Court: District Court, E.D. New York; March 31, 2014; Federal District Court
Plaintiff Sandra Wilson initiated legal action against The Hartford and Emblem Health Services Company, LLC, under the Employee Retirement Income Security Act of 1974 (ERISA) for judicial review of her denied claim for long-term disability benefits. The case is currently being decided based on cross-motions for summary judgment from both parties. The court has granted the Defendants’ motion for summary judgment and denied the Plaintiff’s.
Wilson was employed by Emblem from 1988 until July 2010, when she left due to disability. Her position was described as self-paced and allowed for alternating between sitting and standing. Although Wilson claims her role was more demanding than described, she did not contest the physical demands analysis provided by Emblem. Under the long-term disability (LTD) Plan and the life insurance plan, Hartford had full authority to determine benefits eligibility and interpret policy terms. The LTD Plan defines disability in terms of being unable to perform essential duties of one’s occupation, while the Life Plan defines disability as being unable to work in any capacity for which one is qualified.
In July 2010, Wilson filed for short-term disability benefits due to sciatica pain. Hartford approved this claim, extending benefits until November 14, 2010, while initiating a review for long-term benefits eligibility, noting that short-term benefits do not guarantee long-term benefits.
Plaintiff submitted medical records from treating neurologist Dr. Mark Nelson, who provided an Attending Physician’s Statement of Continued Disability (APS) on November 10, 2010, indicating a primary diagnosis of an illegible left cerebral condition and secondary fibromyalgia. Dr. Nelson noted significant limitations on Plaintiff's ability to sit, stand, or walk, allowing only 20 minutes at a time, with a total of 3 hours of sitting and 2 hours of standing/walking per day. Additionally, a report from rheumatologist Dr. Serina Chung, dated October 13, 2010, documented Plaintiff's symptoms of numbness and tingling, severe headaches, and a normal CT scan of the head. An MRI of the spine was normal, and an EMG of the extremities was also normal, with ongoing tests pending. Dr. Chung's APS dated November 22, 2010, indicated a primary diagnosis of migraines and secondary peripheral neuropathy, imposing restrictions on lifting, bending, and prolonged sitting or standing. There were no follow-up records from Dr. Chung thereafter. In February 2011, Plaintiff reported to Dr. Nelson that Dr. Chung found her results normal. A physical therapist's APS from December 2010 noted Plaintiff's pain with excessive ambulation and restricted lifting capacity. Hartford approved Plaintiff’s long-term disability benefits and Social Security Disability payments around this time. After approval, Hartford continued to gather medical records but faced issues obtaining further information from Dr. Nelson, who indicated he could no longer fill out forms. Despite monthly visits early on, Plaintiff's visits to Dr. Nelson slowed significantly after November 2010, with the next appointment not occurring until October 2011. An assessment from February 2011 indicated multiple somatic complaints with an unclear etiology. In June 2011, Hartford arranged for an independent review of Plaintiff’s medical file by Dr. Gary Smith, who evaluated the documentation but did not examine Plaintiff directly and was unable to gather more information from Dr. Chung or Dr. Nelson.
Dr. Smith sought clarification on Plaintiff's ability to work at a light level, but Dr. Chung declined to provide an assessment, stating Plaintiff was not being evaluated for disability or work-related issues. Dr. Smith attempted to obtain information from Dr. Nelson but was unsuccessful after multiple messages. Ultimately, Dr. Smith concluded that Plaintiff could work at a light level, provided she could change positions for comfort consistently, based on Dr. Nelson's previous findings of normal neurological and motor exams but with noted neuropathy and various somatic complaints. On November 18, 2011, Hartford requested confirmation from Dr. Nelson regarding Dr. Smith’s assessment. Dr. Nelson later indicated that Plaintiff was "totally, permanently disabled" but did not provide specific functional restrictions. In January 2012, Hartford sought further information from Dr. Nelson about Plaintiff's last examination and functional capabilities, which he confirmed occurred on October 17, 2011. In February 2012, Hartford sent a questionnaire to Plaintiff, who reported chronic pain and difficulty with daily activities. On March 8, 2012, Hartford terminated Plaintiff’s long-term disability benefits, stating Dr. Nelson's lack of specific functional restrictions and referencing Dr. Smith’s review of medical records indicating normal physical examinations and imaging results. Hartford concluded that Plaintiff could perform her job duties as she could change positions.
On April 19, 2012, the Plaintiff filed an administrative appeal after Hartford denied her benefits. Hartford commissioned Dr. E. Frank Livingstone for an independent medical evaluation to assess Plaintiff's functionality and required a telephone conference with Dr. Nelson for further review. Dr. Livingstone analyzed the Plaintiff's medical records, including a recent examination by Dr. Nelson from October 2011, which indicated ongoing complaints of pain, numbness, and weakness, alongside diagnoses of fibromyalgia and lumbar radiculopathy. Dr. Livingstone requested additional information from Dr. Nelson regarding the Plaintiff’s physical limitations, to which Dr. Nelson responded that 'pain limits exertion' and noted variability in her condition. Dr. Livingstone's evaluation concluded that the findings did not support an inability to work, asserting that the Plaintiff could perform full-time sedentary work with necessary accommodations. Consequently, on June 26, 2012, Hartford upheld its decision to terminate the Plaintiff's long-term disability claim.
Regarding a separate matter, on May 4, 2011, Hartford informed the Plaintiff that she was ineligible for Waiver of Premium benefits due to not meeting the disability criteria defined under the Life Plan, as she was capable of alternating between sitting, standing, and walking. This determination was upheld on June 7, 2011, based on the requirement that the Plaintiff be completely precluded from performing any work, not just her specific job.
After exhausting administrative remedies, the Plaintiff initiated legal action under ERISA, with both parties filing for summary judgment. The court will apply a deferential 'arbitrary and capricious' standard of review, assessing whether Hartford's decisions were reasonable, supported by substantial evidence, and legally sound, without substituting its judgment for that of the plan administrator.
Hartford's denial of disability benefits was deemed reasonable, as the review process and conclusions drawn from Plaintiff's medical records were neither arbitrary nor capricious. Plaintiff argued that Hartford and its medical reviewers inadequately considered her treating physician Dr. Nelson's opinions on total and permanent disability, along with those of her physical therapist, Ronald Bredow. However, medical reviews by Dr. Smith and Dr. Livingstone indicated that, while Dr. Nelson noted disability, other findings showed that Plaintiff could perform some physical activities. Dr. Smith, after reviewing various medical notes, concluded that the evidence did not support a complete inability to work. Dr. Livingstone's later review highlighted a decrease in visits to Dr. Nelson and unsuccessful attempts to gather clarifying information about Plaintiff's condition. Consequently, the Court found Hartford's decision consistent with the medical evidence and determined it was justified to deny disability benefits. Additionally, Hartford's denial of the Life Plan Premium Waiver was also upheld, as the definition of "disabled" under the Life Plan was broader than that under the LTD Plan, necessitating proof that Plaintiff was unable to perform any work, not just her specific job. Hence, the Court granted Hartford's motion for summary judgment and denied Plaintiff's motion.
Hartford's denial of Plaintiff's disability benefits is deemed reasonable and not arbitrary, despite her receipt of social security disability (SSD) benefits. The court references the Second Circuit's position that while plan administrators should explain discrepancies with SSA determinations, failure to do so does not inherently invalidate their decisions. The SSD award, made in February 2011, did not consider subsequent medical evidence reviewed by Hartford later that year, which influenced their determination. Additionally, the SSA's adherence to the "treating physician rule" does not obligate Hartford to similarly defer to Plaintiff's treating physician's opinions.
The court emphasizes that the definition of disability must align with the terms of the Plan, not the SSA's criteria, and finds sufficient evidence to support Hartford's decision. Regarding the alleged conflict of interest in Hartford's dual role as claim evaluator and payer, Plaintiff has not presented evidence that this influenced Hartford's decision-making. As a result, Plaintiff's claims regarding the conflict are insufficient to affect the court's review. The court grants Hartford's motion for summary judgment and denies Plaintiff's, concluding the case. The court also notes the relevance of Plaintiff's job description and physical demands over the specific title discrepancies.
