Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-arwd-3_05-cv-03029/USCOURTS-arwd-3_05-cv-03029-1/pdf.json

Nature of Suit Code: 110
Nature of Suit: Insurance
Cause of Action: 29:1002 E.R.I.S.A.: Employee Retirement

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IN THE UNITED STATES DISTRICT COURT

WESTERN DISTRICT OF ARKANSAS

HARRISON DIVISION

TRISHA E. HOWARD PLAINTIFF

v. Civil No. 05-3029

BAXTER HEALTHCARE CORP. AND

HARTFORD LIFE GROUP INSURANCE CO. DEFENDANTS

ORDER

NOW on this the 25th day of June 2007, comes on for

consideration plaintiff’s Motion for Summary Judgment (document

#20) and defendants’ response thereto (document #23). The Court,

having reviewed the Administrative Record, the briefs of the

parties, and all other matters of relevance before it, and being

well and sufficiently advised, finds and orders as follows:

1. Plaintiff Trisha E. Howard (“Howard”) was a participant in

a disability plan (the “Plan”) provided by her former employer,

defendant Baxter Healthcare Corporation (“Baxter”). Hartford Life

Group Insurance Company (“Hartford”) issued the Plan to Baxter,

effective July 1, 2002. The Plan provided both short-term and

long-term disability benefits to eligible Baxter employees. Howard

was found eligible for benefits under the Plan, but such benefits

were later terminated by Hartford. Howard now appeals Hartford’s

decision to terminate her benefits under the Plan.

2. The parties have treated the matter now under

consideration as one for summary judgment, but the procedural

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posture of this case is that of an administrative appeal. The

usual presumptions applicable to motions for summary judgment do

not apply. The facts are those contained in the Administrative

Record and the standard for review is dictated by the terms of the

Plan. 

3. The Plan is governed by the provisions of the Employee

Retirement Income Security Act (“ERISA”). Denial of ERISA benefits

is “reviewed on a de novo standard unless the benefit plan gives

the administrator or fiduciary discretionary authority to determine

eligibility for benefits or to construe the terms of the plan.”

Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989). If

the administrator has discretionary authority, its eligibility

decisions are reviewed for abuse of discretion. Groves v.

Metropolitan Life Insurance Co., 438 F.3d 872 (8th Cir. 2006).

That standard has been described as follows:

In applying an abuse of discretion standard, we must

affirm if a reasonable person could have reached a

similar decision, given the evidence before him, not that

a reasonable person would have reached that decision. A

reasonable decision is fact based and supported by

substantial evidence. We may consider both the quantity

and quality of evidence before a plan administrator. And

we should be hesitant to interfere with the

administration of an ERISA plan.

Groves, 438 F.3d 872, 875 (internal citations and quotation marks

omitted). 

Although abuse of discretion review puts a heavy burden on a

participant whose benefits have been terminated, it does not amount

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to “rubber-stamping the result.” A termination decision must be

reasonable, i.e., “supported by substantial evidence that is

assessed by its quantity and quality.” Torres v. UNUM Life

Insurance Co. of America, 405 F.3d 670, 680 (8th Cir. 2005).

“Substantial evidence” is “more than a scintilla but less than a

preponderance.” Leonard v. Southwestern Bell Corp. Disability

Income Plan, 341 F.3d 696, 701 (8th Cir. 2003). 

4. In the instant case, it is undisputed that the Plan gives

Hartford discretion to determine eligibility for and entitlement to

benefits. See Firestone Tire & Rubber Co., 489 U.S. at 115 (1989)

(stating that to qualify for deferential review, the plan

administrator and fiduciaries under ERISA need only reserve

discretionary authority to themselves in the Plan document); see

also Clapp v. Citibank, N.A. Disability Plan (501), 262 F.3d 820,

827 (8th Cir. 2001) (holding that the “as determined by” provision

in an insurance plan was explicit “discretion-granting language”).

Specifically, the Plan provides that Hartford has “discretionary

authority to determine your eligibility for and entitlement to

benefits under the Policy.” Such provisions have been held

sufficient to give the claims administrator discretionary authority

to determine eligibility. Ferrari v. Teachers Ins. and Annuity

Ass’n, 278 F.3d 801 (8th Cir. 2002). The Court will, therefore,

review Hartford’s benefits-related decisions for abuse of

discretion. 

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5. With the foregoing principles in mind, the Court has

examined the Administrative record, from which it has derived the

following relevant facts:

* The Policy provides, in pertinent part, that a

participant is disabled when Hartford determines that a

claimant is “(1) continuously unable to perform the

Material and Substantial Duties of [his/her] regular

occupation; and (2) not working for wages in any

occupation for which [he/she] is or became qualified by

education, training, or experience.”

* The Policy defines the phrase “Material and Substantial

Duties” as “the necessary functions of Your Regular

Occupation which cannot be reasonably omitted or

altered.”

* The Policy further states that a claimant “may be asked

to submit proof that you continue to be disabled and are

continuing to receive Appropriate and Regular Care of a

Doctor.” Failure to provide such proof of continuing

disability may result in a termination of benefits.

* In March 2004, Howard, an assembler at Baxter’s Mountain

Home, Arkansas facility, submitted a short-term

disability claim under the Plan to Hartford. The

diagnosis supporting her claim was left shoulder vascular

necrosis. She underwent a left shoulder hemiarthroplasty

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on March 18, 2004. After an elimination period, Howard

was approved for short-term disability benefits beginning

April 8, 2004 – having left work on March 17, 2004.

* Short-term disability benefits were periodically extended

by Hartford, as Howard remained off work for postoperative recovery.

* In a progress note dated May 30, 2004, Dr. William

Goodman, Howard’s treating physician, noted that Howard

was “doing fantastic.” Dr. Goodman also noted that x-ray

reports taken that day showed “satisfactory alignment of

all [shoulder] components.” Despite these comments, Dr.

Goodman instructed Howard not to use her left arm if she

returned to work. Baxter could not accommodate this

restriction, and Howard remained off work. Based on this

information, Hartford extended benefits through June 16,

2004. 

* On June 4, 2004, Dr. Goodman provided a status report

indicating that Howard should remain off work through

August 5, 2004. Dr. Goodman’s records showed that Howard

still had decreased range of motion in her left shoulder.

Accordingly, Hartford extended disability benefits to

Howard through August 5, 2004. By letter dated June 18,

2004, Hartford informed Howard of this extension and the

need to provide medical documentation if she was unable

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to return to work by August 9, 2004.

* Howard returned to Dr. Goodman for a follow-up visit on

August 13, 2004. Dr. Goodman recorded that Howard still

had limited motion, but her pain was resolved. Further,

Dr. Goodman described x-rays of the left shoulder as

“look[ing] great,” with satisfactory alignment of the

component. 

* During her August 13, 2004 follow-up visit with Dr.

Goodman, Howard reported that she was now bothered by her

right shoulder. Upon examination, Dr. Goodman determined

that the right shoulder reflected a very positive

impingement sign. His diagnosis of the right shoulder

problem was “right shoulder rotator cuff tendonitis

impingement syndrome.” Dr. Goodman recommended

arthroscopy of the right shoulder, open subacromial

decompression, and possible repair of the rotator cuff.

Surgery was tentatively scheduled for September 9, 2004.

* Upon reviewing the Functional Assessment Tool provided by

Dr. Goodman after the August 13th follow-up visit with

Howard, Hartford determined that Howard’s limited range

of motion in her left shoulder would continue to preclude

the performance of job duties in her occupation. With

regard to the right shoulder surgery, Hartford

anticipated functional impairment for at least 90 days

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post-operation.

* On September 1, 2004, Hartford notified Howard that her

short-term benefit period had been extended pending

further evaluation with her physician.

* On September 9, 2004, Howard underwent surgery on her

right shoulder.

* On September 27, 2004 Hartford informed Howard that longterm disability benefits had been approved through

November 30, 2004. The period from March 18 through

September 29, 2004 had been used to satisfy the Policy’s

28-week elimination period. Accordingly, long-term

disability benefits were commenced on September 30, 2004.

* In notes taken during a telephone conversation between

Hartford representative Kamilah Lowery and Howard on

November 29, 2004, Lowery reported that Howard said she

had finished physical therapy for her right shoulder and

had only home exercises to do. Howard also stated that

her last office visit with Dr. Goodman had been on

November 19, 2004, and they did not discuss a return-towork date. No further visits were scheduled with Dr.

Goodman; but, Howard was to return as needed. Howard

further stated that she could not return to work because

she had been terminated from her job. She also reported

that she could use her right shoulder better than her

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left, and she could not reach overhead or pick up heavy

objects. Howard also stated that, due to their

repetitive nature, she did not feel she could perform her

job duties.

* On December 17, 2004, Hartford received back a preprinted Functional Assessment Tool form that was

completed by Dr. Goodman. In response to the inquiry

“[d]o you feel your patient is currently capable of

performing full time work which requires 4 hours

standing, 2 hours walking, 4 hours sitting, with

occasional reaching above shoulders and frequent reaching

below shoulders?,” Dr. Goodman answered “yes.” The

limitations indicated were described by Dr. Goodman as

“permanent.”

* In a letter dated December 21, 2004, Hartford informed

Howard that Dr. Goodman had indicated that she could

return to work and her benefits would cease on December

31, 2004. The letter informed Howard that she could

appeal the decision or provide additional medical

information within 180 days from the date of the letter.

* By letter dated February 2, 2005, Howard sought

reconsideration of Hartford’s decision to terminate

benefits. In this letter, Howard explained that even

after her surgeries she did not have full rotation of her

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left shoulder and arm, and had only limited rotation and

use of her right shoulder and arm. Howard also stated

that she had debilitating arthritis in her hands. Given

these conditions, Howard stated, she knew that she could

not give the 100 percent effort needed for her job.

* During a February 18, 2005 telephone communication with

Hartford representative Lowery, Howard stated that she

had an additional office visit with Dr. Goodman sometime

after November 19, 2004 – she could not recall the exact

date of the visit. Howard also stated that she was not

seeing any other physician and was not taking any pain

medication. She also described having full range of

motion in her right shoulder, but some pain in her left

shoulder. Howard indicated that her work on the Baxter

assembly line did not require overhead reaching, but did

involve frequent reaching at eye level.

* By letter dated March 21, 2005, Hartford informed Howard

that her February letter had been treated as a request

for appeal, and her file had been forwarded to Hartford’s

Appeals Unit for review. 

* The decision to terminate benefits was subsequently

upheld by the Appeals Unit. The outcome of the appeal

and basis for the decision were communicated to Howard by

Appeal Team Leader Cheryl Sauerhoff in a letter dated

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March 23, 2005. This letter noted that Dr. Goodman had

approved Howard’s return to full-time work with

occasional reaching above the shoulders and frequent

reaching below the shoulders. While the letter

acknowledged that Howard could not do frequent overhead

or heavy lifting, her job description did not call for

these particular abilities.

* In a letter dated April 1, 2005, counsel for Howard

sought reconsideration of the Appeals Unit’s final

decision. Sauerhoff responded by letter dated April 11,

2005, advising Howard’s attorney that his letter had been

received, but that the administrative record had been

closed as of the final decision of the Appeals Unit. 

6. When the foregoing history of Howard’s claim for disability

benefits is viewed as a whole, the Court finds substantial evidence

supporting Hartford’s conclusion that Howard’s benefits should have

been terminated as of December 31, 2004. Certainly it cannot be

said that no reasonable person could have reached the decision

reached by Hartford in this case.

Pursuant to the Plan, it is a basis for termination of benefits

that a participant is no longer disabled under the terms of the

Plan, i.e., that she is no longer “unable to perform the Material

and Substantial Duties” of her regular occupation due to her injury.

There is substantial evidence that Howard had reached this point by

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December 31, 2004. Howard had a satisfactory outcome from her

surgeries, and she was in good enough shape that Dr. Goodman

released her to return to work as of December 17, 2004. Dr. Goodman

noted that while Howard had certain permanent limitations, these

limitations would not hinder her from performing full-time work

which requires “4 hours standing, 2 hours walking, 4 hours sitting,

with occasional reaching above shoulders and frequent reaching below

shoulders.” Baxter’s prior decision to terminate Howard’s

employment does not merit a finding of disability for purposes of

the Plan, although it may well be a legitimate subject of litigation

for other reasons.

For the foregoing reasons, the Court finds that the decision

of Hartford to terminate Howard’s long-term disability benefits as

of December 31, 2004 was supported by substantial evidence and

should be affirmed.

IT IS THEREFORE ORDERED that the decision of Hartford Life

Insurance Group Company to terminate the long-term disability

benefits of Trisha E. Howard is AFFIRMED.

IT IS SO ORDERED.

/s/ Jimm Larry Hendren 

 JIMM LARRY HENDREN

 UNITED STATES DISTRICT JUDGE 

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