Court: District Court, District of Columbia; January 27, 2014; Federal District Court
Thia Jai Brown filed a lawsuit against Hartford Life and Accident Insurance Company, contesting the termination of her Long Term Disability (LTD) benefits. In response, Hartford counterclaimed, asserting that Brown had been overpaid and owed them over $36,000. Both parties sought summary judgment. The court ruled in favor of Hartford, denying Brown's motion and granting Hartford's.
Brown, a 38-year-old histotechnologist, had been employed by Universal Health Services from March 2002 until July 2008, when she stopped working due to chronic swelling and pain. Following her application for LTD benefits, Hartford approved her claim in January 2009, awarding her $2,331.68 monthly benefits retroactively.
In September 2009, Hartford grew suspicious of Brown's alleged physical limitations after receiving a fax linked to a catering business she owned. During a phone call, Brown claimed she was unable to work and was not earning any income, despite sounds of a baby in the background. Hartford's concerns led to the case being referred to their Special Investigation Unit. Surveillance conducted over four days revealed that Brown was caring for a child and engaging in activities inconsistent with her claimed disability, including shopping and driving.
Two unidentified males visited Brown, leaving with food trays and a beverage cup. Brown was seen holding a child near the door before running towards the men's vehicle. An investigator noted a lack of evidence indicating Brown worked for a catering company, suggesting she might be selling food from her residence.
On January 4, 2010, the Social Security Administration (SSA) denied Brown’s disability benefits application, stating that medical evidence showed she was responding to treatment and capable of daily activities without assistance. The SSA concluded that her condition was not severe enough to prevent her from working in non-physically demanding roles. Hartford provided legal counsel for her appeal, which was subsequently denied.
By April 29, 2010, Dr. Grader-Beck indicated that Brown's medical conditions had mostly improved, with only sarcoidosis, arthralgias, and a dry cough remaining. He observed no clear signs of inflammation in her left ankle pain and deemed the dry cough unlikely to be a recurrence of pulmonary issues.
In August 2010, Dr. Grader-Beck signed an Attending Physician’s Statement noting sarcoidosis as the primary diagnosis and described Brown's condition as improved, stating she could engage in various physical activities for limited durations and lift up to 20 pounds occasionally. As a result, Hartford arranged for a Vocational Rehabilitation Counselor, who confirmed Brown could manage the demands of at least six occupations, including histotechnologist. Consequently, Hartford notified Brown on September 27, 2010, that she did not qualify for long-term disability (LTD) benefits beyond September 30.
Brown appealed this decision on March 23, 2011, mentioning new diagnoses of fibromyalgia by Drs. Grader-Beck and Paik. Medical records from October 2010 reflected worsening pain complaints and noted no clear inflammatory signs, with the doctors stating she did not meet fibromyalgia criteria. Reports from March 2011 indicated no abnormalities in imaging tests, with her sarcoidosis being essentially in remission. Although Dr. Grader-Beck noted multiple tender points consistent with fibromyalgia, he did not confirm the diagnosis as she lacked the requisite point tenderness. Initially, Dr. Paik's report suggested Brown was disabled by fibromyalgia, but Dr. Grader-Beck expressed uncertainty, stating he was concerned she might have developed fibromyalgia.
In late May, Dr. Asian Mubashir began treating Brown's sarcoidosis, previously deemed to be in remission by Dr. Grader-Beck. Dr. Mubashir did not diagnose Brown with fibromyalgia or assert she was disabled. A nerve conduction study conducted by Dr. Marc Schlosberg on June 6, 2011, indicated a very mild, mainly demyelinating neuropathy. On June 8, 2011, Brown sought care from Dr. Janaki Kalyanam, who certified her inability to work on June 29, 2011, without providing an explanation. Dr. Navdeep Mathur later gave a more negative assessment of Brown's condition on July 18, 2011, citing only "patient's history" in support of his conclusions and did not personally examine Brown before suggesting a presumptive fibromyalgia diagnosis. Dr. Kalyanam submitted a similar assessment shortly afterward, also referencing fibromyalgia but lacking details of any examination.
Hartford referred Brown's case to an independent rheumatologist, Dr. Chelsea I. Clinton, who reviewed the medical records and attempted to contact Brown's treating physicians, but they did not respond. Dr. Clinton concluded that Brown could perform full-time work activities. Subsequently, Hartford denied Brown's appeal, stating that its decision considered medical information, input from treatment providers, and an independent review. Later, the Social Security Administration awarded Brown disability benefits, but Hartford cautioned her that these benefits would offset her Hartford benefits, potentially leading to an overpayment obligation.
Brown is now seeking summary judgment, claiming Hartford's termination of her long-term disability (LTD) benefits violated ERISA. She requests reinstatement of her LTD benefits retroactively to August 16, 2011, continued payments until the policy ends or she reaches retirement age, declaratory relief, and recovery of costs and attorney fees. Hartford counterclaims for reimbursement of LTD benefits paid during the period Brown received retroactive SSD benefits, asserting a stronger legal argument overall.
Plaintiff’s ERISA claim is reviewed under a "plainly deferential" standard due to Hartford's discretion in determining benefit eligibility. The inquiry centers on the reasonableness of Hartford's decision to terminate Brown’s long-term disability (LTD) benefits, which aligns with the "arbitrary and capricious" or "abuse of discretion" standards. A reviewing court cannot overturn a reasonable decision even if an alternative outcome may also seem reasonable. While conflicts of interest are considered in assessing reasonableness, they do not alter the standard of review.
In Hartford's counterclaim for repayment, the court adheres to summary judgment standards, granting it only when no genuine dispute exists over material facts. The moving party must demonstrate this lack of dispute, and if successful, the burden shifts to Brown to provide specific facts indicating a genuine issue for trial.
The analysis determines that Hartford's decision to terminate Brown's LTD benefits was reasonable based on the evidence available at the time. Hartford reviewed all medical and non-medical evidence, and the only condition Brown claims was overlooked—fibromyalgia—was not cited in Hartford's initial termination because she had not provided medical evidence of the condition until after the termination. Hartford subsequently reviewed this evidence during the appeal process.
Hartford, as the plan administrator, was not obligated to reinstate the plaintiff's benefits based solely on her new medical evidence, given its discretion to evaluate conflicting evidence in the administrative record. The plaintiff presented reports from Dr. Grader-Beck, who noted her disability due to fibromyalgia, but his report lacked definitive diagnostic criteria and included ambiguous statements about the diagnosis. Additionally, other medical assessments from Drs. Kalyanam and Mathur relied heavily on the plaintiff's history and Dr. Grader-Beck's recent presumptive diagnosis without independent evaluation or objective findings to support their conclusions. Dr. Kalyanam's documentation did not provide a physical assessment, further weakening the plaintiff's claim. Conversely, Hartford had evidence indicating the plaintiff's condition had improved, including reports from Dr. Grader-Beck affirming her capability to meet the demands of various occupations and noting that her sarcoidosis was in remission with no abnormalities found in her tests. The overall assessment suggested that the evidence did not sufficiently substantiate the plaintiff's claim for benefits.
A nerve conduction study three months later indicated that Brown had only a "very mild" neuropathy. Surveillance by Hartford revealed that in late 2009, Brown was able to perform various physical activities, including walking, running, and caring for a child, without showing signs of pain, contradicting her claims of limited capability. An independent assessment by Dr. Chelsea Clinton, who reviewed Brown's medical records and attempted to consult her care providers, determined that the evidence did not support Brown's disability claim. Hartford was justified in prioritizing Dr. Clinton's opinion, despite her not examining Brown directly, and it was reasonable for Hartford to reach a conclusion contrary to assessments from other doctors. The review of the administrative record supported Hartford's decision.
The potential conflict of interest in Hartford's dual role as claims evaluator and payer was deemed less significant due to steps taken to ensure unbiased decision-making, including multiple levels of review and input from a neutral third party. There was no evidence presented that Hartford had a history of biased claims administration or that any self-interested behavior influenced its decision. Hartford previously awarded Brown benefits, allowed her to provide new medical evidence, reinstated her benefits when she failed to substantiate her disability, and extended deadlines for her appeal—all actions suggesting fair administration of the plan.
Regarding Hartford's counterclaim, Brown did not contest it or present evidence against Laurie Tubbs's affidavit. She requested that repayments be deducted from future long-term disability (LTD) payments, but Hartford is not obligated to make additional payments. Consequently, Brown must reimburse Hartford $36,473.40 to offset her retroactive Social Security Disability (SSD) payments.
Defendant’s Motion for Summary Judgment is granted, while plaintiff's Motion for Summary Judgment is denied. Judgment favors the defendants on the plaintiff's claims and grants the defendant’s counterclaim for $36,473.40. Although Hartford's counterclaim initially stated an overpayment of $32,907.41, the defendant clarified the correct amount through supporting documentation, which the plaintiff did not contest. Various medical terms are defined, including "histology," "synovitis," "synovial," "etiology," and "sarcoidosis," along with specific conditions diagnosed by Dr. Grader-Beck, such as ankle arthritis and Reynaud's phenomenon. The plaintiff, however, does not use these diagnoses in her lawsuit, instead focusing on a later diagnosis of fibromyalgia.
Fibromyalgia is characterized as a chronic musculoskeletal pain syndrome with an unclear cause. The American College of Rheumatology stipulates that diagnosis requires pain on both sides of the body, above and below the waist, along with tenderness at a minimum of 11 out of 18 designated points. Neuropathy refers to disorders affecting any segment of the nervous system, while demyelination denotes the loss of myelin, which insulates nerve fibers and enhances impulse conduction.
The plaintiff alleges that Social Security Disability (SSD) benefits were granted in November 2011, while the defendant contends the date was December 27, 2011, although this distinction is deemed immaterial. In ERISA cases, the review for abuse of discretion limits the analysis to the evidence available to the administrator, with summary judgment serving primarily to present the legal issue to the court, rather than testing for material fact disputes.
Additional evidence received includes a May 4, 2011 report from Dr. Mathur, which indicated a diagnosis of fibromyalgia by a Johns Hopkins rheumatologist, noting multiple tender points supporting the diagnosis. However, a separate report failed to specify the exact location, number, or duration of these tender points. For a fibromyalgia diagnosis, chronic pain must persist for at least three months, with tenderness at the requisite points.
Defendants are not required to give special consideration to treating doctors if they do not provide supporting evidence for their conclusions, and the demand for objective proof of disability is reasonable. The plaintiff's policy defines disability based on the inability to perform essential duties of one’s recognized occupation, not just the specific job held. Surveillance records were included in Hartford's complete review of the claim file, despite not being explicitly mentioned in termination letters.
Plan administrators are permitted to use surveillance to evaluate the credibility of disability claims and the assessments made by physicians, as affirmed in case law such as *Finley v. Hartford Life* and *Cusson v. Liberty Life Assurance Co.*. The plaintiff, Brown, did not contest Hartford's surveillance findings that she was caring for a child and selling food from her home. Hartford substantiated its conclusions, and Dr. Clinton did not disregard the fibromyalgia diagnosis from Dr. Grader-Beck, referencing it in her clinical summary. Even if Dr. Clinton overlooked some medical evidence, Hartford, as the decision-maker, reviewed all relevant records, including plaintiff's and her treatment providers' information.
Hartford and Dr. Clinton interpreted the plaintiff’s lack of medication as an indication that side effects were not impairing her, rather than as proof of her ability to work. There is no requirement under ERISA for plan administrators to give special weight to treating physicians' opinions or face a heightened burden when rejecting them, as established in *Marcin v. Reliance Standard Life Ins. Co.* Insurance companies can rely on consultant reports to counter treating physicians' claims of disability, as seen in *Williams v. UNUM Life Ins. Co. of Am.* The plaintiff claimed Hartford overwhelmed her with documentation requests but did not provide evidence of timely responses from her or her physician.
Hartford terminated the plaintiff’s benefits in July 2010 due to her and Dr. Grader-Beck's failure to submit necessary medical updates. Benefits were reinstated retroactively after the plaintiff submitted paperwork in September 2010. There is no evidence to support the claim that Hartford expedited the termination letter to preempt a Social Security Administration (SSA) ruling on Brown’s appeal. Although it might have been unreasonable for Hartford to ignore a favorable SSA ruling had it existed at that time, the plaintiff did not provide legal grounds to require Hartford to delay its processes while awaiting all potential SSA appeals. The SSA’s benefits decision for another claimant was not considered relevant to Hartford's actions regarding Brown's claim, and it was not part of the information available to Hartford when it made its determination. Brown was also informed that receiving SSA benefits could lead to her owing money to Hartford.
