Opinion ID: 855794
Heading Depth: 2
Heading Rank: 3

Heading: Level of Absenteeism

Text: Hartford turned to an in-house vocational specialist to determine whether Neaton’s rate of absenteeism could be accommodated. The vocational specialist opined: “It is reasonable given the common practice of employers, the sedentary nature of the claimant’s occupation, and that the occupations identified can be full-filled [sic] by working from home, the claimant would reasonably be accommodated for a recovery period of 3 to 4 days bi-monthly.” The vocational specialist cited no evidence or data about allowable rates of absenteeism beyond “the common practice of employers.” A fiduciary has an obligation to evaluate its hired expert’s opinion and to make certain that reliance on the expert’s advice is justified under the circumstances. Gregg v. Transp. Workers of Am. Int’l, 343 F.3d 833, 841 (6th Cir. 2003).15 15 A fiduciary’s duty to investigate extends to vocational questions. “Just as a plan administrator must make some inquiry into the nature and transferability of a claimant’s job skills, a plan administrator must make some inquiry into whether the jobs selected are ones that the -17- A determination whether a fiduciary’s reliance on an expert advisor is justified is informed by many factors, including the expert’s reputation and experience, the extensiveness and thoroughness of the expert’s investigation, whether the expert’s opinion is supported by relevant material, and whether the expert’s methods and assumptions are appropriate to the decision at hand. Id. at 841-43. Moreover, conclusory medical and vocational opinions that fail to provide evidence or reasoning to support the conclusions are insufficient to support a denial of benefits. Elliott v. Metro. Life Ins. Co., 473 F.3d 613, 618-19 (6th Cir. 2006). However, “reliance on a file review does not, standing alone, require the conclusion that [a plan administrator] acted improperly.” Calvert, 409 F.3d at 295. Hartford contends that the opinion was not conclusory because, in the analysis, the vocational analyst referred to Neaton’s job description, the job’s sedentary exertional level, and a labor market survey finding that the job could be performed from home. Notably, these references are silent with respect to an acceptable rate of absenteeism, stating only that the occupation could be performed from home. Average paid sick leave for “professional, technical and related employees” in 1996 was 8.5 days for individuals with one year of service, and up to 10.6 days for individuals with over 25 years of service.16 A subsequent March 2010 publication from the Bureau of Labor Statistics shows that claimant can reasonably perform in light of specific disabilities.” Brooking v. Hartford Life & Accident Ins. Co., 167 F. App’x 544, 549 (6th Cir. 2006). 16 http://www.bls.gov/news.release/ebs.t05.htm (last visited October 17, 2012). Hartford complains that these government statistics are not part of the administrative record and therefore cannot be considered in this court’s analysis. However, Federal Rule of Evidence 201 states that a court may take judicial notice of facts that “can be accurately and readily determined from sources whose accuracy cannot reasonably be questioned.” Fed. R. Evid. 201(b)(2). Courts commonly consult reference sources in order to better understand matters that are not typically common knowledge. Doss v. Barnhart, 247 F. Supp. 2d 1254, 1259 (N.D. Ala. 2003); see, e.g., Brooking, 167 F. App’x at 549 n.5 (claimant sued plan administrator for denying her LTD benefits, and the -18- full time workers with one year of service are now, on average, allowed 8 days of paid sick leave.17 Even accepting the lowest calculation of recovery time, Neaton would miss 3 to 4 days after a Moh’s surgery and just 1-2 days following a curettage and cautery. This would mean that Neaton would have missed 20-28 days for the six Moh’s procedures and two curettage and cautery procedures from January 2008-January 2009 (1.7-2.3 days per month).18 Neaton would have missed 16-22 days over just eight months from May 2008-January 2009 (2-2.8 days per month). At the most basic level, Hartford could have easily made an inquiry to Navy Federal regarding whether this degree of absenteeism was acceptable, but it did not. Accordingly, the record is devoid of any data regarding absenteeism at Navy Federal. Neaton claims that Hartford acted arbitrarily by relying on the opinion of an in-house vocational expert who cited no data, conducted no labor market investigation, and instead cited court took judicial notice of 20 C.F.R § 220.132, which defines “sedentary” and “light work” pursuant to Fed. R. Evid. 201); Sevens v. Metro. Life Ins. Co., 190 F. App’x 429, 436 n.7 (6th Cir. 2006) (recognizing that courts may take judicial notice of the Dictionary of Occupational Titles). Even if this court held that the Labor Department statistics were not admissible, there is a significant lack of evidence to support Hartford’s denial of benefits where the record is silent as to Navy Federal’s acceptable rate of absenteeism. 17 http://www.bls.gov/opub/perspectives/program_perspectives_vol2_issue2.pdf. (Last visited on October 17, 2012). 18 In Douglas v. Bowen, a social-security disability case, the vocational expert conceded that “if [Douglas] had an absentee rate in excess of one or two days a month, he’d not be able to work in any” of the sedentary or light jobs described by the vocational expert. 836 F.2d 392, 396 (8th Cir. 1987). This finding supports Neaton’s argument, as the record evidence shows that he would miss more than one or two days a month. Id. -19- solely to “the common practice of employers” in ascertaining the degree of absenteeism that could be accommodated in Mr. Neaton’s occupation.19 Hartford argues that “the common practice of employers” is not conclusory, but a direct reference to evidence in the claim file that Navy Federal was willing to accommodate and facilitate Neaton’s return to work. (“[I]t was determined by the employer that the employer would offer the option to the employee for working out of his house.”). However, the fact that Neaton could work from home is insufficient to support Hartford’s ambiguous statement that missing work 3-4 days bimonthly was within “the common practice of employers.” Hartford fails to reference evidence in the claim file that Navy Federal was willing to accommodate Neaton’s absenteeism.20 An administrator acts arbitrarily and capriciously when it “engages in a ‘selective review of the administrative record’ to justify a decision to terminate coverage.” Metro Life Ins. Co. v. Conger, 474 F.3d 258, 265 (6th Cir. 2007) (quoting Moon, 405 F.3d at 381). There is not “a reasoned explanation, based on the evidence, for [the] particular outcome [in this case].” Shields v. Reader’s Digest Ass’n, Inc., 331 F.3d 536, 541 (6th Cir. 2003). Specifically, Hartford: (1) failed to provide supported evidence that, if working from home, Neaton could recover from a Moh’s procedure in 3-4 days; (2) failed to accurately calculate the frequency of Neaton’s surgeries and work absences; and (3) relied on the opinion of an in-house vocational expert who cited no evidence in 19 At oral argument Neaton maintained that had he known Hartford would adopt this finding and had he been given the opportunity before the issuance of the final denial, he would have submitted data regarding acceptable rates of absenteeism. 20 Simply because an employee works from home does not mean that the employee is not “absent” when a medical issue prevents the employee from working. To withstand review, the insurer’s decision must result from a “deliberate principled reasoning process.” Killian, 152 F.3d at 520. Hartford cannot have completed a deliberate, principled, reasoning process as to Neaton’s ability to work if it did not even consider Navy Federal’s policy on absenteeism. -20- claiming that Navy Federal could accommodate Neaton’s high rates of absenteeism. Accordingly, the court holds that the termination of Neaton’s LTD benefits was arbitrary and capricious.21 This leaves us with the question of remedy. “In cases such as these, courts may either award benefits to the claimant or remand to the plan administrator.” Elliott, 473 F.3d at 621. Where the decision to terminate LTD benefits was arbitrary and capricious, the appropriate remedy is reinstatement of benefits. See Glenn v. Metro. Life Ins. Co., 461 F.3d 660, 674-75 (6th Cir. 2006); Evans v. UnumProvident Corp., 434 F.3d 866, 880 (6th Cir. 2006); McDonald, 347 F.3d at 166 (affirming district court’s order reinstating benefits after finding that “Western-Southern’s decision to terminate McDonald’s LTD benefits was arbitrary and capricious because Western-Southern could not offer a reasoned explanation, based upon the evidence in the administrative record, for finding that McDonald was able to engage in gainful employment and, thereby, rendering him ineligible for LTD benefits under the plan.”). While Hartford may subsequently conclude, after engaging in a proper review of Neaton’s file, that Neaton’s expected rate of absenteeism does not warrant further long-term disability benefits, it does not alter the fact that Neaton was originally found disabled and was entitled to continue receiving benefits until Hartford offered a “deliberate principled” reasoned decision for terminating those benefits. For example, in Houston v. Unum Life Insurance Co. of America, the court considered a procedural ERISA violation under 29 U.S.C. § 1133 and observed: For violations of § 1133, reversal and remand to the district court or to the plan administrator for full and fair review is ordinarily appropriate. Marks, 342 F.3d at 21 “[T]he ultimate issue in an ERISA denial of benefits case is not whether discrete acts by the plan administrator are arbitrary and capricious but whether its ultimate decision denying benefits was arbitrary and capricious.” Spangler v. Lockheed Martin Energy Sys., Inc., 313 F.3d 356, 362 (6th Cir. 2002). -21- 461 (citing VanderKlok v. Provident Life & Accident Ins. Co., 956 F.2d 610, 619 (6th Cir. 1992)). Where, as here, an insurer’s final determination is also arbitrary and capricious, the court has discretion to fashion an appropriate remedy. While this circuit has not adopted a categorical rule, it has noted that, a “retroactive award is usually proper when [the] claimant had benefits and lost them,”while “remand is appropriate when a decision-maker fails to make adequate findings or fails to provide [] adequate reasoning.” Elliott, 473 F.3d at 622 (quoting Buffonge v. Prudential Ins. Co. of America, 426 F.3d 20, 31 (1st Cir. 2005) (internal citation omitted)). 246 F. App’x 293, 303 (6th Cir. 2007). Accordingly, because (1) Hartford previously determined that Neaton was entitled to continued long-term benefits and (2) Neaton presented objective evidence of ongoing disability based on the frequency of his surgeries and the restrictions prescribed by his doctor, we conclude that Neaton remains presumptively entitled to the continuation of his previously awarded long-term disability benefits. See, e.g., id. A retroactive award of long-term disability benefits wrongfully withheld and reinstatement of Neaton’s long-term disability payments is the appropriate remedy in this case. Id.