Kurth v. Hartford Life & Accident Insurance
Kurth v. Hartford Life & Accident Insurance
Opinion of the Court
FINDINGS OF FACT AND CONCLUSIONS OF LAW
I. INTRODUCTION
This is an action for benefits pursuant to the Employee Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C. § 1001 et seq., brought by Plaintiff Donald J. Kurth, M.D. (“Plaintiff’) against Defendant Hartford Life and Accident Insurance Co. (“Defendant”). The suit stems from Defendant’s alleged failure to conduct a full and fair review of Plaintiffs disability claim. On August 9, 2011, the Court held a bench trial. One of the key issues was whether Defendant erred in failing to conduct an independent medical evaluation (“IME”), such that, at a minimum, the matter must be remanded for further consideration.
Having considered the evidence presented at the trial and the parties’ briefs, the Court now makes the following findings of fact and conclusions of law.
II. PROCEDURAL HISTORY
Plaintiff commenced this action on February 18, 2011, invoking diversity jurisdiction, 28 U.S.C. § 1332.
On May 3, 2011, Plaintiff filed a “Request to Conduct a Pre-trial ‘Nolan Hearing’ to Consider Extrinsic Evidence Rele
III. FINDINGS OF FACT
“In bench trials, Fed.R.Civ.P. 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 Fed.R.Civ.P. 52(a)). “One purpose behind Rule 52(a) is to aid the appellate court’s understanding of the basis of the trial court’s decision. This purpose is achieved if the district court’s findings are sufficient to indicate the factual basis for its ultimate conclusions.” Id. (citations omitted). Furthermore, the court “is not required to base its findings on each and every fact presented at trial.” Id. at 792. The following constitutes the findings of fact based on the Administrative Record (“A.R.”) and extrinsic evidence. The Administrative Record in this matter consists of documents stamped “H0001-1719.”
A. Plaintiffs Occupation and Job Duties
Plaintiff was employed by the Faculty Physicians and Surgeons of Loma Linda University School of Medicine (“Loma Linda”).
In addition to his employment with Loma Linda, at the time Plaintiff applied
B. Plaintiffs LTD Coverage
The Policy confers upon Defendant “full discretion and authority to determine eligibility for benefits.”
The pertinent sections of Dr. Kurth’s Policy provide:
Disability or Disabled means You are prevented from performing one or more of the Essential Duties of: 1) Your Occupation, during the Elimination Period; and 2) Your Occupation, following the Elimination Period, and as a result Your Current Monthly Earnings are less than 80% of Your Indexed Pre-disability Earnings.25
For physicians, the coverage further provides:
Your Occupation means the general or sub-specialty in which You are practicing for which there is a specialty or sub-specialty recognized by the American Board of Medical Specialties. If the sub-specialty in which You are practicing is not recognized by the American Board of Medical Specialties, You will be considered practicing in the general specialty category.26
“Essential Duty” is defined by the Policy as “a duty that (1) is substantial, not incidental; (2) is fundamental or inherent to the occupation; and (3) cannot be reasonably omitted or changed.”
C. Plaintiffs Claim & Defendant’s Denials
Plaintiff left work on June 1, 2007 “due to acute myocardial infarction and severe coronary artery disease.”
Plaintiff was paid short term disability insurance benefits, but was originally denied LTD benefits.
Defendant continued paying Plaintiff LTD benefits until February 20, 2009, when, for the second time, it denied the payments of LTD benefits.
On January 22, 2009, Defendant forwarded a copy of the in-person statement made by Plaintiff to Tingley and the reports and surveillance videos to Dr. Patadia, Plaintiffs cardiologist.
Based on the foregoing information, Defendant concluded that Plaintiff has “demonstrated a significant degree of cognitive and psychological functioning and stress tolerance based on [his] ability to complete an MBA, MPA, operate and oversee operations of various companies, and maintain the office of Mayor of Rancho Cucamonga while being on disability.”
In September 2009, Plaintiff appealed Hartford’s decision to terminate Plaintiffs LTD benefits.
In a letter dated December 8, 2009 (hereinafter, “12/28/2009 Denial Letter”), Hartford Appeal Specialist Chris B. Davis (“Davis”) notified Plaintiff that his appeal was denied. Davis explained that in interpreting Plaintiffs occupational responsibilities, Defendant consulted with Loma Linda and The American Society of Addiction Medicine (“ASAM”) to obtain their input on the requirements of an Addictionist.
Davis also disagreed with Plaintiffs contention that the determination of whether his disability prevented him from one or more “essential duties of his occupation” should be done without regard to his extra curricular activities and accomplishments.
To obtain a comprehensive evaluation, Defendant sent Plaintiffs medical documentation obtained during the original claim investigation process and appeal to UDC. Defendant also forwarded to UDC copies of the surveillance evidence.
Dr. Portrid concluded that “there was no evidence for any heart failure” and opined that “there was no evidence showing that Plaintiffs use of prescription drugs warrants any additional restrictions or limitations.”
With regard to Plaintiffs cognitive complaints, Dr. Johnston observed that while Plaintiff indicated that he has problems with cognitive functioning, Plaintiff did not report these concerns to his treating providers, nor has he taken initiative in seeking assessment or treatment for such symptoms. For these reasons, Dr. Johnston concluded that the need for restrictions or limitations to Plaintiffs psyehological/cognitive functioning is not supported by information available for his review.
IY. STANDARD OF REVIEW AND BURDEN OF PROOF
“Where an ERISA plan confers discretionary authority upon a plan administrator to determine eligibility for benefits, [courts] generally review the administrator’s decision to deny benefits for an
However, it is undisputed in this ease that Defendant operates under a “structural conflict of interest”
“[W]eighing a conflict of interest as a factor in abuse of discretion review requires a case-by-case balance.” Abatie, 458 F.3d at 968; see also, Montour, 588 F.3d at 630 (“The weight the court assigns to the conflict factor depends on the facts and circumstances of each particular case.”). As the Ninth Circuit instructs:
A district court, when faced with all the facts and circumstances, must decide in each case how much or how little to credit the plan administrator’s reason for denying insurance coverage. An egregious conflict may weigh more heavily (that is, may cause the court to find an abuse of discretion more readily) than a minor, technical conflict might. But in any given case, all the facts and circumstances must be considered.... Abatie, 458 F.3d at 968. The significance of a conflict may be low in instances where there is no evidence of “malice, self dealing, or of a parsimonious claims-granting history.” Id. at 968. However, the “court may weigh a conflict more heavily if, for example, [1] the administrator provides inconsistent reasons for denial; [2] fails adequately to investigate a claim or ask the plaintiff for necessary evidence; [3] fails to credit a claimant’s reliable evidence; or [4] has repeatedly denied benefits to deserving participants by interpreting plan terms incorrectly or by making decisions against the weight of evidence in the record.” Id. at 968-969 (internal citations omitted). The court “must determine the extent to which the conflict influenced the administrator’s decision and discount to that extent the deference” the court accords to the administrator’s decision. Saffon v. Wells Fargo & Co. Long Term Disability Plan, 522 F.3d 863, 868 (9th Cir. 2008). Further, the Court may consider extrinsic evidence outside the administrative record to determine “the conflict’s ‘nature, extent, and effect on the decision-making process.’ ” Nolan, 551 F.3d at 1153 (citations omitted).
V. CONCLUSIONS OF LAW
A. Application of Abuse of Discretion with Enhanced Skepticism
Defendant acknowledges that a structur
1. Weighing the Conflict Heavily in this Case is Appropriate
A court may weigh a conflict more heavily if the administrator failed to adequately investigate a claim or ask the plaintiff for necessary evidence. Id. at 968 (citing Booton v. Lockheed Med. Benefit Plan, 110 F.3d 1461, 1463-64 (9th Cir. 1997)). Having considered the administrative record and the extrinsic evidence presented, the Court finds that it must assign significant weight to the conflict because it tainted much of the administrative decision-making process.
Preliminarily, the nature of Defendant’s relationship with the vendors and their reviewing physicians creates an incentive for the vendors to reach results that are favorable to Defendant in order to foster and sustain their business relationship.
In addition, Plaintiff has proffered evidence showing that Defendant’s claims personnel are not completely “walled off’ from those personnel who are involved in its financial operations.
Further, Plaintiff also offered other evidence that may be relevant in ascertaining the quantum of skepticism that the Court
Defendant counters that the “level of scrutiny applied to a claim administrator’s decision is increased only if Plaintiff demonstrates a causal relationship between the structural conflict of interest inherent in an insured plan and the decisions reached.”
Where, as in this case, the plan gives the administrator discretion, and the administrator has a conflict of interest, we are to judge its decision to deny benefits to evaluate whether it is reasonable.... We must judge the reasonableness of the plan administrator skeptically where, as here, the administrator has a conflict of interests.... The conflict of interest requires additional skepticism because the plan acts as judge in its own cause.
Salomaa, 642 F.3d at 675 (emphasis added; citation omitted). In view of Salomaa’s clear mandate, the Court finds that Defendant’s argument — that some kind of “causal link” is necessary before the abuse of discretion could be tempered — lacks merit. Therefore, the Court reviews Defendant’s denial of benefits for abuse of discretion with enhanced skepticism. Montour, 588 F.3d at 631.
2. The Court Finds in Favor of Plaintiff in Applying the Abuse of Discretion Standard with Enhanced Skepticism
“[T]he test for abuse of discretion in a factual determination (as opposed to legal error) is whether ‘we are left with a definite and firm conviction that a mistake has been committed,’ and we may not merely substitute our view for that of the fact finder. To do so, we consider whether application of a correct legal standard was ‘(1) illogical, (2) implausible, or (3) without support in inferences that may be drawn from the facts in the record.’ ” Salomaa, 642 F.3d at 676. For the reasons explained below, the Court finds that Defendant has abused its discretion in terminating Plaintiffs LTD benefits.
Defendant argues that although the Policy grants the administrator the right to request an IME, nothing in the Policy requires the administrator to conduct one. As such, Defendant’s argument goes, the administrator acted within its authority when it refused to conduct an in-person IME prior to terminating Plaintiffs benefits. Defendant further explains that an in-person IME will not add anything to Plaintiffs case and is unnecessary because
Defendant’s conclusion is not supported by sufficient evidence. In Plaintiffs Appeal Letter, dated September 25, 2009, Plaintiff submitted his medical records to support his claim.
Next, Defendant claims that it did not abuse its discretion because it conducted a full investigation of Plaintiffs claim. The Court disagrees. While conceding that Dr. Patadia clearly opined that Plaintiff should be considered “permanently disabled,” Defendant counters that Dr. Patadia’s statement is conclusory and is inconsistent with the medical records, Plaintiffs activities, and the functional capacity demonstrated in surveillance.
Defendant also argues that Plaintiffs cardiac condition is susceptible to objective testing, and it is not obligated to blindly accept Plaintiffs self-reports of chest pains and shortness of breath, especially when those are not supported by objective evidence.
Therefore, the Court concludes that Defendant abused its discretion by terminating Plaintiffs LTD benefits. If there was a question as to Plaintiffs functionality, ERISA requires Defendant to conduct a “full and fair” review of a denial. 29 U.S.C. § 1133(2), which it failed to do.
3. Plaintiffs Cognitive Impairment
In Plaintiffs letter of appeal, he claims that in addition to his physical limitations, he also suffers from cognitive impairment due to his condition and the medications he is taking.
4. Remedies
Plaintiff asks the Court to remand the matter for Defendant to conduct full and fair review by (1) obtaining an appropriate job description and (2) conducting an IME.
The Court finds that a reversal is not warranted under these circumstances as Plaintiff has not conclusively established that he continues to be entitled to LTD benefits. As further investigation of Plain
ERISA benefits may be reinstated if the claimant would have continued receiving benefits absent the administrator’s wrongful conduct. Pannebecker, 542 F.3d at 1221. If an administrator terminates continuing benefits as a result of wrongful conduct, the claimant should continue receiving benefits until the administrator properly applies the plan’s provisions. Id. Such is the case here. But for Defendant’s erroneous determination that Plaintiff was no longer entitled to benefits, Plaintiff would have continued receiving LTD benefits. Accordingly, reinstatement of the LTD benefits is appropriate.
VI. CONCLUSION
Based on the above findings of fact and conclusions of law, the Court remands the matter to Defendant for further consideration of Plaintiffs claim to LTD benefits, and reinstates benefits pending such review and reconsideration.
IT IS SO ORDERED.
. Remand for reevaluation of the merits of a claim is warranted in circumstances where "an ERISA plan administrator, with discretion to apply a plan, misconstrued the Plan and applied a wrong standard to a benefits determination.” Saffle v. Sierra Pac. Power Co. Bargaining Unit Long Term Disability Income Plan, 85 F.3d 455, 461 (9th Cir. 1996).
. 8/9/11 Tr. 48:22-25.
. 8/9/11 Tr. 16:3-4.
. 8/9/11 Tr. 43:9-11.
. To the extent any findings of fact may be deemed conclusions of law, they shall also be considered conclusions. Similarly, to the extent any conclusions as stated may be deemed findings of fact, they shall also be considered findings.
. Docket No. 1.
. DocketNo.il.
. Docket No. 17.
. Docket No. 30.
. Docket Nos. 35 & 40, respectively.
. 8/9/11 Tr. 4:2-6.
. Defendant filed evidentiary objections to Plaintiff's exhibits in support of his Request for a Nolan Hearing, and Plaintiff filed a response. (Docket Nos. 36 & 40, respectively.) As to the deposition transcripts of Bruce Luddy and Jonathan Strang, these transcripts are properly authenticated. (Docket No. 40, Exhs. A-l, B-l.) The Court overrules Defendant's hearsay objections because evidence that is necessary to conduct an ERISA review "need not satisfy the strict rules for the admissibility of evidence in a civil trial, and may be considered so long as it is relevant, probative, and bears a satisfactory indicia of reliability.” Tremain v. Bell Indus., 196 F.3d 970, 978 (9th Cir. 1999). The Court also overrules the objection to the Interrogatory Responses in Ahmad v. Hartford, since Plaintiff has submitted a declaration to properly authenticate the evidence. (Docket No. 40-1, Exh. C — 1.) Lastly, the Court need not address Defendant’s objection to Exhibit F as that evidence has no bearing on the disposition of this claim.
. Docket Nos. 25-29.
. A.R. H1220.
. A.R. H0200, 1220, 1222, 0024.
. A.R. H0024.
. A.R. H0024.
. A.R. H1237.
. A.R. H1221.
. A.R. H0071; H0202.
. A.R. H0072.
. A.R. H1673.
. A.R. H1664.
. A.R. H1670.
. A.R. HI674.
. A.R. H1678.
. A.R. H1675.
. A.R. H1223; H0071.
. A.R. H0071.
. A.R. H1223.
. PL’s Opening Trial Br. at 6.
. A.R. H1061.
. A.R. H0040.
. PL's Opening Trial Br. at 6.
. A.R. H0069.
. A.R. H0071.
. A.R. H0071; H0911-0922.
. A.R. H0071.
. A.R. H0071.
. A.R. H0071.
. A.R. H0072.
. A.R. H0072; H0016.
. A.R. H0072.
. A.R. H0072.
. A.R. H0821.
. A.R. H0073.
. A.R. H0073.
. PL’s Opening Trial Br. at 8; A.R. H0228.
. A.R. H0201.
. A.R. H0201.
. A.R. H0201.
. A.R. H0202.
. A.R. H0202.
. A.R. H0203.
. A.R. H0203-204.
. A.R. H0204.
. A.R. H0205.
. A.R. H0206.
. See Abatie, 458 F.3d at 965 ("[A]n 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.”).
. 8/9/11 Tr. 10:24-11:1.
. 8/9/11 Tr. 10:24-11:1.
. Defendant Hartford and UDC’s symbiotic relationship was noted in Caplan v. CNA Fin. Corp., 544 F.Supp.2d 984, 989-990 (N.D.Cal. 2008). Citing the administrative record, the court finds that as of February 2006,
close to seventy-five percent of UDC's revenue was derived from Hartford. UDC initially charged $300 per hour for its physicians to review disability files, but its hourly charge to Hartford under a 2002 contract was reduced to $225 per hour in what UDC owner Jonathan Strang described as a "volume discount type arrangement.” UDC's gross revenue increased between fifty and one hundred percent from 2002 to 2004 after it signed its contract with Hartford. Since 2002, Hartford has paid UDC more than thirteen million dollars for review services.
. Docket No. 30 at 6.
. 8/9/11 Tr. 11:14-19.
. Kantor Deck, Ex. B, Strang Dep. Tr., 42:9-15 [Docket 30-2.].
. Kantor Deck, Ex. B, Strang Dep. Tr., 42:13-20.
. Kantor Deck, Ex. B, Strang Dep. Tr., 43:13-20.
. Kantor Deck, Ex. C at 12.
. A.R. H1367.
. Delta Family-Care Disability & Survivorship Plan v. Marshall, 258 F.3d 834, 841 (8th Cir. 2001).
. Kantor Decl., Ex. A, Luddy Dep. Tr., 86:9-18.
. Kantor Decl., Ex. A, Luddy Dep. Tr., 86:14-18.
. A.R. H1366.
. Def.’s Responsive Trial Br. at 13.
. Plaintiff claims that reference to the amount of $447,947.00 in the claim file represents Defendant’s financial savings attributable to the termination of Plaintiff’s claim, and “its reference in his file can only be viewed as irrefutable evidence as to the actual motivation behind Hartford's claim denial.” (PL's Opening Trial. Br. at 20.) While this is one way of evaluating the significance of this particular piece of evidence, it is not the only conclusion that can be drawn from Defendant's reference to a monetary amount in its claims file.
. Def.'s Opp'n to Request for a Nolan Hearing at 1.
. Def.'s Opp’n to Request for a Nolan Hearing at 2.
. Def.'s Responsive Tr. Br. at 2.
. Def.'s Responsive Tr. Br. at 2.
. A.R. H0243-0249.
. A.R. H0244.
. A.R. H0244.
. A.R. H0283.
. A.R. H0283.
. A.R. H0246.
. A.R. H0366.
. A.R. H0366.
. A.R. H0367.
. A.R. H0367.
. A.R. H0367-68; Pl.’s Opening Tr. Br. at 8.
. PL's Opening Tr. Br. at 9.
. Plaintiff argues that Defendant abused its discretion by failing to obtain an appropriate job description outlining the essential duties and physical demands of his occupation. (PL's Responsive Trial Br. at 6.) In establishing the "essential duties” of Plaintiff’s occupation, Defendant consulted numerous sources, including the American Medical Association ("AMA”), the American Society of Addiction Medicine ("ASAM”), the Dictionary of Occupational Titles ("DOT”), Loma Linda, and Plaintiff himself. (A.R.H0024, H0845.) Defendant has not erred in considering other sources in addition to Plaintiff's own understanding of his job description. The Policy states that “Your Occupation means Your Occupation as it is recognized in the general workplace, that you were routinely performing prior to becoming disabled.” (A.R. H1678 (emphasis added).) As such, Defendant’s reliance on ASAM, AMA, and DOT’s account of an addictionist's job description is reasonable. Plaintiff's argument that his job description should be limited to his own belief of what his occupation entailed is inconsistent with the Policy's clear provision that "Your Occupation does not mean the specific job You are performing for a specific employer or at a specific location.” Id.
. Def.’s Responsive Br. at 4.
. Def.'s Responsive Br. at 4.
. A.R. H0203; H0073.
. A.R. H0367-368.
. A.R. H0237A.
. A.R. H0237A.
. A.R. H0237A.
. A.R. H0204.
. A.R. H0206.
. PL’s Reply Trial Br. at 6.
. PL’s Responsive Trial Br. at 16-17.
Reference
- Full Case Name
- Donald J. KURTH v. HARTFORD LIFE AND ACCIDENT INSURANCE CO.
- Cited By
- 5 cases
- Status
- Published