Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-alnd-2_06-cv-00339/USCOURTS-alnd-2_06-cv-00339-0/pdf.json

Nature of Suit Code: 791
Nature of Suit: Employee Retirement Income Security Act (ERISA)
Cause of Action: 29:1002 E.R.I.S.A.: Employee Retirement

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IN THE UNITED STATES DISTRICT COURT

NORTHERN DISTRICT OF ALABAMA

SOUTHERN DIVISION

GREGORY HAYES, )

PLAINTIFF, )

VS. ) 2:06-cv-339-JHH

THE HARTFORD LIFE )

INSURANCE COMPANY,

d/b/a Benefit Management )

Services,

)

DEFENDANT.

MEMORANDUM OPINION

I. INTRODUCTION

Pending before the court are Plaintiff’s Motion (doc. #18) for Summary

Judgment filed January 17, 2007 and the Motion (doc. #20) for Summary Judgment

by Hartford Life and Accident Insurance Company (“Hartford”) filed January 17,

2007. Plaintiff filed his Complaint (doc. #1) in this court on February 21, 2006,

seeking reinstatement of disability benefits pursuant to a long term disability

insurance policy insured by Hartford. (See generally Compl.). 

On January 17, 2007, Plaintiff filed his motion (doc. #18) for summary

judgment, brief (doc. #22) in support thereof, and evidentiary submission (docs. #24-

27). On the same date, Hartford filed its motion (doc. #20) for summary judgment,

FILED

 2007 May-15 PM 03:15

U.S. DISTRICT COURT

N.D. OF ALABAMA

Case 2:06-cv-00339-JHH Document 42 Filed 05/15/07 Page 1 of 35
 Because the court’s role in ERISA cases is more akin to an appellate one, the scope of 1

its review on summary judgment is notably different than when it sits as a trial court. See

Providence v. Hartford Life & Accident Ins. Co., 357 F. Supp.2d 1341, 1342 n. 1 (M.D. Fla.

2005) (“[T]he Court’s task is to review the benefit decision based on the administrative record

available to the decision maker at the time he or she made the decision.”). 

2

brief (doc. #21) in support thereof, and evidentiary submission (doc. #23). Both

parties have filed responsive pleadings (docs. #33-34, 39-40) and evidence in support

thereof (docs. # 35-38). 

In addressing the parties’ competing summary judgment motions, this court

must determine which standard of review applies and decide whether plaintiff is

entitled to ERISA benefits as a matter of law. As discussed more fully below, the 1

court finds that Hartford’s motion (doc. #20) for summary judgment is due to be

granted and plaintiff’s motion (doc. #18) for summary judgment is due to be denied.

II. STANDARD OF REVIEW

Under Federal Rule of Civil Procedure 56(c), summary judgment is proper “if

the pleadings, depositions, answers to interrogatories, and admissions on file, together

with the affidavits, if any, show that there is no genuine issue as to any material fact

and that the moving party is entitled to judgment as a matter of law.” Celotex Corp.

v. Catrett, 477 U.S. 317, 322 (1986). The party asking for summary judgment always

bears the initial responsibility of informing the court of the basis for its motion and

identifying those portions of the pleadings or filings which it believes demonstrate

Case 2:06-cv-00339-JHH Document 42 Filed 05/15/07 Page 2 of 35
3

the absence of a genuine issue of material fact. See id. at 323. Once the moving

party has met his burden, Rule 56(e) requires the nonmoving party to go beyond the

pleadings and by his own affidavits, or by the depositions, answers to interrogatories,

and admissions on file, designate specific facts showing that there is a genuine issue

for trial. See id. at 324.

The substantive law will identify which facts are material and which are

irrelevant. See Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 248 (1986). All

reasonable doubts about the facts and all justifiable inferences are resolved in favor

of the non-movant. See Fitzpatrick v. City of Atlanta, 2 F.3d 1112, 1115 (11 Cir. th

1993). A dispute is genuine “if the evidence is such that a reasonable [trier of fact]

could [find] for the nonmoving party.” Anderson, 477 U.S. at 248. If the evidence

is merely colorable, or is not significantly probative, summary judgment may be

granted. See id. at 249.

Although there are cross-motions for summary judgment, each side must still

establish the lack of genuine issues of material fact and that it is entitled to judgment

as a matter of law. See Chambers & Co. v. Equitable Life Assur. Soc. of the U.S.,

224 F.2d 338, 345 (5 Cir. 1955); see also Matter of Lanting, 198 B.R. 817, 820 th

(Bankr. N.D. Ala. 1996). The court will consider each motion independently, and in

accordance with the Rule 56 standard. See Matsushita Elec. Indus. Ltd. v. Zenith

Case 2:06-cv-00339-JHH Document 42 Filed 05/15/07 Page 3 of 35
4

Radio Corp., 475 U.S. 574, 587-88 (1986). “The fact that both parties simultaneously

are arguing that there is no genuine issue of fact, however, does not establish that a

trial is unnecessary thereby empowering the court to enter judgment as it sees fit.”

See WRIGHT, MILLER & KANE, FEDERAL PRACTICE AND PROCEDURE § 2720 at 327-

28 (3d ed. 1998). Also, these are the facts for summary judgment purposes only; they

may not be the actual facts. See Cox v. Administrator U.S. Steel & Carnegie, 17 F.3d

1386, 1400 (11 Cir. 1994) (“‘[W]hat we state as ‘facts’ in this opinion for purposes th

of reviewing the rulings on the summary judgment motion [] may not be the actual

facts.’”) (internal citation omitted). 

III. STATEMENT OF FACTS

A. Introduction and Plan Provisions

Hartford issued a long term disability (“LTD”) policy, GLT-024554 (the

“Policy”) to Wal-Mart Stores, Inc., to insure the long term disability component of

the employee welfare benefit plan established and maintained by Wal-Mart Stores.

(Aff. at ¶ 3.) The Policy includes and incorporates a Certificate of Insurance

(“Certificate”) also referred to as a Booklet-certificate. (Id. at ¶ 4.) 

Hartford is vested with full discretionary authority to construe and interpret the

terms of the Policy and determine eligibility for benefits thereunder. (Administrative

Case 2:06-cv-00339-JHH Document 42 Filed 05/15/07 Page 4 of 35
 The Policy’s definition of “total disability” shifted in October 1997. Prior to this time, 2

“total disability” was determined based upon plaintiff’s inability to perform his own occupation. 

(See doc. #21 at 32, n.4.)

5

Record [“AR”] at 919.) Under the Policy, “total disability” is defined as follows:2

(1) During the Elimination Period; and 

(2) for the next 12 months, you are prevented by:

(a) accidental bodily injury;

(b) sickness;

(c) mental illness;

(d) substance abuse; or

(e) pregnancy,

from performing the essential duties of your occupation, and as a result

you are earning less than 40% of your pre-disability earnings, unless

engaged in a program of Rehabilitative Employment approved by us.

After that, you must be so prevented from performing the essential

duties of any occupation for which you are qualified by education,

training, or experience. “Your occupation” includes similar job

positions with the employer which may be offered to you, with the rate

of pay 60% or higher than your indexed, pre-disability earnings.

(AR at 918.) 

The claimant is responsible for providing on-going proof of disability or

benefits will terminate. In relevant part, the Policy states:

The Hartford will pay benefits until the first to occur of:

(1) the date you are not longer Disabled;

(2) the date you fail to furnish proof that you are continuously

Disabled;

(3) the date you refuse to be examined, if the Hartford requires an

examination . . . 

(AR at 949.)

Case 2:06-cv-00339-JHH Document 42 Filed 05/15/07 Page 5 of 35
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B. Plaintiff’s Disability Claim

1. Introduction

Plaintiff, Gregory Hayes, attended school through the 10 Grade. (AR at 164.) th

Thereafter he worked as a truck driver, delivering mobile homes from factory to

dealer lots. (AR at 225.) In 1989, he began working for Wal-Mart as a truck driver

throughout the Southeast in an approximate 500-mile radius from Cullman, Alabama.

(AR at 224-25.) On July 8, 1996, he suffered injury to his back while rolling a dolly

on a trailer at a Wal-Mart vendor location. (AR at 405, 672.)

On his application for LTD benefits, plaintiff stated he had a 10 grade

th

education. (AR at 671.) Dr. David Brase, an orthopedist, completed an Attending

Physician’s Statement of Disability, listing plaintiff’s primary diagnoses as lumbar

radiculopathy and degenerative disc disease. (AR at 677-78.) By letter dated

September 19, 1996, Hayes’ claim for LTD benefits was approved pursuant to the

policy, effective October 8, 1996. (AR at 93, 660-61.) In that letter, Hayes was

informed that benefits would remain payable after 12 months only if he was “unable

to performthe duties of any occupation for which you are qualified based on previous

training, education, and experience.” (AR at 660-61.) 

As the pain worsened, Hayes was referred to Dr. Charles Clark, a neurologist,

who performed back surgery in August 1997. (AR at 572-73, 582.) Immediately

Case 2:06-cv-00339-JHH Document 42 Filed 05/15/07 Page 6 of 35
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following the surgery, Dr. Clark recommended that Hayes be off work for two to

three months. (AR at 583.) Several months following the surgery, an MRI on Hayes’

back revealed low intensity sclerosis at the L5-S1 level which “could represent a spur

formation that is causing some compression upon the right exiting nerve root at the

L5-S1 level.” (AR at 557.) Otherwise, the scan was normal showing no acute

herniated discs and a normal fusion at the site of the lumbar discs where the surgery

was performed. (Id.) Upon review of the MRI, Dr. Clark extended plaintiff’s driving

restriction for another month but released Hayes back to work effective October 18,

1998, with the restrictions of no prolonged bending,stooping, climbing, or sitting and

a 25 pound weight lifting restriction. (AR at 542, 555.) Hayes did attempt to return

back to work, but found that he “could not stand it;” he has not worked since

November 1998. (AR at 530.) 

In February 1999, Hayes underwent a Functional Capacity Evaluation (“FCE”)

at Dr. Clark’s request. (AR at 530-37.) Hayes reported to the therapist that he could

perform the activities of daily living, smoked two packs of cigarettes a day, and was

able to drive the approximate one hour trip to the appointment but experienced

increased pain thereafter. (AR at 530.) The FCE summary demonstrated that Hayes

could lift up to 15 pounds, occasionally sit, stand, reach overhead, squat, bend, climb

stairs, climb ladders and crawl. (AR at 537.) He could frequently walk and kneel and

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there were no activities he was unable to perform. (Id.) Overall, Hayes scored 125%

on the assessment of whole body range of motion, where 100% was the industrial

norm. (AR at 536.)

Upon his March 1999 review of the FCE findings, Dr. Clark concluded that

Hayes was unable to perform any duty that required prolonged sitting (such as a truck

driver) but stated no other restrictions or limitations. (AR at 540.) “I think he has

reached [maximum medical improvement] as of today. We will plan on seeing him

back only on an as needed basis.” (AR at 540.)

Thereafter, Hayes’ medical care was referred to Dr. Sandra Durham with the

Lighthouse Pain Clinic for chronic pain management. (AR at 518.) In July 2000,

Hayes reported to Dr. Durham that the medication helped him tremendously and

allowed him to remain active and get out in the yard and walk. (AR at 517.)

However, in November 2001, Hayes experienced increased pain, and his dosage of

OxyContin was increased; thereafter Hayes reported a feeling of stability and a desire

to maintain the dosage. (AR at 509.) Medical records note no problems with

cognitive functioning as a result of the increased dosage. (Id.)

In February 2002, Hartford requested an updated attending physician statement

and claimant questionnaire from Hayes. (AR at 457.) In response thereto, Dr.

Cosgrove, an anesthesiologist, submitted a statement of disability listing primary

Case 2:06-cv-00339-JHH Document 42 Filed 05/15/07 Page 8 of 35
 Dr. Cosgrove’s notes reveal that Hayes took the Klonopin sporadically while the Lortab 3

benefitted him greatly. (AR at 385.) 

9

diagnoses as degenerative lumbar disc disease and failed back surgery syndrome. (AR

at 448-49, 453.) However, Dr. Cosgrove declined to comment on plaintiff’s physical

restrictions, stating instead that Hayes needed an updated FCE. (AR at 448-49.)

Records from Dr. Cosgrove indicate that Hayes met with him every four months to

maintain medications of Lortab and Klonopin. (AR at 386.) 3

On March 13, 2003 Hartford notified Hayes by letter that it would be

commencing an investigation to determine whether he would qualify under the “any

occupation” definition of disability. (AR at 377-78.) “Please be advised that we are

continuing your LTD benefits in order to avoid a financial hardship on you as we

have not completed our investigation. The payment of benefits beyond 10/7/97 is not

to be construed as an admission of further liability on your claim. We reserve all

rights and defenses available to us under the policy, and waive none.” (Id.)

2. The “Any Occupation” Investigation

In conjunction with the “any occupation” investigation, Hartford sent Hayes

a claimant questionnaire. In response to the question regarding his current medical

condition, Hayes referred to his August 1997 surgery on his back and Dr. Brase’s

1996 restriction of no lifting over ten pounds. (AR at 371.) At the same time, Dr.

Case 2:06-cv-00339-JHH Document 42 Filed 05/15/07 Page 9 of 35
 Hayes’ internist refused to treat the high blood pressure with medication. (AR at 346.) 

4

10

Cosgrove completed another Attending Physician Statement. (AR at 363-68.) Dr.

Cosgrove listed plaintiff’s primary diagnosis as degenerative disc disease – lumbar

and failed back surgery syndrome. (AR at 368.) He further stated that plaintiff’s

condition was treated with medication but declined to provide restrictions or

limitations, indicating that an updated FCE should be completed. (Id.) 

An in-house nurse with Hartford agreed that plaintiff should undergo a FCE.

(AR at 354.) Although one was scheduled for June 2003, it was never completed

because of plaintiff’s high blood pressure. (AR at 346, 350-53.) Thereafter, on June 4

23 and 24, 2003, Hartford conducted video surveillance of plaintiff. (AR at 724-28

and Video.) The investigative report regarding the video states:

while bent over, with his chest parallel with the ground, he picks up the

ice and throws it forcefully to the ground again. During this action the

subject shows no physical signs of pain or caution. The subject picks up

the bag with both hands, stands without hesitation and walks to the back

of the truck where he transfers the bag to the right hand. He puts the ice

in the bed of the truck then reaches into the bed with both arms, standing

on his tiptoes. The subject appears to open the ice bag and empty its

contents into another container.

(AR at 727-28 and Video.)

Hartford then scheduled Hayes for an independent medical examination

(“IME”) in Decatur, Alabama for August 28, 2003. (AR at 342.) Plaintiff did not

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appear for this appointment, despite a letter fromHartford informing him that “failure

to attend the examination may result in immediate termination of your benefits.” (AR

at 741.) Therefore, Hartford requested independent physician Dr. William Sniger,

board certified in physical medicine and rehabilitation, review plaintiff’s medical

records (through 3/21/03) and surveillance video. (AR at 323-27.) Upon review, Dr.

Sniger noted that several of plaintiff’s physicians recorded plaintiff’s normal gait and

station and motor strength since the 1997 surgery, and concluded that Hayes was

capable of performing sedentary to light work on a full time basis. (AR at 327.)

On December 10, 2003, a Hartford representative conducted an in-person

continuing disability interview with plaintiff, which lasted approximately an hour and

a half. (AR at 765.) Hayes represented during the interview that he was: (1) able to

walk approximately 100 yards before pain in lower back, hips, and both legs rises to

level 10; (2) able to stand for approximately 10 minutes before pain escalates to level

10, has to immediately sit down or he will fall down; (3) able to lift and carry items

that weigh 10 pounds (for example, a gallon of milk from car to house); (4) not able

to bend at the waist without experiencing pain to level 5; would collapse if tried to

bend forward at the waist; (5) not able to twist at the waist without experiencing pain

to a level 4 or 5; (6) not able to squat or kneel without experiencing pain to a level 4

or 5; (7) not able to keep his balance; (8) has full use of his hands and fingers

Case 2:06-cv-00339-JHH Document 42 Filed 05/15/07 Page 11 of 35
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although his grip strength is poor; (9) can sleep approximately 8 hours a night but

only in 2 to 3 hour segments; (10) does not have any computer skills; (11) can drive

approximately one hour before experiencing pain to a level 8 in back, legs and hips,

easier to ride in a car than drive himself; (12) able to sit one hour before experiencing

pain to a level 8 in lower back, hips, and legs, must get up and walk about before he

can sit back down. (AR at 767-69.) Hayes stated that he was prevented “from

returning to my own or any occupation because I experience too many bad days and

I experience chronic back, hip and leg pain to a level 10. I can not lift and carry

anything over 10 pounds in weight. I can not stand, sit or walk for extended periods

of time.” (AR at 770.) When shown the video surveillance tape, Hayes

acknowledged that it accurately depicted his level of functionality but commented

that he has to go about living his life. (AR at 771.) Upon conclusion of the

interview, the interviewer noted “Mr. Hayes did not complain of pain and he did not

display any objective symptoms of pain during the time I spent with him. Mr. Hayes

was able to walk to and from our table with a normal gait and without difficulty. Mr.

Hayes never lost his balance when he arose from the table after sitting in the same

chair for over an hour and a half.” (AR at 765.) 

In February 2004, a Vocational Rehabilitation Clinical Case Manager for

Hartford, Larry Underwood, performed an employability analysis of Hayes. (AR at

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13

309.) Underwood’s conclusion identified three alternative unskilled occupations that

Hayes could perform, taking into account his physical limitations and educational

background – loading inspector, truck safety inspector, and perishable freight

inspector. (AR at 244, 309.)

• Loading Inspector: as per D.O.T., the occupational physical demands

include but are not limited to climbing, balancing, stooping, kneeling,

crouching, crawling, and other activities. Prolonged static posture

would not be expected to occur in the performance of this occupation.

By D.O.T. definition walking/standing to a significant degree would be

involved. Completion of paperwork/reports would require some sitting.

The walking/standing and sitting required would likely eliminate

prolonged static posture positions. (AR at 140.)

This position also requires general educational development:

• Reasoning: Grades 7-8

• Mathematics: Grades 4-6

• Language: Grades 7-8

(AR at 251.)

• Safety Inspector: as per D.O.T. the occupational physical demands

include stooping, kneeling, crouching, and crawling. Prolonged static

posture would not be expected to occur in the performance of this

occupation. By D.O.T. definition walking/standing to a significant

degree would be involved. Completion of paperwork/reports would

require some sitting. The walking/standing and sitting required would

likely eliminate prolonged static posture situations. (AR at 140.)

This position also requires general educational development:

• Reasoning: Grades 7-8

• Mathematics: Grades 4-6

Case 2:06-cv-00339-JHH Document 42 Filed 05/15/07 Page 13 of 35
14

• Language: Grades 4-6

(AR at 261.)

• Perishable-Freight Inspector: as per D.O.T., walking/standing to a

significant degree would be involved. Completion of paperwork/reports

would require some sitting. The walking/standing and sitting required

would likely eliminate prolonged static posture situations. (AR at 140.)

This position also requires general educational development:

• Reasoning: Grades 7-8

• Mathematics: Grades 4-6

• Language: Grades 7-8

(AR at 264.)

Hartford then requested an updated evaluation from Dr. William Sniger. (AR

at 891.) In response thereto, Dr. Sniger stated “it remains my medical opinion that

the claimant has the functional capacity to perform sedentary to light work on a fulltime basis.” (Id.) 

Dr. Sniger also contacted Dr. Cosgrove regarding the positions identified by

Underwood. (AR at 307, 887-90.) Dr. Cosgrove again responded that he would

require a FCE to be performed before providing further comment. (AR at 894-95.)

However, additional medical records were submitted by Dr. Cosgrove at this time,

indicating that Hayes continued to experience left lower extremity pain but yet

ambulated with a “fairly normal gait and station.” (Id.) Moreover, “examination of

the thoracolumar spine is essentially unchanged from previous,” “there is no

Case 2:06-cv-00339-JHH Document 42 Filed 05/15/07 Page 14 of 35
15

significant tenderness on deep palpation,” “range of motion is fair in all planes with

pain provoked on the extremes of range of motion,” and “lower extremities – normal

for power and tone.” (Id.) Because Hayes was complaining of increased pain in his

left leg, Dr. Cosgrove scheduled him for an MRI. (AR at 301.) The MRI indicated

inflammation but no definite disc herniation or spinal stenosis. (AR at 306.)

Hartford then scheduled Hayes for an orthopedic independent medical

examination (“IME”) in June 2004 with Dr. Larry Parker. (AR at 82-83, 790.) After

a physical examination and reviews of the original FCE, vocational report, and

history, Dr. Parker concluded that Hayes was capable of working in a “light to

sedentary” occupational setting. (AR at 287.) Dr. Parker did not identify any

occupation that fell within that range, but did note “[r]easonable restrictions and

limitations for plaintiff would include restriction from prolonged sitting or repetitive

bending and lifting with a general lifting restriction of 30 pounds occasionally and

10 pounds regularly.” (AR at 287-88.) Dr. Parker also noted that Hayes “did not

display or reveal any significant symptoms of symptom magnification, job

dissatisfaction or secondary gain during his history or physical examination.” (AR

at 287.) 

Hartford requested Dr. Cosgrove’s comments on the decision that Hayes was

capable of performing sedentary to light work. Dr. Cosgrove refused to comment,

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16

instead once again stating that he would need to see an updated FCE in addition to

the job description of any potential jobs slated for Hayes. (AR at 272-73.) 

Hartford informed Hayes by letter dated August 24, 2004 that his LTD benefits

would be terminated effective August 31, 2004 because “to continue to receive

benefits, you must be disabled . . . according to the LTD policy language.” (AR at

76-78.) The letter stated that in contrast to the policy definition of disability, “the

functionality you demonstrated during the surveillance and the results of the MAG

review indicated you possess work capacity. The Independent Medical Evaluation

results indicate you have the capacity to perform light duty work . . . an Employability

Analysis report indicated you have transferrable skills to perform several occupations

which meet policy requirements.” (AR at 80-81, 236-41.)

3. The Appeal

Hayes appealed this decision by letter dated February 17, 2005. (AR at 183-

84.) The appeal included the following supplemental information: a letter from the

primary treating physician, Dr. David Cosgrove, the FCE performed at Dr.

Cosgrove’s request by HealthSouth, and a vocational evaluation performed by

Thomas Elliott concerning the analysis of the medical information taken together with

other tests to determine whether Hayes had the ability of performing any occupation.

(Id.) 

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17

The January 13, 2005 FCE completed by Dr. Beck and submitted on appeal

made the following work restriction recommendations:

• Standing: one-half hour at a time. The patient may resume activity if he

has the opportunity to change positions for five to ten minutes.

• Walking: one-half hour at a time. The patient may resume activity if he

has the opportunity to change positions for five to ten minutes.

• Sitting: up to two hours at a time. The patient may resume activity if he

has the opportunity to change positions for five to ten minutes.

• Lifting: occasional lift 20 pounds, frequent lift 15 pounds.

• Climbing: no restrictions.

• Balancing: no restrictions.

• Stooping: occasional.

• Twisting: occasional.

• Kneeling: no restrictions.

• Crouching: occasional.

• Squatting: occasional.

• Reaching, handling, and fingering: no restrictions.

(AR at 198-99.) The February 11, 2005 letter from Dr. Cosgrove submitted on appeal

advised that he generally agreed with the FCE, with the exception that Hayes should

not perform climbing, balancing, and/or kneeling at work. (AR at 194.) Moreover,

Case 2:06-cv-00339-JHH Document 42 Filed 05/15/07 Page 17 of 35
18

Dr. Cosgrove’s letter dispelled concerns about Hayes’ medications, stating: “Based

upon the patient’s office visits and discussions concerning side effects of his current

medication regimen, it would appear he does not suffer significant problems in these

areas. Formal cognitive testing could be performed during both the presence and

absence of the medication to confirm this observation, but it is likely not necessary.”

(Id.) 

Also attached to the appeal letter was a vocational evaluation performed by

Thomas Elliott, Licensed Professional Counselor, Rehabilitation and Vocational

Expert, Registered Psychometrist on February 14, 2005. (AR at 224-32.) Elliott

made the following conclusions:

• Hayes continues with a Commercial Driver’s License and went to the

Bradford Treatment Center for alcohol problems. (AR at 224, 228-29.)

• With the administration of the Wechsler Abbreviated Scale of

Intelligence, Mr. Hayes obtained a verbal I.Q. of 77, performance I.Q.

of 86, and full scale I.Q. of 79. These results place him within the upper

limits of the borderline range of intellectual functioning, and at the 8th

percentile rank. At the 90% confidence level, his full scale I.Q. would

range from 76-83.

• With the administration of the reading portion of the Wide Range

Achievement Test, Third Edition, he obtained a standard score of 70

which falls within the borderline range, consistent with his intellect. He

is currently reading at 4 grade level of ability. th

• The restrictions of the FCE preclude his ability to perform any of his

past relevant work or any work to which acquired skills would be

Case 2:06-cv-00339-JHH Document 42 Filed 05/15/07 Page 18 of 35
19

transferrable.

• His intellectual and educational background limit him to unskilled to no

greater than low-end semi-skilled work, the vast majority of which is

physically demanding and/or is production based work set in industrial

or factory setting.

• Mr. Hayes is considered to have a 100% vocational disability rating.

• He is not capable of performing any occupation to which he is otherwise

qualified to perform on the basis of education, training, and work

experience.

(AR at 229-30.)

Armed with this additional information, Hartford continued the appeals

process. As part thereof, Hartford requested a peer review through the University

Disability Consortium. (AR at 175-77.) Dr. Barry Turner, a board certified doctor

in orthopedic surgery, reviewed the IME results, the January 2005 FCE results, the

video surveillance, and Dr. Sniger’s peer review report. (AR at 171.) Turner

concluded:

• Low back pain with degenerative disc disease. There is no evidence of

herniated disc, nerve root compression, myelopathy or radiculopathy.

• The two functional capacity evaluations suggested the capability of

doing light work in high correlation to the surveillance video.

• There is no evidence that he has any significant impairment whatsoever

and no reason that he could not perform sedentary or light duty level

work full-time without further restrictions and limitations.

Case 2:06-cv-00339-JHH Document 42 Filed 05/15/07 Page 19 of 35
20

• Examination findings are essentially normal.

• Dr. Cosgrove noted that the claimant could be cognitively impaired as

a result of medications that he takes, however, there is no evidence in

any of the records that I reviewed where he complains of being

cognitively impaired from medications and no one has reported

objective findings, especially of the FCE noting that he was cognitively

impaired while performing FCE testing. Thus, there does not appear to

be any merit in the allegation of impairment as a result of medications.

• I have no hesitation to recommend that he is capable of performing light

full-time duty work without further restrictions and limitations as long

as he remains at that level of labor and has the ability to change

positions at will and as necessary.

(AR at 131-32.) Hartford followed up with this peer review report by requesting its

vocational counselor, Larry Underwood, to again revisit plaintiff’s employability

report. (AR at 167.) Underwood again identified three occupations for which Hayes

was qualified – loading inspector, safety inspector, and perishable freight inspector.

(AR at 166.) Underwood noted that each of the three occupations required both

walking/standing and sitting, and concluded that the varied physical requirements

would likely eliminate prolonged static posture situations. (Id.) 

Hayes’ appeal of the long term disability decision was submitted to Corey

Welch, appeals specialist. (Welch Dep. at 5-6, 11, 19-20.) Welch reviewed all of the

information in the file and agreed with the finding of Underwood that Hayes was

qualified and able to perform the positions of loading inspector, truck safety

Case 2:06-cv-00339-JHH Document 42 Filed 05/15/07 Page 20 of 35
 Hartford uses the national economy to make the employability analysis. (Welch Dep. at

5

54.) Location is not a factor. (Welch Dep. at 54-55.) 

21

inspector, and perishable freight inspector. (Welch Dep. at 33-34.) Welch 5

performed no independent testing on Hayes’ reading, mathematics, and reasoning

skills, instead relying on Underwood’s vocational report and employability analysis.

(Welch Dep. at 44, 46-47, 52.) 

By letter dated March 16, 2005, Hartford notified Hayes that the decision to

terminate LTD benefits was upheld on appeal. (AR at 64-67.) The letter addressed

each new piece of information that Hayes had submitted on appeal, particularly

addressing the vocational report by Elliott. (AR at 65.)

You provided a 2/16/05 vocational report by Elliott MA, CRC which

concluded in part “on the basis of this evaluation with the adverse

profile of an individual of age 45 who has not worked in any capacity

since the Fall of 1998; limited education; no GED or vocational training;

marginal reading skills; borderline intellect; past relevant work history

entirely that of a truck driver; medical history of lumbar fusion with

continuing radiculopathy and back pain; significant work restrictions

that preclude his past work or any work to which acquired skills would

be transferrable; need to frequently change postural positions; and

continuing significant levels of pain, Mr. Hayes is considered to have a

100% vocational disability rating.”

(Id.) Hartford responded to the findings of Elliott by stating: “our employability

analysis determined he [plaintiff] is qualified for several occupations based on the

information in our file including his medical status, his demonstrated employment

Case 2:06-cv-00339-JHH Document 42 Filed 05/15/07 Page 21 of 35
22

history, and his education level. We do not agree that Mr. Hayes’ work restrictions

preclude all work. Please also note that Mr. Hayes attended school to the 10 grade. th

The occupations we identified for him require only 7 to 8 grade reasoning, th th

mathematics, and language abilities.” (AR at 65.)

The final decision of Hartford denying continuing long term disability benefits

is now under review.

IV. FRAMEWORK OF ANALYSIS

A. Three Levels of Scrutiny

The Eleventh Circuit has articulated three different levels of scrutiny in suits

involving benefits denials by the administrator of an ERISA plan. See, e.g., Shaw v.

Conn. Gen. Life Ins. Co., 353 F.3d 1276, 1282 (11th Cir. 2003). First, in

circumstances where the plan does not vest the administrator with discretion to

determine eligibility for benefits or to construe the terms of the plan, the court

reviews the denial decision de novo. See Firestone Tire & Rubber Co. v. Bruch, 489

U.S. 101, 115 (1989). Second, where the terms of the plan provide the administrator

with such discretion, its decision to deny benefits is, as a general matter, afforded

substantial deference and subjected to an “arbitrary and capricious” standard of

review. See Brown v. Blue Cross & Blue Shield of Ala., 898 F.2d 1556, 1558 n.1

Case 2:06-cv-00339-JHH Document 42 Filed 05/15/07 Page 22 of 35
 A plan administrator has a conflict of interest where it retains control over the 6

decision-making process, and also pays the relevant benefits out of its own funds. See Brown,

898 F.2d 1556 at 1566-67. 

 Although the Eleventh Circuit has articulated the steps in several different ways, see, 7

e.g., Williams v. BellSouth Telecomms., Inc., 373 F.3d 1132, 1138 (11th Cir. 2004) (integrating

23

(11th Cir. 1990).

However, where a plan administrator, vested with discretion, has a conflict of

interest, this deferential review is adjusted, and a third standard of review is 6

employed. See id. at 1566-67. That standard is one of “heightened” arbitrary and

capricious review, and affords the administrator’s decision to appreciably less

deference than it would receive absent the conflict of interest. Id. This “heightened”

level of scrutiny applies regardless of whether the dispute in question turns on a

question of fact, or on the proper construction to be given the plan. See Torres v.

Pittston Co., 346 F.3d 1324, 1329 (11th Cir. 2003).

Here, the parties agree that Hartford was both vested with discretion under the

plan and suffered from a conflict of interest. (See Doc. #21 at 27-30; see also Doc.

#22 at 14-15 and Doc. #33 at 12.) As such, it is undisputed that the “heightened”

arbitrary and capricious standard applies.

B. Heightened Arbitrary and Capricious Review

Under the “heightened” arbitrary and capricious standard of review, the court

must apply three steps. First, under de novo review, the court determines whether 7

Case 2:06-cv-00339-JHH Document 42 Filed 05/15/07 Page 23 of 35
steps to determine proper level of scrutiny with remainder of “test,” arriving at six-prong

analytical framework), where the parties agree that the administrator both possessed discretion in

denying benefits and suffered from a conflict of interest, only three steps are needed to resolve

the claimant’s case.

24

the decision to deny benefits was “wrong.” Williams v. BellSouth Telecomms., Inc.,

373 F.3d 1132, 1138 (11th Cir. 2004). A decision is “wrong” when the court

disagrees with it. See id. If it is not “wrong,” then the administrator prevails. Id. 

If the court determines that the decision was “wrong,” however, it goes to the second

step and determines whether the decision was nevertheless reasonable. Id. A

decision is reasonable when “there was a reasonable basis for the decision, based

upon the facts as known to the administrator at the time the decision was made.” Jett

v. Blue Cross & Blue Shield of Ala., Inc., 890 F.2d 1137, 1139 (11th Cir. 1989). If

the court determines that the administrator’s decision was both “wrong” and not

reasonable, then the claimant prevails. Williams, 373 F.3d at 1138.

A more difficult situation arises, however, when the administrator’s decision

to deny benefits is “wrong,” but nevertheless reasonable. Were the decision to be

subjected only to an arbitrary and capricious standard of review, it would be entitled

to deference, and the administrator would prevail. Id. Under the “heightened”

arbitrary and capricious standard, however, something more is required before the

administrator may escape liability. See id. The Eleventh Circuit has not decided

Case 2:06-cv-00339-JHH Document 42 Filed 05/15/07 Page 24 of 35
25

what that “something” is. See id.

In Brown v. Blue Cross & Blue Shield of Alabama, where the Eleventh Circuit

first articulated the parameters of the “heightened” arbitrary and capricious standard,

the Eleventh Circuit held 

that when a plan beneficiary demonstrates a substantial conflict of

interest on the part of the fiduciary responsible for benefits

determinations, the burden shifts to the fiduciary to prove that its

interpretation of plan provisions committed to its discretion was not

tainted by self-interest. That is, a wrong but apparently reasonable

interpretation is arbitrary and capricious if it advances the conflicting

interest of the fiduciary at the expense of the affected beneficiary or

beneficiaries unless the fiduciary justifies the interpretation on the

ground of its benefit to the class of all participants and beneficiaries. 

898 F.2d at 1566-67. As the above indicates, however, Brown dealt with a dispute

where the issue was the proper interpretation to be given the plan itself. See id. Later

Eleventh Circuit decisions stated that Brown’s “heightened” arbitrary and capricious

standard of review applied equally to challenges to an administrator’s factual

determinations. See, e.g., Torres, 346 F.3d at 1329. Such decisions did not, however,

address the mechanics of the heightened standard to challenges of an administrator’s

factual conclusions. 

In Williams v. BellSouth Telecommunications, Inc., however, the Eleventh

Circuit reflected on earlier decisions which seemingly applied the “heightened”

arbitrary and capricious standard in the context of factual challenges to an

Case 2:06-cv-00339-JHH Document 42 Filed 05/15/07 Page 25 of 35
26

administrator’s denial of benefits. 373 F.3d at 1138-39. Although acknowledging the

apparent application of the Brown test in these cases, the Eleventh Circuit

emphasized that it “did not say whether Brown’s ‘heightened arbitrary and

capricious,’ burden-shifting approach should be applied to factual determination

cases like this.” Id. at 1139. The Eleventh Circuit, however, declined to articulate

an alternative formulation of the “heightened” arbitrary and capricious standard to be

applied in factual determination cases, because the case before it did not require the

Court to get to that step. Id. Instead, the Court “le[ft] the issue for another day.” Id.

V. APPLICATION

A. Was Hartford’s Decision Denying Benefits Wrong When

Reviewed On A De Novo Basis?

Under Williams, the court’s initial task is to review, on a de novo basis,

whether Hartford’s decision to deny plaintiff’s claim for disability benefits based on

the “any occupation” definition of disability was correct. This first step calls for the

court to decide whether it agrees or disagrees with the claim administrator’s benefitsdenial decision. If the court determines that the administrator’s decision is correct,

then summary judgment is due to be entered in favor of Hartford and no further

inquiry is necessary.

Case 2:06-cv-00339-JHH Document 42 Filed 05/15/07 Page 26 of 35
27

1. There is no dispute that Hayes’ medical condition allows him to

perform sedentary/light work.

“The plaintiff does not disagree with defendant that simply based upon medical

evidence [Hayes] is qualified physically for ‘light duty’ work.” (Doc. #32 at 16, 19;

see also Doc. #40 at 3.) In fact, all of the medical evidence available in this case

indicates that Hayes, from a purely medical standpoint, is able to work. 

• Dr. Clark, the neurologist who performed back surgery on

plaintiff in August 1997, released Hayes back to work with the

restrictions of no prolonged bending, stooping, climbing, or

sitting and a 25 pound weight lifting restriction. (AR at 542,

555.)

• The FCE results from February 1999 revealed that Hayes could

lift up to 15 pounds, occasionally sit, stand, reach overhead,

squat, bend, climb stairs, climb ladders, and crawl. The FCE also

demonstrated that Hayes could frequently walk and kneel, and

that there were no activities he was unable to perform. (AR at

537.)

• Dr. Clark reviewed the February 1999 FCE and concluded that

Hayes was unable to perform any duty that required prolonged

sitting (such as a truck driver) but stated no other restrictions or

limitations. (AR at 540.)

• Medical records from the Lighthouse Pain Clinic indicate no

problems with cognitive functioning as a result of pain

medication. (AR at 509.)

• Video surveillance of Hayes in 2003 revealed his ability to bend

over, with his chest parallel to the ground, pick up a bag of ice,

and throw it forcefully to the ground. (AR at 727-28.)

Case 2:06-cv-00339-JHH Document 42 Filed 05/15/07 Page 27 of 35
28

• Independent physician Dr. William Sniger reviewed Hayes’

medical records and surveillance video, and concluded that Hayes

was capable of performing sedentary to light work on a full-time

basis. (AR at 327.)

• In February 2004, Hartford’s vocational rehabilitation case

manager identified three positions which Hayes would be

medically capable of performing: loading inspector, safety

inspector, and perishable freight inspector. (AR at 166, 244,

309.)

• Dr. Sniger performed an updated evaluation, concluding “it

remains my medical opinion that the claimant has the functional

capacity to perform light work on a full-time basis.” (AR at 891.)

• Dr. Larry Parker, an independent medical examiner, performed an

orthopedic IME on Hayes in June 2004 and concluded that Hayes

was capable of working in a “light to sedentary” occupational

setting. (AR at 287.)

• Dr. Cosgrove never claimed Hayes was totally disabled, instead

repeatedly stating his need for an updated FCE. (AR at 194, 198.)

• The FCE results from January 2005, submitted by the plaintiff on

appeal, suggest that if given the opportunity to change position,

plaintiff can lift up to twenty pounds at a time, sit for up to two

hours at a time, and stand and walk for one-half hour at a time.

(AR at 196.)

• Dr. Cosgrove reviewed the results of the January 2005 FCE and

generally agreed with it, but stated that Hayes should not perform

climbing, balancing, and/or kneeling at work. (AR at 194.) The

same review noted that Hayes’ pain medications likely did not

interfere with his cognitive reasoning. (Id.)

• The vocational opinion of Thomas Elliott states that plaintiff has

the ability to perform “unskilled to no greater than low-end semiCase 2:06-cv-00339-JHH Document 42 Filed 05/15/07 Page 28 of 35
29

skilled work,” while at the same time noting that the “vast

majority” of these types of jobs are physically demanding and/or

is production based work set in industrial or factory setting. (AR

at 229-30.) 

• Dr. Barry Turner reviewed all of the information on appeal,

recommending “[Hayes] is capable of performing light full-time

duty work without further restrictions and limitations as long as

he remains at that level of labor and has the ability to change

positions at will and as necessary. (AR at 131-32.)

Thus, Hartford’s decision that Hayes is medically able to perform sedentary/light

work was correct on de novo review of that decision. 

The heart of the dispute, however, is whether plaintiff has the intellectual

capacity to perform “any occupation.” Corey Welch, Hartford’s 30(b)(6)

representative and appeals specialist, testified that Hartford claims managers use the

“60% of predisability indexed earnings” as an “administrative guide” in an effort to

provide claimants a reasonable source of income. (Welch Dep. at 23-24.) Hartford

in fact utilized this 60% benchmark in identifying three positions for which Hayes

might be qualified – loading inspector, truck safety inspector, and perishable freight

inspector. (AR at 308-09.) Plaintiff’s argument is, essentially, that since the

vocational report completed by Elliott concludes that Hayes possesses only 4 grade

th

reasoning skills, he is not qualified to perform these three positions (the definition of

which require minimum 7th-8th grade reasoning skills) and therefore he is disabled

Case 2:06-cv-00339-JHH Document 42 Filed 05/15/07 Page 29 of 35
 As noted earlier, the parties have filed cross motions for summary judgment. (See Docs. 8

#18, 20.) Each motion contends that no material facts are in dispute. In fact, the parties agree

that the administrative record, and facts available to Hartford at the time the decision to deny

benefits were made, encompass the scope of this court’s review. Therefore, that one doctor

opines Hayes is mentally capable of performing “any occupation” while another opines that

Hayes is not so capable does not create a question of material fact as contemplated by Rule 56 of

the Federal Rules of Civil Procedure. It is undisputed that each doctor held the opinion as

reflected within the administrative record. What is in dispute is whether Hartford gave proper

weight and review to the competing opinions.

30

from “any occupation” and Hartford’s decision to deny benefits was wrong. (See

Doc. #32 at 16-19; see also Doc. #22 at 17.)

2. Hartford was correct in deciding that Hayes possessed the

intellectual capacity to perform unskilled occupations consistent

with the occupational qualifier test.

The following evidence is undisputed:

8

• On his application for LTD benefits, plaintiff stated that he had a 10th

grade education. (AR at 671.)

• After high school, plaintiff worked as a truck driver, delivering mobile

homes from factory to dealer lots. (AR at 225.)

• Plaintiff began working for Wal-Mart in 1989 as a truck driver

throughout the Southeast in an approximate 500-mile radius from

Cullman, Alabama. (AR at 224-25.)

• Hayes said that the reason he was prevented “from returning to my own

or any occupation [is] because I experience too many bad days and I

experience chronic back, hip, and leg pain to a level 10. I can not lift

and carry anything over 10 pounds in weight. I can not stand, sit, or

walk for extended periods of time.” (AR at 770.)

• During the in-person interview with a Hartford representative, the

interviewer noted that plaintiff was “able to understand the questions

Case 2:06-cv-00339-JHH Document 42 Filed 05/15/07 Page 30 of 35
31

and provide cogent responses to questions. Mr. Hayes was able to

effectively review and edit both of his statements.” (AR at 799.)

• When asked about his ability to read during the interview, plaintiff

admitted he could read without restriction or limitation. (AR at 802.)

• Plaintiff’s cognitive abilities are not significantly compromised due to

his medication. (AR at 131-32, 194.)

• Hayes continues with a Commercial Driver’s License. (AR at 224, 228-

29.)

• Plaintiff is at the borderline range of intellectual functioning, and at the

8 percentile rank. (AR at 229-30.) th

• Plaintiff is currently reading at a 4 grade level of ability. (AR at 229- th

30.)

• Plaintiff’s intellectual and educational background limit him to unskilled

to no greater than low-end semi-skilled work, the vast majority of which

is physically demanding and/or is production based work set in

industrial or factory setting. (AR at 229-30.) 

• Each of the Attending Physicians who evaluated plaintiff’s condition

indicated that plaintiff was capable of handling his own finances and

was competent to endorse checks and direct the use of the proceeds

thereof. (AR at 368, 583, 597, 678, 715.) 

• During the initial stage of his disability, plaintiff performed office work

for Wal-Mart including answering the phone and other administrative

work. (AR at 639.) 

On de novo review, the overwhelming weight of this evidence indicates that Hayes

has the experience, mental capacity, and training to work in unskilled occupations

other than truck driver. Although Thomas Elliott, a Licensed Professional Counselor,

Case 2:06-cv-00339-JHH Document 42 Filed 05/15/07 Page 31 of 35
 Contrary to plaintiff’s argument otherwise, Hartford did not ignore plaintiff’s creditable 9

evidence in order to cut off benefits. (See Doc. # 32 at 18 and AR at 64-67.)

 Elliott agreed that plaintiff’s prior occupation was best described by the DOT as

10

Tractor-Trailer-Truck Driver. (AR at 225.)

32

Rehabilitation and Vocational Expert, and Registered Psychometrist, performed

testing which indicated that Hayes possessed borderline intellectual functioning and

was reading at a 4 grade level of ability, those findings belie Hayes’ intellectual th 9

capacity to drive trucks throughout the Southeast for ten years and maintain a

Commercial Driver’s License even to this day. In fact, when conducting the

employability analysis, Hartford’s rehabilitation case manager looked specifically at

the profiles of plaintiff’s previous occupations, Tractor-Trailer-Truck Driver and 10

Escort-Vehicle Driver. (AR at 311-12.) All three identified occupations of loading

inspector, truck safety inspector, and perishable-freight inspector have the very same

requirements for reasoning, mathematics and language as plaintiff’s previous

occupations, and, in fact, the truck safety inspector occupation has a less onerous

language requirement than his previous occupations. (See Doc. #33 at 19; see also

Doc. #39 at 2-3.)

Armed with overwhelming evidence attesting to Hayes’ mental capacity to

perform unskilled work which would earn him approximately 60% of his predisability

indexed earnings, Hartford was under no obligation to perform additional IQ or

Case 2:06-cv-00339-JHH Document 42 Filed 05/15/07 Page 32 of 35
33

vocational testing. See Archible v. Metropolitan Life Ins. Co., 85 F. Supp.2d 1203,

1220 n. 13 (S.D. Ala. 2000) (“We hold that consideration of vocational evidence is

unnecessary where the evidence in the administrative record supports the conclusion

that the claimant does not have an impairment which could prevent him from

performing some identifiable job. The plan administratoris not required in every case

where the ‘any occupation’ standard is applicable to collect vocational evidence in

order to prove there are available occupations for the claimant.”); see also Hufford

v. Harris Corp., 322 F. Supp. 2d 1345, 1359 (M.D. Fla. 2004) (“When, as here, the

claimant’s previous employment was not highly skilled or technical, the plan

administrator need not conduct a vocational assessment or consider vocational

evidence to determine that the claimant is disabled under the ‘any occupation’

standard”). In fact, “rehabilitation case managers are able to draw conclusions from

other information about how education and work history would support a level of

mental capacity.” (Welch Dep. at 44, 61.) It was plaintiff’s burden to demonstrate

his continuing disability from “any occupation” due to mental capacity. See Farley

v. Benefit Trust Life Ins. Co., 979 F.2d 653, 658 (11 Cir. 1992). His failure to do

th

so was not Hartford’s burden. See Hufford, 322 F. Supp. 2d at 1360 (“The Plan

participant seeking to challenge [the plan administrator’s] denial of benefits [] must

demonstrate that he was entitled to receive the residual disability benefits under the

Case 2:06-cv-00339-JHH Document 42 Filed 05/15/07 Page 33 of 35
 See discussion, supra, Section IV.B. 11

34

terms of the Policies”).

Thus, Hartford was de novo correct to conclude that Hayes possessed the

intellectual capacity to perform “any occupation.”

B. Because Hartford’s Decision to Deny Benefits was De Novo Correct,

the Inquiry Ends and Hartford Prevails.

Under de novo review, this court has determined that the decision to deny

benefits was correct. See Williams, 373 F.3d at 1138. Therefore, Hartford prevails.

See id. There is no reason for the court to advance to the next step in analyzing the

claim for benefits. See id. 11

V. CONCLUSION

For the reasons asserted above, the Motion for Summary Judgment by Hartford

Life and Accident Insurance Company (doc. #20) is due to be granted and Plaintiff’s

Motion for Summary Judgment (doc. #18) is due to be denied. A separate order will

be entered.

DONE this the 15th day of May, 2007.

 

SENIOR UNITED STATES DISTRICT JUDGE 

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35

Case 2:06-cv-00339-JHH Document 42 Filed 05/15/07 Page 35 of 35