldrich submitted an Attending Physician's Statement of Disability, reflecting a primary diagnosis of severe osteoporosis, a secondary diagnosis of vertebral compression fracture, and subjective symptoms of back pain. (AR at H224-25). Dr. Aldrich indicated that Plaintiff would have unspecified lifelong limitations regarding certain physical activities (e.g., standing, walking, lifting/carrying; reaching/working overhead; pushing; pulling; driving; keyboard use/repetitive hand motion). Id. at H225. On September 11, 2007, Hartford approved Plaintiffs claim for LTD benefits, with benefits effective as of September 5, 2007. (AR at ¶ 198-201; D.E. No. 77 at ¶ 8; D.E. No. 84 at ¶ 8). Pursuant to the terms of the Policy, benefits were payable for the first 24 months while Plaintiff met the definition of "Disability" as related to his own occupation. (AR at H198). Thereafter, Plaintiff was only entitled to benefits if Hartford determined that he could not perform one or more of the essential duties of any occupation. (AR at H199; D.E. No. 86 at ¶ 20).
(AR at H705-06; see also D.E. No. 33, Notice of Filing Surveillance Discs). Dr. Knapp further stated that:
(AR at H708).
On July 20, 2009, Hartford completed its review of Plaintiff's claim for LTD benefits,
(AR at H496). Plaintiff appealed the benefits termination decision. (D.E. No. 77 at 1122; D.E. No. 86 at 1122). To assist in Hartford's consideration of Plaintiff's appeal, Vicki Kalen, M.D. ("Dr. Kalen"), a physician Board Certified in Orthopedic Surgery, reviewed Plaintiffs medical records. (AR at H669-70; D.E. No. 77 at 1123). Dr. Kalen determined:
(AR at H671) (emphasis added). Dr. Kalen further found that:
Id. After reviewing Dr. Kalen's report, Defendant reversed the benefits termination decision on the basis that Plaintiffs own occupation was medium-level, and neither Dr. Kalen nor Dr. Aldrich deemed Plaintiff capable of medium-level work.
Subsequently, Defendant performed an Employability Analysis using the Occupational Access System program to identify a representative sample of two occupations, recognized by the United States Department of Labor's Dictionary of Occupational Titles ("DOT"), that were within the capabilities described by Dr. Kalen and also within the appropriate wage range. (AR at H652-53; D.E. No. 77 at ¶ 27). The results of the Employability Analysis identified three occupations within the closest match, including computer security specialist and reworker, printed circuit board. (AR at H653). Accordingly, on November 5, 2009, Defendant notified Plaintiff that he no longer met the Policy's definition of "Disability" that became applicable to his claim effective September 5, 2009 (i.e., "totally disabled"). (AR at H484). Defendant specified that, "Based on the response from Dr. Knapp and Dr. Kalen, as well as the investigative documentation obtained, the weight of the evidence in [Plaintiffs] file support[ed] that [he was] physically capable of performing full-time work with the opportunity to sit/stand frequently and never lift more than 20 pounds." (AR at H489). Ultimately, because Defendant concluded that Vivas was not prevented from performing the essential duties of any occupation, Hartford terminated his LTD benefits, and no benefits were payable beyond September 4, 2009. (AR at H490; D.E. No. 77 at 28). In a letter dated March 8, 2010, Plaintiff again appealed Hartford's decision. (AR at H569-70; D.E. No. 77 at ¶ 29; D.E. No. 86 at ¶ 23). In connection with his appeal, Plaintiff submitted a letter from Dr. Aldrich stating:
(AR at H564).
On April 7, 2010, Hartford notified Plaintiff that it was upholding its decision to terminate his LTD benefits. (AR at H478-81; D.E. No. 77 at ¶ 31; D.E. No. 86 at ¶ 26). Defendant noted that Dr. Aldrich's letter "did not provide any evidence or suggestion of further worsening of [Plaintiffs] osteoporosis, and did not make any recommendations for additional functional limitations or restrictions." (AR at H480; D.E. No. 77 at ¶ 34). On February 8, 2011, Plaintiff received a notice of a favorable disability determination by the Social Security Administration ("SSA"), finding Vivas disabled as of February 25, 2007 "because [his] impairment or combination of impairments is so severe that [he] cannot perform any work existing in significant numbers in the national economy." (AR at H1284; D.E. No. 86 at ¶ 27).
Plaintiff filed suit against Defendant in state court, and the case was removed to this Court pursuant to 28 U.S.C. §§ 1331 and 1441. (D.E. No. 1). In his Second
In October 2012, Dr. Siegel, Hartford's independent medical reviewer, was instructed to provide the recommendation he felt the overall documentation best supported. (AR at H1437; D.E. No. 86 at ¶ 29). Dr. Siegel issued a Medical Record Review of Ramses Vivas on December 6, 2012. (AR at H1262). In pertinent part, Dr. Siegel found Vivas's alleged physical restrictions and physical limitations "far overstated." Id. at 1273. Summarizing his overall findings, Dr. Siegel found that "Vivas should have been physical [sic] capable of performing regular, full-time, work duties without specific physical restrictions or physical limitations as of 9/5/09" based on the totality of the information reviewed. Id. at 1274. Pursuant to this Court's Order, Hartford's Appeal Unit reviewed Vivas's file separately from the individuals who made the original decision to terminate benefits, with no deference to that decision. (AR at H1250). In coming to its final decision that no benefits were payable beyond September 4, 2009, Hartford considered the following information:
(AR at H1250). Additionally, Hartford explicitly indicated that it considered the fact that Vivas was approved for Social Security Disability ("SSD") benefits, but noted that "it is possible to qualify for SSD, but no longer continue to qualify for private LTD benefits from [Hartford]." Id. at 1251. Hartford explained that while it considered the SSA's disability determination as one piece of relevant evidence, it is not conclusive because "[t]he standards governing receipt of these public and private benefits are different in critical ways." Id. Ultimately, Hartford found that the preponderance of the evidence established that as of September 5, 2009, Plaintiff had the functional capacity to perform the Essential Duties of Any Occupation as defined by the Policy. As such, he did not satisfy the definition of Disability applicable
Thereafter, this Court granted Plaintiff's Unopposed Motion to Reopen (D.E., No. 70) based on Defendant's final determination as to Plaintiffs claim. (D.E. No. 76). The Court reopened the matter in order to determine the propriety of Defendant's most recent denial decision. (D.E. No. 76 at 1). The parties thereafter filed their respective motions for summary judgment, which the Court considers herein.
The Policy expressly grants discretionary authority to Defendant in making benefits determinations. (AR
The Policy provides that payment of LTD benefits will terminate when a claimant is no longer disabled or fails to furnish requested proof of continuing disability. (AR at H32; D.E. No. 77 at ¶ 3; D.E. No. 84 at ¶ 3). Further, the Policy contains the following applicable definition of the term "disabled":
(AR at H41, 42; D.E. No. 77 at ¶ 4; D.E. No. 86 at ¶ 2) (emphasis added). "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 at H41). Additionally, the Policy sets forth procedures for processing appeals of benefit termination decisions. Specifically,
When deciding an appeal that is based in whole or part on medical judgment, we will consult with a medical professional having the appropriate training and experience in the field of medicine involved in the medical judgment and who is neither an individual consulted in connection with the initial benefit decision, nor a subordinate of such individual.
(AR at H70).
Pursuant to Fed.R.Civ.P. 56(a), "The court shall grant summary judgment if the
If the moving party bears the burden of proof at trial, the moving party must establish all essential elements of the claim or defense in order to obtain summary judgment. See U.S. v. Four Parcels of Real Prop. in Greene & Tuscaloosa Cntys., 941 F.2d 1428, 1438 (11th Cir.1991). The moving party "`must support its motion with credible evidence ... that would entitle it to a directed verdict if not controverted at trial.'" Id. (quoting Celotex Corp. v. Catrett, 477 U.S. 317, 331, 106 S.Ct. 2548, 91 L.Ed.2d 265 (1986) (Brennan, J., dissenting)). "If the moving party makes such an affirmative showing, it is entitled to summary judgment unless the nonmoving party, in response, `come[s] forward with significant, probative evidence demonstrating the existence of a triable issue of fact.'" Four Parcels, 941 F.2d at 1438 (quoting Chanel, Inc. v. Italian Activewear of Fla., Inc., 931 F.2d 1472, 1477 (11th Cir.1991)).
By contrast, if the non-moving party bears the burden of proof at trial, the moving party may obtain summary judgment simply by establishing the nonexistence of a genuine issue of material fact as to any essential element of a non-moving party's claim or affirmative defense. Celotex Corp., 477 U.S. at 324, 106 S.Ct. 2548. When the non-moving party bears the burden of proof, the moving party does not have to "support its motion with affidavits or other similar material negating the opponent's claim." Id. at 323, 106 S.Ct. 2548 (emphasis in original). The moving party may discharge its burden in this situation by showing the Court that "there is an absence of evidence to support the non-moving party's case." Id. at 324, 106 S.Ct. 2548. Once the moving party discharges its initial burden, a non-moving party who bears the burden of proof must cite "to particular parts of materials in the record" or show "that the materials cited do not establish the absence or presence of a genuine dispute." Fed.R.Civ.P. 56(c)(1).
An ERISA benefit plan participant may bring a civil action to recover, enforce or clarify his rights to benefits under the terms of the plan. 28 U.S.C. § 1132(a)(1)(B). The "denial of benefits challenged under § 1132(a)(1)(B) is to be reviewed under a de novo standard of review 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 & Rubber Co. v. Bruch, 489 U.S. 101, 115, 109 S.Ct. 948, 103 L.Ed.2d 80 (1989); Hunt v. Hawthorne Assoc., Inc.,
Williams, 373 F.3d at 1138; Capone v. Aetna Life Ins. Co., 592 F.3d 1189, 1195 (11th Cir.2010). The Supreme Court has questioned the sixth step of this analysis, see Metro. Life Ins. Co. v. Glenn, 554 U.S. 105, 128 S.Ct. 2343, 171 L.Ed.2d 299 (2008), and the Eleventh Circuit recognizes that it does not require a "heightened" standard of review when a conflict of interest is present. Doyle, 542 F.3d at 1360. "[T]he existence of a conflict of interest should merely be a factor for the district court to take into account when determining whether an administrator's decision was arbitrary and capricious." Walker-Hall, 788 F.Supp.2d at 1358 (quoting Capone, 592 F.3d at 1196); Doyle, 542 F.3d at 1360. Additionally, "the burden remains on the plaintiff to show the decision was arbitrary; it is not the defendant's burden to prove its decision was not tainted by self-interest.'" Walker-Hall, 788 F.Supp.2d at 1358 (quoting Doyle, 542 F.3d at 1360). "Even where there is a conflict of interest, courts still `owe deference' to the administrator's `discretionary decisionmaking.'" Rickey, 608 F.Supp.2d at 1310 (quoting Doyle, 542 F.3d at 1363).
Under this framework, Vivas initially bears the burden to prove that he is disabled
Under the terms of the Policy, Kendall Imports, Plaintiff's employer, is the named policyholder and Hartford is the named fiduciary. (AR at H1). As the fiduciary, and per the parties' stipulation, Hartford had full discretion and authority to determine Plaintiff's eligibility for benefits. (AR at H40; D.E. No. 77 at 1; D.E. No. 84 at 1). The Court must now consider whether the aggregate evidence, viewed in the light most favorable to Plaintiff, could support Hartford's decision under the deferential ERISA standards set forth above. See Leahy v. Raytheon Co., 315 F.3d 11, 18 (1st Cir.2002).
Plaintiff fails to introduce evidence that he was totally disabled when Hartford terminated his benefits and, therefore, the Court does not find a genuine issue of material fact as to whether Hartford's decision was wrong. As of September 5, 2009, Plaintiff no longer met the Policy's definition of "Disability" as it became applicable to his claim effective September 5, 2009. Namely, Plaintiff failed to show that he was prevented from performing one or more of the essential duties of any occupation. Three Board Certified reviewing physicians — Dr. Knapp,
Plaintiff's argument that Dr. Aldrich, Vivas's treating physician, found Vivas incapable of working as a result of suffering from severe osteoporosis and a prior lumbar fracture does not make Hartford's final decision to terminate LTD benefits wrong. Hartford "need not accord extra respect to the opinions of a claimant's treating physicians," Blankenship, 644 F.3d at 1354, and this Court cannot say that Hartford was wrong to credit the opinions of the reviewing physicians over that of Dr. Aldrich. See Giertz-Richardson, 536 F.Supp.2d at 1291 ("While Plaintiffs doctors believe that Plaintiff was unable to work, it was not wrong for Defendant to credit the opinions of the [] doctors that reviewed Plaintiffs medical records over the opinions of Plaintiff's [sic] doctors.") (citing Helms v. General Dynamics Corp., 222 Fed.Appx. 821, 833 (11th Cir.2007)). Furthermore, in his 2009 discussions with Dr. Kalen after viewing the video surveillance, Dr. Aldrich noted that Vivas was doing more than he said he was able to do. (AR at H670). Specifically, Dr. Aldrich indicated that Vivas could work per the DOT at the Sedentary level. Id. As Defendant points out in its reply in support of its motion for summary judgment, despite numerous opportunities, Dr. Aldrich has never disputed Dr. Kalen's account of his recommendation. (D.E., No. 91 at 4). The only conflicting account came two years later, on October 31, 2012, when Dr. Aldrich filled out a checklist and indicated "yes" to the question, "Based on your treatment of [Vivas], in your medical opinion, has [he] been UNABLE to perform all the essential duties of any occupation, since you started to treat him and continuously through the present time?" (AR at H1401).
Additionally, Plaintiff argues that Dr. Lichtblau's medical opinion provided Hartford with additional objective evidence of Vivas's functionality which should have been considered before Defendant made its final decision. (D.E. No. 83 at 5). Specifically, Dr. Lichtblau opined that Vivas "`d[id] not have the functional capacity to work 4 hours per day at this time' among a number of other functional limitations." Id. (quoting AR at H1423) (emphasis added). However, Dr. Lichtblau examined Vivas for the first time on October 3, 2012 and, therefore, "at this time" clearly referred to October 2012. (AR at H1420). Accordingly, Dr. Lichtblau's medical examination sheds no light on Vivas's functionality during the relevant time period in 2009 when Hartford discontinued his LTD benefits. See Warming v. Hartford Life & Acc. Ins. Co., 663 F.Supp.2d 10, 20 (D.Me. 2009) (finding that administrator was not required to base its decision on testing that addressed the plaintiffs condition as of the date of testing conducted in 2008, rather than her condition as of the relevant time when her benefits were terminated in 2006). Dr. Lichtblau later sent a letter to Plaintiffs counsel clarifying that he had meant to include the following language in his report: "[Vivas] would not
As further evidence of a "wrong" and manifestly "unreasonable" decision, Plaintiff characterizes Hartford's medical reviewers' reliance on the surveillance footage as inappropriate. (D.E. No. 83 at 9). In the face of "mounting objective evidence establishing Vivas's disability[,]" Plaintiff argues that Defendant cannot solely rely on the surveillance footage. Id. at 10. However, Hartford specifically indicated that it based its final determination to discontinue Plaintiffs LTD benefits on policy language, and all of the papers contained in his file were reviewed as a whole, including the following:
(AR at H496). Furthermore, in his Statement of Continued Disability dated April 10, 2009, Vivas even submitted that some of the activities depicted in the surveillance video were "more than what [he] told Hartford that [he] can do, but [he] was able to do them on those days because [he] ha[d] good and bad days." (AR at H773). Accordingly, Plaintiffs argument that Defendant improperly relied solely on the surveillance footage is unpersuasive, as the facts indicate a much more thorough and inclusive review of Plaintiff's claim.
On February 8, 2011, the SSA decided that Plaintiff was disabled as of February 25, 2007, (AR at H1284). Plaintiff argues that Hartford unreasonably disregarded this decision, and points out that "`A determination of disability by SSA may be considered in reviewing a plan administrator's determination of benefits ...'" (D.E. No. 83 at 14) (internal citations omitted). Defendant replies that Vivas's SSA award does not, per se, entitle him to LTD benefits under the Policy. (D.E. No. 91 at 8). Furthermore, the Administrative Record establishes that Hartford did consider the fact that Vivas was approved for SSD benefits. (AR at H1251). In its December 12, 2012 correspondence denying Plaintiffs appeal as to the termination of LTD benefits,
Plaintiff argues, even assuming arguendo that "reasonable" grounds existed to support Hartford's decision, it is evident from the Administrative Record that Defendant's conflict of interest caused it to be financially biased in rendering an arbitrary and capricious decision. (D.E. No. 83 at 15). In response, Defendant submits that the district court's basic analysis under arbitrary and capricious review centers on "`whether a reasonable basis existed for the administrator's benefits decision.'" (D.E. No. 91 at 9) (quoting Blankenship, 644 F.3d at 1355). Additionally, Defendant disputes Plaintiffs submission that Hartford has had a history of biased claims administration. Id. at 10.
A conflict of interest may arise where a party is responsible for both determining eligibility and paying benefits. See Doyle, 542 F.3d at 1359; Williams, 373 F.3d at 1136. In this case, the Policy itself gave Hartford full discretion and authority to determine eligibility and interpret the policy provisions. Hartford was also responsible for paying benefits to Kendall Imports' employees. Under these facts, a structural conflict of interest existed between Hartford's fiduciary and profit-making interests, since Hartford was responsible not only for determining eligibility, but also for paying benefits.
Notwithstanding, the existence of a conflict of interest is not dispositive; rather, a conflict is simply one factor to be considered. See Firestone, 489 U.S. at 115, 109 S.Ct. 948. Further, the conflict of interest is to be evaluated on a case-specific basis, and not under a heightened standard of review. Glenn, 554 U.S. at 116-17, 128 S.Ct. 2343; Miller v. Prudential Ins. Co. of Am., 625 F.Supp.2d 1256, 1262 (S.D.Fla.2008). Additionally, "Where a conflict exists and a court must reach step six, the burden remains on the plaintiff to show the decision was arbitrary; it is not the defendant's burden to prove its decision was not tainted by self-interest.'" Blankenship, 644 F.3d at 1355 (quoting Doyle, 542 F.3d at 1360). This Court must, therefore, determine whether the conflict of interest tainted Hartford's decision to terminate Plaintiffs LTD benefits. See Miller, 625 F.Supp.2d at 1266. In considering the weight of this factor, a court may give the conflict of interest low importance when the Administrative Record lacks evidence of "malice, self dealing, a parsimonious claims granting history, or other circumstances suggesting a higher likelihood that the structural conflict affected the benefits decision." Id.
Based on a thorough review of the Administrative Record, this Court finds no evidence to suggest that the structural conflict of interest affected Hartford's decision to terminate Plaintiffs LTD benefits. Indeed, there are reasonable grounds
The Administrative Record establishes reasonable grounds for Hartford's interpretation and application of the Policy. Further, this Court finds no evidence to support Plaintiffs argument that the conflict of interest in any way affected Hartford's decision to terminate Plaintiffs LTD benefits. Accordingly, it is hereby
ORDERED AND ADJUDGED that:
(AR at H708).