Court Opinion

ID: 50558
Source: CourtListenerOpinion
Date Created: 2010-04-26 00:53:35+00
Date Added: 2024-06-11T17:18:52.301700
License: Public Domain

United States Court of Appeals
                                                                                 Fifth Circuit
                                                                              F I L E D
                     IN THE UNITED STATES COURT OF APPEALS
                                                                                June 8, 2007
                              FOR THE FIFTH CIRCUIT
                                                                           Charles R. Fulbruge III
                               __________________________                          Clerk

                                      No. 06-60776
                                   Summary Calendar
                               __________________________

JAMES MORGAN WILLIAMS,
                                                  Plaintiff-Counter Defendant-Appellant,

versus

HARTFORD LIFE INSURANCE COMPANY,

                                                 Defendant-Counter Claimant-Appellee.

                 ___________________________________________________

                       Appeal from the United States District Court
                         for the Southern District of Mississippi
                                    (No. 3:05-CV-110)
                 ___________________________________________________

Before JOLLY, DENNIS, and CLEMENT, Circuit Judges.
                 *
PER CURIAM:

         James Williams appeals the district court’s grant of summary judgment in favor of

Hartford Life Insurance Company (“Hartford”) on Williams’s claim for wrongful

termination of his disability benefits and on Hartford’s counterclaim for a refund of

disability overpayments in the amount of $27,186.87. We affirm.

         *
        Pursuant to 5TH CIR. R. 47.5, the court has determined that this opinion should not
be published and is not precedent except under the limited circumstances set forth in 5TH
CIR. R. 47.5.4.
                             I. FACTS AND PROCEEDINGS

       Williams was employed as an electrician with Helmerich & Payne, Inc.

(“Helmerich”). He injured his knee in June 1999 and thereafter applied for and received

disability benefits from Hartford, which administered Helmerich’s employee welfare

benefit plan. The plan is governed by ERISA, 29 U.S.C. § 1001 et seq. The Hartford policy

provides that, during the first twenty-four months of disability, the participant is entitled

to receive benefits if he is unable to perform one or more of the essential duties of his job.

Benefits continue only if the participant is unable to perform the essential duties of any job

for which he is qualified by education, training, or experience. In accordance with the

policy, Hartford notified Williams in June 2001 that his first 24 months of disability

benefits would soon expire and that Hartford had begun an investigation into whether

Williams was entitled to continuing benefits.

       Hartford determined that Williams could perform sedentary work and discontinued

disability benefits in August 2002. Following an unsuccessful appeal of that decision with

Hartford, Williams commenced this action in July 2004. Hartford asserted a counterclaim

for overpaid disability benefits.

                               II. STANDARD OF REVIEW

       This court reviews de novo the district court’s decision whether the plan

administrator abused its discretion in discontinuing disability benefits. Barhan v. Ry-Ron

Inc., 121 F.3d 198, 201 (5th Cir. 1997). Since the terms of the ERISA benefit plan give the

plan administrator discretionary authority to determine benefits, the district court reviews

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the denial of benefits for abuse of discretion. See id. “[I]f the administrator’s decision on

eligibility is supported by substantial evidence and is not erroneous as a matter of law, it

will be upheld.” Id. Notwithstanding, because Hartford acts as both the insurer and the

claims administrator, it operates under a conflict of interest because it “potentially benefits

from every denied claim.” Vega v. Nat’l Life Ins. Servs., Inc., 188 F.3d 287, 295 (5th Cir.

1999). As the district court did, this court therefore applies a “sliding scale standard” and

grants Hartford’s decision less than full deference. Gooden v. Provident Life & Acc. Ins.

Co., 250 F.3d 329, 333 (5th Cir. 2001).

                                     III. DISCUSSION

A. Benefits decision

       Williams first challenges Hartford’s decision to discontinue disability benefits on

the basis that Hartford’s reviewing physician, Dr. Wagner, misconstrued a statement from

one of Williams’s physicians, Dr. Pasco. Pasco informed Wagner that Williams was capable

of functioning at a sedentary level. Based on his review of Williams’s medical records and

Pasco’s statement, Wagner concluded that Williams could perform work at a sedentary

level with lifting restrictions. Though Pasco later wrote a letter to Hartford to urge that he

did not mean his statements to Wagner “to imply that [Williams] was not disabled,”

Hartford did not abuse its discretion in discontinuing benefits. Pasco’s letter was sent three

years after Hartford’s discontinuance of Williams’s benefits, and Hartford did not rely on

Pasco’s statement alone. Hartford relied on Wagner’s opinion, Williams’s medical records,

and a report from a Hartford rehabilitation expert who concluded that Williams had

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sufficient skills that would allow him to be readily employable with earning equal to his

pre-disability wages. Williams has not demonstrated a genuine issue of fact as to whether

Hartford abused its discretion in discontinuing benefits. See Simoneaux v. Cont’l Cas. Co.,

101 F. App’x 11–12 (5th Cir. 2004) (rejecting a benefits determination challenge because the

determination was rationally connected to the facts in the administrative record).

       Williams also argues that summary judgment was error because Hartford

considered neither Williams’s back problems nor a letter from a physician, Dr. Eicke, who

asserted that Williams was unable to perform sedentary work due to mental illness. As to

the back problems, though the evidence was submitted after the benefits discontinuance

decision, we conclude, as did the district court, that Hartford nonetheless considered the

evidence as part of Williams’s appeal with Hartford and determined that it was consistent

with other medical information that Hartford already had reviewed.

       Dr. Eicke’s letter was not submitted to Hartford until after Williams’s appeal with

Hartford was denied. The letter, moreover, was not accompanied by any medical records,

and it presented a new basis for disability benefits—Williams originally applied for and

received disability benefits due to physical disability. Under these circumstances, we

cannot say that Hartford abused its discretion in discontinuing benefits. See Vega, 188 F.3d

at 298 (“There is no justifiable basis for placing the burden solely on the administrator to

generate evidence relevant to deciding the claim, which may or may not be available to it,

or which may be more readily available to the claimant.”); Simoneaux, 101 F. App’x at 12

(finding no abuse of discretion where the administrator declined to give overriding weight

                                             4
to medical opinions not supported by objective medical findings).

       We also find no merit in Williams’s argument that because a part of the medical

records reviewed by Wagner were illegible, the administrator must have abused his

discretion by discontinuing benefits. Williams’s argument misapprehends Hartford’s

burden. The existence of some unspecified quantity of illegible notes does not render

meaningless the legible medical records, Wagner’s investigation, including phone calls to

Williams’s treating physician, Wagner’s medical evaluation, and the employability

analysis performed by Hartford. There is substantial evidence supporting Hartford’s
                            1
disability determination.

       Considering the full record and the parties’ submissions, we hold that the district

court did not err in granting summary judgment in favor of Hartford on Williams’s claim
                                                      2
for improper discontinuance of disability benefits.

B. Williams’s requests for remand and additional discovery

       1
        Hartford declined to defer to the Social Security Administration’s determination
that Williams, an electrician by trade, had no skills transferable to sedentary work, but this
decision does not necessitate reversal. Hartford is not required to defer to a Social Security
ruling. See Horton v. Prudential Ins. Co., 51 F. App’x 928 (5th Cir. 2002) (“[W]hile an
ERISA plan administrator might find a social security disability determination relevant or
persuasive, the plan administrator is not bound by the social security determination.”
(citation omitted)). Hartford, moreover, conducted an employability analysis, the
substance of which Williams has challenged in only a conclusory fashion.
       2
        As to Hartford’s counterclaim, Williams does not dispute that he is contractually
obligated to refund overpayments. He instead argues that, since Hartford assigned the
collection of the overpayments to a collection agency, Hartford has no standing to pursue
the claim. However, the right to collect the payments and the right to the payments
themselves are distinct. The assignment of collection responsibility alone does not establish
that the right to the overpayments was also assigned.

                                              5
       Williams seeks a remand to Hartford for consideration of certain evidence,

including Dr. Pasco’s letter submitted three years after the benefits determination and Dr.

Eicke’s letter regarding Williams’s mental illness. Williams also seeks remand because

portions of the records were illegible and because Dr. Wagner never successfully contacted

two of Williams’s treating physicians, even though the medical records from Williams’s

treatment by those physicians was before Hartford either during Wagner’s initial

evaluation or during the Hartford appeal. We decline to remand on this basis. See Vega,

188 F.3d at 302 n.13 (“We decline to remand to the administrator to allow him to make a

more complete record on this point. We want to encourage each of the parties to make its

record before the case comes to federal court, and to allow . . . another opportunity to make

a record discourages this effort.”).

       Williams also seeks review of the district court’s denial of his discovery requests.

Under ERISA, as a general rule, the district court is limited to a review of the

administrative record that existed when reviewed by the administrator. See Estate of

Bratton v. Nat’l Union Fire Ins. Co., 215 F.3d 516, 521 (5th Cir. 2000). There are limited

exceptions to the rule, including exceptions for evidence related to how an administrator

interpreted certain policy provisions and for evidence that assists the district court in

understanding medical terminology. See id. Williams argues that he should have been

allowed to depose Hartford employees about the disability determination. At issue is a

factual determination of no disability by Hartford, not Hartford’s interpretation of plan

terms. Williams has not explained why his discovery requests fit into the limited

                                             6
exceptions to the administrative record rule. We find no merit in his contentions.

                               IV. CONCLUSION

      The judgment of the district court is AFFIRMED.

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