Document ID: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-arwd-5_06-cv-05089/USCOURTS-arwd-5_06-cv-05089-0/pdf.json

Parties Involved:
Hartford Life and Accident Insurance Company
Defendant
Susan K. Sears
Plaintiff

Document Text:

IN THE UNITED STATES DISTRICT COURT

WESTERN DISTRICT OF ARKANSAS

FAYETTEVILLE DIVISION

SUSAN K. SEARS PLAINTIFF

v. Case No. 06-5089

HARTFORD LIFE AND ACCIDENT

INSURANCE COMPANY DEFENDANTS

MEMORANDUM OPINION

Plaintiff brings this action pursuant to the provisions

of the Employee Retirement Income Security Act of 1974

(“ERISA”), 29 U.S.C. § 1001 et seq., alleging that Defendant’s

decision to deny her claim for long-term disability benefits

was unreasonable. 

This matter is before the Court for decision on the

stipulated administrative record (Doc. 5), Plaintiff’s Motion

for Summary Judgment and Supporting Brief (Docs. 9 and 12),

Defendant’s Cross Motion for Summary Judgment (Doc. 18),

Defendant’s response to Motion for Summary Judgment (Doc. 19),

Defendant’s Brief in Response to Plaintiff’s Motion for

Summary Judgment and In Support of Defendant’s Cross Motion

for Summary Judgment (Doc. 22), and Response to Cross Motion

for Summary Judgment by Plaintiff (Doc. 23). 

 For the reasons stated below, the Court concludes

Defendant’s decision was supported by substantial evidence and

is AFFIRMED. Plaintiff’s claim is denied and Plaintiff’s

Complaint (Doc. 1) is dismissed with prejudice. 

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BACKGROUND. 

Plaintiff was employed as an Inventory Coordinator for

Sam’s Club, last working full time on January 9, 1999.

Plaintiff had been employed, in various positions, by Wal-Mart

Stores, Inc., since November 5, 1979.

Plaintiff was diagnosed with systemic lupus erythematosis

(“SLE”)in January 1996, which caused Plaintiff to suffer from

pancreatitis and lupus cerebritis. She also incurred

psychological problems associated with lupus cerebritis. 

In 1997 Plaintiff took a 90-day medical leave of absence

due to acute anxiety. She took intermittent leaves from

January 1998 through August 1998 due to the SLE. Plaintiff

was removed from her position as Inventory Coordinator in

August of 1998 because she could no longer fulfill all the

responsibilities of the position. Plaintiff tired easily,

lost her concentration in performing the job and was unable to

handle the stress of the position.

Plaintiff is a participant in a Long Term Disability

Policy issued by Defendant. After being hospitalized for two

weeks due to SLE, Plaintiff applied for long term disability

benefits in August of 1998. Plaintiff was diagnosed by Dr.

David as being able to only stand 5 minutes, walk less than

100 feet, sit indefinitely, unable to carry groceries, unable

to reach or work overhead, unable to push a shopping cart more

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than 100 feet, and only able to drive short distances. 

Hartford determined that Plaintiff could not perform her

own occupation, and approved her claim for long term

disability benefits through August of 1999. In October of

1999, Defendant notified Plaintiff that her claim for benefits

was terminated in August of that year. That decision was

ultimately reversed.

Plaintiff was awarded disability benefits in June of 1999

from the Social Security Administration. This benefit was

from April 1998 until April of 1999. In 2000, Plaintiff

received a Notice of Decision - Fully favorable from the

social security administration.

In 2003 Plaintiff advised Dr. David that she had begun

taking care of her granddaughter part-time. Dr. David noted

that Plaintiff’s progress was “unchanged” in December 2003 and

that she was doing “extremely well” with her lupus. 

In May 2004, Defendant participated in a telephone

conference with Plaintiff. Plaintiff stated she would see her

grandson to pick him up from day-care; could perform only one

household task per day; could drive but not outside her

comfort zone, for example, 20 miles would be too far; her

anxiety was controlled with medication; and the medication

limited her SLE “flares.” After this conversation, Defendant

determined the differences between the limitations noted from

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Plaintiff’s physicians and Plaintiff’s self reported

limitations were extreme. Defendant then elected to conduct

video surveillance. 

The video surveillance showed Plaintiff driving with

little difficulty, multitasking, carrying a 20 to 25 pound

child with no noticeable discomfort, and engaging in social

activities with family members. Dr. Brown, a consulting

physician, after a review of Plaintiff’s file, concluded that

Plaintiff was capable of working in some capacity. Dr.

Ferrante, another consulting physician, also conducted an

independent review of Plaintiff’s records. Dr. Ferrante spoke

with Dr. David, Plaintiff’s treating physician, about

Plaintiff and Dr. David observed that Plaintiff was unable to

work, mainly due to her cognitive impairment and poor decision

making. Ultimately, Dr. Ferrante concluded Plaintiff was

capable of work at the light level.

Defendant attempted to obtain a job description from

Plaintiff’s employer for an Employability Analysis to be

performed. However, Wal-Mart/Sam’s Club had no job

description for Plaintiff’s position, but provided a

description for a position with similar duties and

responsibilities and confirmed that Plaintiff’s previous

position had been a “sedentary” one. 

On May 10, 2005 Defendant notified Plaintiff that she no

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longer met the definition of “total disability” as defined in

the Policy from a physical perspective. Defendant did not

immediately terminate Plaintiff’s benefits but notified her it

was applying the 24-month Mental Nervous limitation to her

claim and that she would have benefits through April of 2007.

Plaintiff completed a Functional Capacity Evaluation

(“FCE”) in September of 2005. This FCE reflected Plaintiff

could perform sedentary work on a full time basis. The FCE

did not reference the video, or other physicians’ reports.

There was also an independent medical evaluation, apparently

made without reference to any of the records in Plaintiff’s

file, which concluded Sears could not return to her previous

working condition or perform specific tasks of her previous

work. Another independent medical review was conducted by a

Rheumatologist, Dr. Beck. Dr. Beck reviewed the medical

records and surveillance video and observed that Plaintiff was

seen in the video undertaking greater physical tasks than

sedentary or light work would permit. Dr. Beck stated

Plaintiff could work at the full time sedentary level. 

Plaintiff appealed the May 2005 decision terminating her

benefits. Defendant denied the appeal stating that the

“weight of the evidence continues to support that Ms. Sears

retains the physical capacity for working on a full time basis

in a sedentary or light duty capacity. . ..”

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On May 19, 2006, Plaintiff filed this action under ERISA

seeking to overturn the denial of long-term disability

benefits.

DISCUSSION. 

Under ERISA, a denial of benefits by a plan administrator

must be reviewed de novo unless the benefit plan gives the

administrator discretionary authority to determine eligibility

for benefits or to construe the terms of the plan, in which

case the administrator’s decision is reviewed for an abuse of

discretion. Woo v. Deluxe Corp., 144 F.3d 1157, 1160 (8th

Cir. 1998) citing Firestone Tire & Rubber Co. v. Bruch, 489

U.S. 101, 115 (1989). Accordingly, the Court must be guided

by the language of the plan to determine the proper standard

of review.

The parties agree abuse of discretion is the correct

standard to apply in this case. The Eighth Circuit Court of

Appeals has "variously defined . . . an abuse of discretion as

being 'extremely unreasonable,' 'virtually' the same as

arbitrary and capricious, and 'extraordinarily imprudent.'"

Shell v. Amalgamated Cotton Garment, 43 F.3d 364, 366 (8th

Cir. 1994) (citations omitted). "The proper inquiry into the

deferential standard is whether 'the plan administrator's

decision was reasonable; i.e., supported by substantial

evidence.'" Cash v. Wal-Mart Group Health Plan, 107 F.3d 637,

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641 (8th Cir. 1997) (quoting Donaho v. FMC Corp., 74 F.3d 894,

899 (8th Cir. 1996)). 

"While the word 'reasonable' possesses numerous

connotations, this court has rejected any such definition that

would 'permit a reviewing court to reject a discretionary

trustee decision with which the court simply disagrees[.]'"

Id. at 641 (citation omitted). A decision is reasonable "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.' Id. If the decision is

supported by a reasonable explanation, it should not be

disturbed, even though a different reasonable interpretation

could have been made." Id. (citation omitted). 

Where there is a difference of opinion between a

claimant’s treating physicians and the plan administrator’s

reviewing physicians, the plan administrator has discretion to

find that the employee is not disabled unless “the

administrative decision lacks support in the record, or . . .

the evidence in support of the decision does not ring true and

is . . . overwhelmed by contrary evidence.” Donaho, 74 F.3d

at 901 (8th Cir. 1996). 

In the present case, Plaintiff alleges the Defendant was

unreasonable in denying Plaintiff’s long-term disability

benefits because she remains “totally disabled” as defined in

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the policy. 

Plan participants are eligible for LTD benefits if they

are “totally disabled.” The Plan defines “Total Disability”

for purposes of LTD benefits as follows: 

“Total Disability” or totally Disabled means that:

(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 are under the continuous care of a Physician and as

a result you are earning less than 20% of your Predisability 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.

The Hartford has full discretion and authority to

determine eligibility for benefits and to construe and

interpret all terms and provisions of the Group Insurance

Policy. 

Plaintiff argues the medical history supports a

conclusion for total disability and her status as totally

disabled has not changed. Plaintiff also points to the Social

Security Administration’s award of long-term disability

benefits.

Defendant contends the discrepancy in information selfreported by Plaintiff and that reported by her physician is

substantial to warrant the investigation with video

surveillance. Defendant further contends the video

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surveillance supports its determination as does the FCE

obtained by Plaintiff to support her appeal, as well as the

medical reviews by an independent rheumatologist and

psychiatrist. Additionally, Defendant contends it is

supported by a second rheumatologist and an independent

neuropsychological examination of Plaintiff. 

While Plaintiff contends the medical reviewers Defendant

relied upon “exaggerated and distorted” evidence of

Plaintiff’s physical abilities and limitations. However, a

review of those reports can not support Plaintiff’s

contentions. She is seen to be performing heavy lifting and

engaging in social interactions as well as performing multiple

activities. Moreover, the medical reviewers, some of whom do

not even cite or refer to the video, do not appear to distort

the evidence. While Plaintiff mentioned she could perform

some of the activities demonstrated in the video, she did not

state she could perform them to the degree the video reflects.

Several physicians who reviewed Plaintiff’s file or who

examined Plaintiff directly opined that Plaintiff was able to

perform jobs at the light or sedentary level. Aside from

Plaintiff’s claims that these physicians distorted the

evidence of her abilities, there is no reason given as to why

Defendant should not have relied upon these medical

determinations. 

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Moreover, Plaintiff contends Defendant abused its

discretion by being inconsistent with its previous

interpretation of the plan, ignoring the language in the plan,

making its decision without adequate information, and ignoring

evidence of Plaintiff’s total disability. However, the

substantial evidence supports Defendant’s decision.

CONCLUSION.

For the reasons stated above, Plaintiff’s Motion for

Summary Judgment (Doc. 9) is DENIED. Defendant’s Cross Motion

for Summary Judgment (Doc. 18) is hereby GRANTED.

IT IS SO ORDERED.

 /s/ Robert T. Dawson 

Dated: February 8, 2007 Robert T. Dawson

United States District Judge

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