JAY C. ZAINEY, District Judge.
Before the Court are the following motions: (1)
For the following reasons,
In early 2011, Plaintiff Thomas A. LaPenter was employed by Dyncorp International LLC ("Dyncorp") as a security manager stationed in Kabul, Afghanistan. (Rec. Doc. 53 at 1). As part of LaPenter's employment agreement with Dyncorp he was afforded short-term and long-term disability insurance benefits. (Id.). These benefits were conveyed via a group benefits plan ("Plan") that purchased short-term and long-term disability insurance policies from Hartford. (Id.; Rec. Doc. 75 at 1-2; Rec. Doc. 26-2 at 79-26-2 at 96).
On or about January 11, 2011, LaPenter took a medical leave of absence from Dyncorp. (Rec. Doc. 75 at 2). Dyncorp personnel noted, in a contemporaneously-produced report of occupational injury or disease ("OIR"), that LaPenter was experiencing "[h]ypertension refractory to current medication" caused by "[w]orkplace [s]tress" affecting his "[c]irculatory" system. (Rec. Doc. 26-2 at 12). Before LaPenter took this leave, on January 8, 2011, Dyncorp human resources employee Karla H. Micka advised LaPenter "to file an OIR and to leave country to seek medical treatment at his earliest convenience" because she was "concerned for his general well-being and d[id]n't want to have his health deteriorate to the point where MEDEVAC [wa]s required." (Id. at 10). LaPenter informed Hartford via affidavit that he "wasn't feeling well starting around Christmas of 2010 and progressively felt worse." (Id. at 8). LaPenter described his symptoms as "stomach upset, diarrhea, respiratory congestion, and inability to sleep." (Ibid.).
After leaving Kabul, Afghanistan LaPenter returned to his home in Bosnia and Herzegovina where, on January 24, 2011, he was seen by Dr. Sinisa Djuricic, a neuropsychiatrist, who diagnosed LaPenter with posttraumatic stress disorder ("PTSD"). (Id. at 13; Rec. Doc. 53 at 1; Rec. Doc. 75 at 2). Dr. Djuricic noted that LaPenter was experiencing "problems with sleeping, increased neurosis, frustration" and "flashbacks" to a traumatic life-threatening event experienced a few months prior. (Rec. Doc. 26-2 at 13). Dr. Djuricic also noted that LaPenter felt insecure, fearful, worried for his safety, and had become reticent, cautious, more distrustful and was suffering from frequent blood pressure elevations that he was having trouble controlling. (Ibid.). After diagnosing LaPenter with PTSD, Dr. Djuricic prescribed him medication noting: "Control in 4-6 weeks: to 2-3 months". (Ibid.). Though Dr. Djuricic did not include the following observation in his contemporaneous physician's report, on March 12, 2012, Dr. Djuricic provided Hartford with an "addition to medical documentation" that stated:
(Rec. Doc. 26-1 at 122 and 123). This medical report addendum was submitted to Hartford on March 14, 2012. (Ibid.).
On January 26, 2011, two days after his visit to Dr. Djuricic, LaPenter was seen by Dr. Milenko Krneta, a cardiologist, who diagnosed LaPenter with angina pectoris and hypertension.
On August 15, 2011, LaPenter submitted the medical records from Drs. Djuricic and Krneta to Hartford and explained that following these visits his "health continued to deteriorate, with symptoms pointing toward lower stomach problems." (Id. at 61). On March 14, 2012, LaPenter presented Hartford an affidavit stating that: "From September 2010 to July 2011, I had numerous bouts of diarrhea. In May 2011 I noticed blood in my stool and made an appointment with Dr. Vaso Gotovac in Teslic, Bosnia, who recommended a colonoscopy with Dr. Dusko Panzalovic." (Rec. Doc. 26-1 at 120). On June 15, 2011, LaPenter was seen by Dr. Gotovac who noted that LaPenter was experiencing "constipation, gases and mucus in stool, once with blood, had diarrhea six months ago. Was in Afghanistan until January 2011, lost weight, takes antihypertensives."
On July 6, 2011, LaPenter traveled back to the United States and was seen by Dr. Jay N. Yepuri, a gastroenterologist, at the Endoscopy Center at Central Park in Bedford, Texas. (Id. at 65-67). Dr. Yepuri's consultation notes reflect that: "Approximately 6-7 months ago, while in Afghanistan, [LaPenter] began having episodes of diffuse abdominal pain and alternating diarrhea and constipation, representing a change in bowel habits." (Ibid.). Dr. Yepuri reviewed LaPenter's physician and pathology reports, found that they revealed evidence and symptoms consistent with colon cancer, and ordered a battery of tests and a second colonoscopy. (Ibid.). On July 8, 2011 Dr. Yepuri performed a colonoscopy and confirmed the presence of a mass in LaPenter's distal descending colon. (Id. at 68-70 and 22-23). This mass was biopsied and on July 11, 2011 a pathology report confirmed it to be an "infiltrating moderately differentiated adenocarcinoma." (Id. at 71-72). The record contains no further medical documentation related to LaPenter's colon cancer treatment but apparently shortly thereafter LaPenter underwent surgery to remove the tumor from his colon. (Rec. Doc. 75 at 3).
On August 5, 2011, LaPenter called Hartford and spoke with a telephone intake nurse.
LaPenter's claim was initially assigned to Hartford Ability Analyst Valeria C. Alvarado ("Alvarado") who emailed Dyncorp on August 8, 2011 to confirm LaPenter's medical leave, and to investigate the gap between LaPenter's last day of work and the assigned date of disability-which at this point Hartford considered to be July 3, 2011. (Rec. Doc. 26-1 at 43-44). Dyncorp promptly responded to Alvarado, confirming that LaPenter began his medical leave on January 11, 2011 and questioning why Hartford had assigned the July 3, 2011 date of disability. (Id. at 42). That same day, August 8, 2011, Alvarado called LaPenter to go over his claim and establish the date from which he would be claiming disability. (Rec. Docs. 66-1 at 13-16; 26-1 at 41-42). LaPenter reiterated that he had been on medical leave since January 2011 with symptoms stemming from his colon cancer. (Ibid.). LaPenter explained that while he was being treated for several conditions in Bosnia and Herzegovina, the process was difficult because he did not speak the language. (Ibid.). LaPenter also stated that he was having trouble finding his medical records from overseas. (Ibid.). Alvarado informed LaPenter that she was going to contact LaPenter's treating physician in the U.S. to obtain LaPenter's medical records, but that she might have trouble approving a date of disability before July 2011. (Ibid.). Alvarado then assigned a date of disability of July 3, 2011 in her claim notes stating that LaPenter informed her that he was unable to obtain his medical records from overseas. (Ibid.).
On August 11, 2011, Alvarado called LaPenter a second time to go over his claim. (Rec. Docs. 26-1 at 39; 66-1 at 16-22). Alvarado informed LaPenter that Hartford would assign a date of disability on "the date [he] stopped working due to [his] condition, so that would probably be January 11." (Ibid.). Alvarado recommended LaPenter get "some sort of documentation way back from January" because "that could probably help because we have to cover that big gap." (Ibid.). When LaPenter asked whether Hartford would be providing benefits from January 2011, Alvarado stated that benefits would be provided from "whenever [LaPenter's] symptoms began" and that his "date of disability is really January 11th, so we have to find some sort of documentation from then to the present so that we can understand what happened." (Ibid.). Noting that LaPenter's disability began more than six months prior, Alvarado informed LaPenter that she was also going to transfer his claim to Hartford's long-term disability department. (Ibid.).
On August 12, 2011, Dr. Yepuri, LaPenter's treating gastroenterologist in the U.S., sent LaPenter's medical records to Hartford. (Rec. Doc. 26-2 at 62-78). As quoted above, Dr. Yepuri noted that: "Approximately 6-7 months ago, while in Afghanistan, [LaPenter] began having episodes of diffuse abdominal pain and alternating diarrhea and constipation, representing a change in bowel habits." (Id. at 65). On August 15, 2011, LaPenter faxed in further disability documentation including the Dyncorp OIR and the treating physician notes from Drs. Djuricic, Krneta, and Yepuri. (Id. at 50-61). LaPenter laid out a brief chronology of the events evidencing his disability and explained that over the course of the past seven months his health had continued to deteriorate with symptoms pointing toward lower stomach problems that ultimately forced in his return to the U.S. where he was diagnosed with colon cancer requiring immediate surgery. (Ibid.).
On August 19, 2011, Hartford Ability Analyst William R. Faber ("Faber") called LaPenter to discuss both his short-term and long-term disability claims. (Rec. Docs. 26-1 at 17-18; 66-1 at 7-11). Faber explained that Hartford was sending paperwork for LaPenter's long-term disability claim and that after this was returned, Faber would undertake a complete review of LaPenter's file and make decisions on both the short-term and long-term disability claims. (Ibid.).
On August 29, 2011, LaPenter filled in and signed both a long-term disability income benefits questionnaire, and a work and educational history form that Hartford provided. (Rec. Doc. 26-1 at 1-8). This same day, August 29, 2011, Hartford sent LaPenter a letter, signed by Faber, stating that Hartford had completed its review of LaPenter's claim for short-term disability benefits and determined that LaPenter had failed to provide proof of an ongoing disability beyond April 24, 2011. (Rec. Doc. 26-1 at 60-62). Hartford stated:
(Ibid.).
On September 12, 2011, Hartford, through a second letter signed by Faber, denied LaPenter's claim for long-term disability benefits. (Rec. Doc. 26-1 at 22-25). In this letter Hartford stated:
(Ibid.).
This same day, September 12, 2011, Hartford also sent LaPenter a denial letter signed by Alvarado, stating that Hartford had determined that LaPenter was not covered under a Hartford short-term disability policy for his "new" short-term disability claim. (Rec. Doc. 26-1 at 80-82). This letter refers to a second application for short-term disability benefits, with a July 6, 2011 date of disability in reference to LaPenter's diagnosis of colon cancer. (Ibid.). Despite LaPenter's consistent description of his condition as one disabling event spanning the past several months, Hartford denied LaPenter benefits because:
(Ibid.).
On October 11, 2011, LaPenter wrote to Hartford appealing these denials. (Rec. Doc. 26-2 at 8-26). LaPenter stated that he was still on medical leave from Dyncorp well into July 2011, when he was eventually diagnosed with colon cancer. (Ibid.). LaPenter attached several medical records, including the June 2011 treatment notes of Drs. Gotovac and Panzalovic, to his appeal letter. (Ibid.).
On November 8, 2011, Hartford Appeal Specialist James Early ("Early") sent LaPenter three separate appeal denial letters. (Rec. Docs. 26-1 at 57-58; 75-77; 19-20). In the first of these, Early explained Hartford's position that the medical documentation submitted by LaPenter was insufficient to warrant disability benefits beyond April 24, 2011 for his initial short-term disability claim. (Rec. Doc. 26-1 at 57-58). Early wrote:
(Ibid.).
In Early's second November 8, 2011 appeal denial letter, he addressed LaPenter's second claim for short-term disability benefits—the July 6, 2011 date of disability claim. (Rec. Doc. 26-1 at 75-77). Early explained that:
(Ibid.).
In the third November 8, 2011 appeal denial letter, Early addressed LaPenter's long-term disability benefit claim. (Rec. Doc. 26-1 at 19-20). Again, Hartford determined that its prior denial was proper. (Ibid.). Early explained that:
(Ibid.).
On February 29, 2012, counsel for LaPenter wrote to Hartford requesting copies of LaPenter's claim file, as well as Hartford's related policies and plan documents. (Rec. Doc. 26-2 at 6). On March 14, 2012, LaPenter's counsel again wrote to Hartford enclosing the aforementioned affidavit in which LaPenter describes the progression of his illness, LaPenter's corresponding treatment documentation, and Dr. Djuricic's treatment addendum wherein Dr. Djuricic recounted the gastrointestinal symptoms LaPenter presented. (Rec. Doc. 26-1 at 119-23).
On March 19, 2012, Early responded to LaPenter's counsel explaining that because Hartford had closed LaPenter's initial claim for short-term disability benefits due to insufficient "Proof of Loss to support continued Disability", the additional documentation provided by LaPenter would be sent back to the initial claim analyst for further review. (Rec. Doc. 26-1 at 55-56). With respect to the short-term and long-term disability benefit claims assigned the July 6, 2011 date of disability, Early explained that Hartford's November 8, 2011 decision was final, and because Hartford considered these claims exhausted, the additional information submitted by LaPenter would not be reviewed in connection with them. (Ibid.).
On March 20, 2012, Faber wrote to LaPenter explaining that Hartford had reviewed LaPenter's new medical information but determined that LaPenter still failed to provide sufficient proof of loss to warrant additional benefits. (Rec. Doc. 26-1 at 51-54). After quoting language from his August 29, 2011 denial letter, Faber provided the following analysis:
(Ibid.). Faber went on to inform LaPenter that LaPenter had the right to appeal this denial within 180 days. (Ibid.).
By letter dated April 16, 2012, LaPenter, through counsel, did just that. (Rec. Doc. 26-1 at 83-86). Counsel reiterated LaPenter's position that his "disability was due to [the] colon cancer symptoms he suffered from, beginning in early 2010." (Ibid.).
On May 10, 2012, Hartford Senior Appeal Specialist Marsh L. Macko ("Macko")sent counsel for LaPenter Hartford's final denial letter. (Rec. Doc. 26-1 at 47-50). Macko stated that after a review of LaPenter's most recent appeal, Hartford determined again that its decision to deny shortterm disability benefits beyond April 24, 2011 was correct. (Ibid.). Macko wrote:
The issue in dispute and under review on appeal is whether the medical findings provided support an ongoing disability beyond 04/24/11 either due to PTSD or to colon cancer.
This decision is final and binding.
(Ibid.).
One month after receiving this final denial letter, on June 6, 2012, LaPenter filed the instant civil action against Hartford claiming an unlawful denial of benefits in violation of the Employee Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. § 1001, et seq. (Rec. Doc. 1). As mentioned above, by joint motion of the parties and approval of the Court, this matter was submitted for final judgment based upon the administrative record and the parties' cross-motions for judgment. For the following reasons, LaPenter's motion is
The Federal Rules of Civil Procedure provide that summary judgment shall be granted "if the movant shows that there is no genuine dispute 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 appropriate only if `the pleadings, depositions, answers to interrogatories, and admissions on file, together with the affidavits, if any,' when viewed in the light most favorable to the non-movant, `show that there is no genuine issue as to any material fact.'" TIG Ins. Co. v. Sedgwick James of Wash., 276 F.3d 754, 759 (5th Cir. 2002) (citing Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 249-50, 106 S.Ct. 2505, 91 L.Ed.2d 202 (1986)). A fact is "material" if its resolution in favor of one party might affect the outcome of the action under governing law. Anderson, 477 U.S. at 248. A dispute about a material fact is "genuine" if the evidence is such that a reasonable jury could return a verdict for the nonmoving party. Ibid. No genuine issue of material fact exists if a rational trier of fact could not find for the nonmoving party based on the evidence presented. National Ass'n of Gov't Employees v. City Pub. Serv. Bd., 40 F.3d 698, 712 (5th Cir. 1994) (citing Matsushita Elec. Indus. Co. v. Zenith Radio Corp., 475 U.S. 574, 584-88, 106 S.Ct. 1348, 1355-56, 89 L.Ed.2d 538 (1986)).
To withstand a properly supported motion for summary judgment, the nonmoving party who bears the burden of proof at trial must come forward with evidence to support the essential elements of its claim. Ibid. (citing Celotex Corp. v. Catrett, 477 U.S. 317, 321-23 (1986)). "[A] complete failure of proof concerning an essential element of the nonmoving party's case renders all other facts immaterial." Celotex Corp., 477 U.S. at 323. Therefore, if "the factfinder could reasonably find in [the nonmoving party's] favor, then summary judgment is improper." Kelley v. Price-Macemon, Inc., 992 F.2d 1408, 1413 (5th Cir. 1993). Even where the Rule 56 standards are met, a court has discretion to deny a motion for summary judgment if it believes that "the better course would be to proceed to a full trial." Anderson, 477 U.S. at 255.
ERISA "permits a person denied benefits under an employee benefit plan to challenge that denial in federal court." Metropolitan Life Ins. Co. v. Glenn, 554 U.S. 105, 108 (2008); see 29 U.S.C. § 1132(a)(1)(B). ERISA provides the federal courts jurisdiction to review benefit determinations by fiduciaries or plan administrators. See 29 U.S.C. § 1132(a)(1)(B). "In determining whether to pay or deny benefits, a plan administrator must make two general . . . determinations: First, he must determine the facts underlying the claim for benefits. . . . Second, he must then determine whether those facts constitute a claim to be honored under the terms of the plan." Schadler v. Anthem Life Ins. Co., 147 F.3d 388, 394 (5th Cir. 1998) (quoting Pierre v. Conn. Gen. Life Ins. Co./Life Ins. Co. of N. Am., 932 F.2d 1552, 1557 (5th Cir. 1991)) (emphasis and internal quotation marks omitted). The plan administrator's initial fact determination is always reviewed for abuse of discretion. Wade v. Hewlett-Packard Dev. Co. LP Short Term Disability Plan, 493 F.3d 533, 537 (5th Cir. 2007), abrogated on other grounds by Hardt v. Reliance Standard Life Ins. Co., 560 U.S. 242, 130 S.Ct. 2149, 2157-58, 176 L.Ed.2d 998 (2010). The plan administrator's second determination, i.e., interpretation of the plan, is reviewed de novo unless the plan "expressly confers discretion on the plan administrator to construe the plan's terms[, in which case,] the administrator's construction is reviewed for abuse of discretion." Id. at 537-38; see also Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 109 S.Ct. 948, 956-57, 103 L.Ed.2d 80 (1989).
When conducting an abuse of discretion review, the Fifth Circuit applies a two-step inquiry into the plan administrator's decision. Stone v. UNOCAL Termination Allowance Plan, 570 F.3d 252, 257 (5th Cir. 2009). First, the court examines whether the plan administrator's decision was legally correct; and if so, there is no abuse of discretion. Ibid. If the court determines that the plan administrator's decision was not legally correct, it proceeds to the second step of this inquiry where it determines whether the plan administrator abused its discretion in making its decision. Ibid.
"A plan administrator abuses its discretion where the decision is not based on evidence, even if disputable, that clearly supports the basis for its denial." Holland v. Int'l Paper Co. Retirement Plan, 576 F.3d 240, 246 (5th Cir. 2009) (internal quotation marks and citation omitted). An abuse of discretion occurs "only where the plan administrator acted arbitrarily or capriciously." Ibid. (internal quotation marks and citation omitted). A decision is considered arbitrary when it is made "without a rational connection between the known facts and the decision or between the found facts and the evidence." Id. at 246-47 (citing Meditrust Fin. Servs. Corp. v. Sterling Chems., Inc., 168 F.3d 211, 215 (5th Cir. 1999)) (internal quotation marks omitted).
"This standard requires only that substantial evidence supports the plan fiduciary's decision." Atkins v. Bert Bell/Pete Rozelle NFL Player Retirement Plan, 694 F.3d 557, 566 (5th Cir. 2012) (citing Ellis v. Liberty Life Assur. Co. of Boston, 394 F.3d 262, 273 (5th Cir.2004)). Substantial evidence is "more than a scintilla, less than a preponderance, and is such relevant evidence as a reasonable mind might accept as adequate to support a conclusion." Ibid. (quoting Deters v. Sec'y of Health, Educ. & Welfare, 789 F.2d 1181, 1185 (5th Cir. 1986)). The court's "review of the administrator's decision need not be particularly complex or technical; it need only assure that the administrator's decision fall somewhere on a continuum of reasonableness-even if on the low end." Corry v. Liberty Life Assur. Co. of Boston, 499 F.3d 389, 398 (5th Cir. 2007) (quoting Vega v. Nat'l Life Ins. Servs., Inc., 188 F.3d 287, 297 (5th Cir. 1999) (en banc), abrogated on other grounds by Metro. Life Ins. Co. v. Glenn, 554 U.S. 105, 128 S.Ct. 2343, 171 L.Ed.2d 299 (2008)). "Although we generally decide abuse of discretion based upon the information known to the administrator at the time he made the decision, the administrator can abuse his discretion if he fails to obtain the necessary information."Salley v. E.I. DuPont de Nemours & Co., 966 F.2d 1011, 1015 (5th Cir. 1992).
Where an administrator has a conflict of interest, this conflict of interest is a factor to be weighed in determining an abuse of discretion. Holland, 576 F.3d at 247 (citing Glenn, 554 U.S at 115-18); see also Schexnayder v. Hartford Life and Acc. Ins. Co., 600 F.3d 465, 469 (5th Cir. 2010). Because a court reviewing an administrator's decision must take into account and weigh several casespecific factors before determining whether an administrator abused his discretion, "[a]ny one factor may act as a tiebreaker when the other factors are closely balanced, the degree of closeness necessary depending upon the tiebreaking factor's inherent or case-specific importance." Schexnayder, 600 F.3d at 496 (quoting Glenn, 554 U.S at 128).
As outlined above, LaPenter's employer Dyncorp offered an ERISA-based group benefits Plan to its employees. This Plan was funded by Hartford group policies GLT-377915 (short-term disability benefits policy) and GRH-377915 (long-term disability benefits policy) both operating with an effective date of January 1, 2008.
Throughout Hartford's motion, it stresses that LaPenter presented two distinct claims for benefits, i.e., one claim relating to his PTSD disability, and one claim relating to his colon cancer disability. Accordingly, in support of its motion for summary judgment, Hartford argues that there are but two central issues before the Court in this matter. First, whether Hartford's decision to terminate the short-term disability benefits related to LaPenter's PTSD disability was an abuse of discretion. And Second, whether Hartford's decision to deny LaPenter's colon cancer disability claim, based on the predicate determination of a lack of coverage, was an abuse of discretion. Hartford maintains that both decisions were correct, and therefore moves the Court to affirm these determinations and dismiss LaPenter's claims with prejudice.
Hartford asserts that its decision to terminate LaPenter's short-term PTSD disability benefits was proper because LaPenter failed "to provide Hartford with evidence of continuing disability due to PTSD". (Rec. Doc. 35-1 at 1-2). Hartford argues that the medical records LaPenter provided clearly support this finding. Hartford makes much of the fact that in Dr. Djuricic's January 24, 2011 medical consultation note, after diagnosing LaPenter with PTSD, Dr. Djuricic "noted that [LaPenter's] condition would be under control anywhere from 4-6 weeks to 2-3 months." (Id. at 6). Further, Hartford points out that when LaPenter was seen by the cardiologist Dr. Krneta two days later, after diagnosing LaPenter with cardiac conditions, Dr. Krneta noted "[d]igestion in order." (Ibid.). Hartford continues, emphasizing that "Dr. Kmeta [sic] stated that LaPenter `[s]hould be spared from psycho-social burdens' until his symptoms were under control, which the doctor estimated would take three to four weeks." (Ibid.). Hartford then quotes from Faber's initial denial letter that "[n]o medical was received to support a claim beyond 04/24/2011, as such further benefits for the PTSD are denied." (Ibid.).
Hartford builds upon this argument in support of its position that the denial of benefits relating to LaPenter's colon cancer disability was correct, because LaPenter was no longer eligible for benefits "following a leave of absence from his job taken several months before being diagnosed with colon cancer, and because [LaPenter] presented no evidence that his cancer or other gastrointestinal issues rendered him disabled during the period within which he had coverage under the Plan." (Rec. Doc. 35-1 at 2). Hartford argues that:
(Id. at 26). Hartford asserts that:
(Id. at 21). The Court finds it important to note that Hartford acknowledges that "because Hartford deemed [LaPenter] disabled from January 11, 2011 through April 24, 2011, the `Coverage while Disabled' terms [included in the Plan] extended [LaPenter's ] short-term disability coverage through April 24, 2011, despite the fact that he was no longer an active employee[.]" (Id. at 20). Therefore, even under Hartford's version of events, where LaPenter presented two independent disability claims, had LaPenter become disabled by his colon cancer or its related symptoms prior to April 24, 2011, LaPenter would have been covered under the Plan and entitled to disability benefits.
LaPenter counters Hartford's arguments, pointing out that:
(Rec. Doc. 32-1 at 11-12). LaPenter continues, arguing that Hartford abused its discretion "especially considering that it failed to provide its own medical review. . . ." (Id. at 12). Hartford acknowledges "[t]his is not a `battle of the experts' where there are competing opinions regarding Plaintiff's ability to work between April 24, 2011, the last date by which Dr. Djuricic predicted Plaintiff's PTSD symptoms would be controlled, and his June 2011 colon cancer diagnosis." (Rec. Doc. 44 at 11). Hartford then quotes from an unpublished Fifth Circuit case, Dramse v. Delta Family-Care Disability & Survivorship Plan, 269 Fed. Appx. 470 (5th Cir. March 12, 2008), for the proposition that "[t]he absence of evidence supporting a claim for disability is sometimes, in and of itself, compelling proof that a claimant is not disabled." Dramse, 269 Fed. Appx. at 479 (citations omitted). Hartford concludes with the assertion that:
(Rec. Doc. 44 at 11).
A decision is considered arbitrary when it is made "without a rational connection between the known facts and the decision or between the found facts and the evidence." Holland, 576 F.3d at 246-47. In summary, Hartford argues that LaPenter submitted an initial claim for short-term disability benefits to cover a PTSD disability, but that the medical evidence provided did not support that he was disabled due to this condition beyond April 24, 2011. That LaPenter's disability ceased as of April 24, 2011 is a finding of fact based solely upon Hartford's interpretation of Dr. Djuricic's treatment note. This is the quintessential example of a "scintilla" of evidence being presented in support of a conclusion. Put simply, more evidence than this was needed to validate Hartford's conclusion that LaPenter's disability ceased as of April 24, 2011. Because the Court can find no rational connection between this found fact—that LaPenter's disability caused by PTSD ceased as of April 24, 2011—and the evidence—that Dr. Djuricic stated: "Control in 4-6 weeks: to 2-3 months" in his treatment note of January 24, 2011, it must find that Hartford abused its discretion in reaching this conclusion based on this evidence. (Rec. Doc. 26-2 at 13).
Hartford reasons that because LaPenter failed to return to work on April 25, 2011 and provided no additional medial evidence of a disabling condition between April 25, 2011 and June 15, 2011
While the Court will "generally decide abuse of discretion based upon the information known to the administrator at the time he made the decision, the administrator can abuse his discretion if he fails to obtain the necessary information."Salley, 966 F.2d at 1015. In the case at bar, it is undisputed that the Hartford failed to obtain an independent medical review of the medical evidence provided by LaPenter. In combination with the steadfast and unequivocal expressions from LaPenter throughout the claim process that he was disabled by symptoms related to his eventual colon cancer diagnosis, and the medical records relating to this colon cancer diagnosis that reference the onset of this condition well in advance of LaPenter's leave of absence, it was patently unreasonable of Hartford, if it had concerns about whether these medical records and LaPenter's eventual diagnosis were consistent with the disabling conditions he was suffering when he took his medical leave of absence, to not consult with LaPenter's physicians or obtain an independent medical review of the available information. Under these facts, this amounts to an obvious failure to obtain the necessary information. See Bellaire Gen. Hosp. v. Blue Cross Blue Shield of Mich., 97 F.3d 822, 832 (finding an abuse of discretion when, inter alia, the insurer claimed that "ample evidence" supported the denial, but that evidence was contradicted by other facts in the record); see also Salley, 966 F.2d at 1015 (administrator abused its discretion when it denied benefits after reviewing only records from plaintiff's first hospital admission and not her second and third admissions); see also Roig v. The Limited Long Term Disability Prog., 2000 WL 1146522, at *14 (E.D. La. Aug. 4, 2000) (administrator's denial of benefits was abuse of discretion because substantial evidence did not exist to rebut the opinion of the plaintiff's physician that the plaintiff was disabled).
As LaPenter points out:
(Rec. Doc. 41 at 6). The Court agrees. And even under the highly deferential standard that the Court must employ in ERISA cases of this type, the Court finds that Hartford abused its discretion because its "decision [wa]s not based on evidence, even if disputable, that clearly support[ed] the basis for its denial." Holland, 576 F.3d at 246. Because Hartford rested its denial of benefits beyond April 24, 2011 on insufficient evidence, the subsequent related determination that LaPenter was no longer covered under the Plan when his "new" claim for disability manifested is necessarily invalidated. Having found that Hartford's decisions were not based on substantial supporting evidence in the administrative record, the Court finds that LaPenter is entitled to judgment in his favor.
Hartford's decision to deny LaPenter benefits was not supported by clear, much less substantial, evidence in the administrative record. From the start LaPenter informed Hartford that he was unable to work due to the disabling symptoms of colon cancer he was suffering. Despite this, from the start, Hartford ignored LaPenter's description of his disability, failed to meaningfully address the evidence supporting his disability, and interpreted ambiguous medical records in a light favoring denial, without bothering to consult a medical expert or request clarification from LaPenter's treating physicians regarding his functional limitations. The Court finds that Hartford acted arbitrarily and capriciously in handling LaPenter's disability claim. This arbitrary and capricious handling amounts to an abuse of discretion in violation of ERISA. Accordingly;
