By | June 24, 2014

A California federal Judge recently reversed Hartford’s denial of long term disability benefits to a former manager that was initially approved from 2008 until July 2011. Hartford once again relied on their use of video surveillance and an IME report to wrongfully deny LTD benefits. Thankfully the claimant in this case took Hartford to court and won. While our disability attorneys have handled hundreds of cases against Hartford, this case was not handled by our law firm. The Judge’s opinion in this case was outstanding as it addresses all of the wrongdoing done by Hartford.

Background of Hartford Disability Lawsuit

The Plaintiff was employed as an engineering document control manager and her job duties were classified as sedentary. Plaintiff submitted her claim for long-term disability benefits in 2008 based on her complaints of back pain, and Hartford approved her claim under the “own occupation” definition of disability.

Plaintiff continued to see her treating physicians and chiropractor for her back pain and Hartford continued to pay her benefits. In 2010, Hartford reviewed her claim for the change of the definition of disability from “own occupation” to “any occupation.” In June 2010, an Employee Analysis Assessment was conducted and it was determined that Plaintiff was not capable at that point of returning to work and that there were no occupations that were reasonable based on the Plan’s definition as Plaintiff was either not qualified to perform the job, the jobs could not be performed within her limitations, or they did not meet the required earnings. Based on these findings, in June 2010, it was determined that Plaintiff continued to be disabled and qualified for benefits under the “any occupation” definition of disability.

Hartford Conducts A Further Investigation of Plaintiff’s Long Term Disability Claim

Prior to approving continued LTD benefits under the “any occupation” definition of disability, in March 2010 Hartford hired an investigator to conduct video surveillance and an in-person interview with the Plaintiff. During the surveillance the Plaintiff was observed walking, driving, standing, slamming down the hood of her car, jogging to a bus, riding a bicycle and twice visiting a massage spa. During the interview, the Plaintiff stated that she saw her chiropractor once a week and got massage therapy twice a month. She reported that the activity in the surveillance video was consistent with her reported abilities.

Hartford sent the video surveillance and investigative reports to Plaintiff’s treating chiropractor and osteopath and asked them to comment on Plaintiff’s work capacity. The osteopath failed to respond. However, Plaintiff’s chiropractor advised Hartford that Plaintiff had a limited ability to sustain activity without increasing her pain level and that this was documented objectively through her imaging studies.

In January 2011, Hartford decided to schedule an IME of the Plaintiff. The IME was conducted in May 2011 by Dr. Swartz, an orthopedic surgeon. Dr. Swartz reviewed Plaintiff’s medical records and performed an examination and concluded that there were no objective neurologic findings supporting Plaintiff’s inability to work.

The IME report was sent to Plaintiff’s chiropractor and he was asked to comment on whether he disagreed with the IME findings. The chiropractor sent Hartford a detailed letter stating that while he respected the opinion of the IME physician, he administered therapy to the Plaintiff for over a year and “was able to establish the effect that certain activities had on the patient’s pain levels.” He stated that the Plaintiff moved out of the area and he was no longer treating her but that he reviewed her records and her reported functional limitations and noted that in treating her, her flare ups of pain were associated with her attempts to exceed her functional limitations. He stated that Plaintiff could walk for 1.5 hours before her pain would spike and she would get fatigued and need to lay down to reduce her pain. She could sit for 2-3 hours before her pain would spike severely. He opined that her stated limits were consistent with her MRI findings. He disagreed with the IME physician’s assertion that Plaintiff’s fatigue was caused by her medications and opined that her fatigue could just as well be attributed to handling her high pain levels and it was unlikely her treating physician would over-prescribe her medication unnecessarily. The chiropractor further stated, “It is my opinion that this patient self-reported her limitations reasonably. The IME report reflects the opinion of a doctor who has seen the patient one time. As a former QME I know the limitations of this type of review. In this case the objective findings are sufficient to justify the type of pain the patient reports. I do not agree with the findings of the IME report.”

In June 2011, Hartford requested an addendum to the prior Employee Analysis Report based on Dr. Swartz’s IME report. The addendum noted multiple qualifying occupations that the Plaintiff could allegedly perform. Subsequently, Hartford’s investigative analyst concluded that Plaintiff could perform full-time light work with restrictions.

Denial of LTD Claim and ERISA Administrative Appeals

Hartford notified Plaintiff in July 2011 that her claim for benefits was denied. The denial letter stated that, based on the medical evidence, Plaintiff could perform light work with restrictions and that she had sufficient skills to obtain qualifying employment and she was not disabled for any occupation.

The Plaintiff appealed the denial in January 2012 to Hartford as required by her policy. She submitted additional medical records which included primary care records, records from her PM&R physician, physical therapy records, as well as personal statements from the Plaintiff, her sister, friend and former co-worker. Plaintiff’s counsel also submitted a medical assessment of her ability to perform work-related activities that listed certain restrictions and limitations.

In their review of Plaintiff’s appeal, Hartford had a record review conducted by PM&R physician, Dr. Lobel. Hartford provided Dr. Lobel with Plaintiff’s medical records, the IME report and the surveillance video. Dr. Lobel concluded that Plaintiff could sit unrestricted, stand and walk up to 20 minutes at a time for up to 2 hours in an 8-hour workday, could occasionally climb stairs and could reach. He stated that though she had pain, her pain was subjective and that it did not add to impairment or require restrictions or limitations.

Hartford did not dispute that it failed to provide Dr. Lobel with Plaintiff’s Social Security award information or witness statements. Additionally, Hartford did not provide Dr. Swartz with information that SSA had awarded Plaintiff disability benefits.

In February 2012, Hartford denied Plaintiff’s appeal and Plaintiff filed her ERISA lawsuit in May 2012.

The Court’s Findings and Ruling on the Parties’ Cross-Motions for Summary Judgment

Upon its review of the totality of the evidence in this matter, the Court disagreed with Hartford’s review of the claim and ultimately determined that Hartford’s decision to terminate Plaintiff’s continued long-term disability benefits was arbitrary and capricious. The Court reached this conclusion based on multiple wrong-doings on the part of Hartford.

1. Hartford failed to adequately explain its reason for terminating Plaintiff’s disability benefits

This issue is particularly significant in this case because Hartford previously determined through their own investigation of the records and evidence in Plaintiff’s claim, that Plaintiff met the Plan’s stricter “any occupation” definition of disability and was entitled to continued long-term disability benefits.

The Court cites to federal statute and several authoritative cases which instruct that “every employee benefit plan shall… provide adequate notice in writing to any participant or beneficiary whose claim for benefits under the plan has been denied, setting forth the specific reasons for such denial, written in a manner calculated to be understood by the participant.” Further, the insurance company’s letter notifying the claimant of the benefits denial must explain why the information previously provided by the claimant was insufficient, and what information the claimant could have provided to perfect the claim.

Hartford’ denial letter failed to explain why the Plaintiff was now being denied benefits, when she was previously found to have met the “any occupation” definition of disability. Additionally, Hartford failed to address the chiropractor’s detailed opinion regarding his disagreement with the IME and his opinion that Plaintiff’s reported pain levels were consistent with the objective findings. Hartford also failed to advise Plaintiff what information she could provide to support her claim in addition to the information already provided.

The Court points out that Hartford’s argument that its doctors reviewed Plaintiff’s claim and determined that her diagnosis was not supported by the medical evidence was “disingenuous.” The Court notes that the reviewing doctors failed to explain why Hartford initially concluded that Plaintiff was fully disabled and then later reversed that decision. The reviewing doctors did not address any change in Plaintiff’s condition or treatment to indicate any improvement. Instead, Hartford implied that Plaintiff had been lying about, or faking, the extent of her disability all along and that her previous doctors had been misled. The Court states, “Defendant’s failure to explain its reversal and failure to distinguish the same medical evidence it previously relied upon to find Plaintiff disabled heightens this Court’s scrutiny of Defendant’s inherent conflict.”

2. Hartford failed to credit Plaintiff’s reliable medical evidence

The Court found that Plaintiff’s medical records reflect that she complained of back pain for several years and underwent treatment, and even received injections, related to her pain. She provided credible evidence of her disability from her 3 treating physicians.

In its denial, Hartford failed to give any weight to the treating physicians’ documentation of Plaintiff’s reported pain. Instead, Hartford relied on the opinion of its reviewing physician, Dr. Lobel, who stated that Plaintiff’s pain was subjective. The Court noted that is has been well-established that plan administrators “may not require pain to be proven by objective evidence because pain, by its nature, is a subjective phenomenon.” Hartford’s reliance on Dr. Lobel’s opinion that Plaintiff’s pain was subjective is indicative of a conflict of interest and how the conflict affected Hartford’s decision to deny her continued benefits.

3. Hartford “cherry-picked” the evidence

Hartford failed to provide either Dr. Lobel or Dr. Swartz with information pertaining to Plaintiff’s award of Social Security Disability benefits. Moreover, Hartford failed to provide Dr. Lobel and Dr. Swartz with the letters from Plaintiff’s chiropractor wherein he disagreed with the IME findings and the surveillance.

The Court points out Hartford provided Plaintiff’s treating physicians with the surveillance and the IME in an effort to change their contrary opinions, so as to benefit Hartford. However, Hartford failed to provide their own reviewing physicians with the contrary opinion of the treating chiropractor, the favorable SSA decision, or the personal statements which corroborated the assessments of Plaintiff’s limited functional capacity.

With regard to the surveillance video, the Court notes that Hartford placed an “inordinate amount” of weight on the surveillance, which only depicted the level of activity that Plaintiff admitted she was able to perform.

4. Hartford failed to address the Social Security Administration’s determination of Plaintiff’s disability

The Court cites the SSA’s definition of disability as “‘any medically determinable physical or mental impairment’ which prevents one from engaging ‘in any substantial gainful activity’ and is expected to result in death or last ‘for a continuous period of not less than 12 months.’” Further, “a claimant will be eligible for benefits only if his impairments ‘are of such severity that he is not only unable to do his previous work but cannot, considering his age, education and work experience, engage in any other kind of substantial gainful work which exists in the national economy…’”

In comparison, Hartford’s definition of disability is less stringent: “Disability or Disabled means that during the Elimination Period or the next 24 months you are prevented by: accidental bodily injury; sickness; mental illness; substance abuse; or pregnancy from performing one or more of the Essential Duties of Your Occupation, and as a result your Currently Monthly Earnings are no more than 80% of your Indexed Pre-disability Earnings… After than, you must be prevented so from performing one or more of your Essential Duties of Any Occupation.” “Any Occupation” is defined as “an occupation for which you are qualified by education, training or experience, and that has an earnings potential greater than an amount equal to the lesser of the product of your Indexed Pre-disability Earnings and the Benefit Percentage and the Maximum Monthly Benefit shown in the Schedule of Insurance.”

Hartford maintained that, while Plaintiff may have been found disabled under the SSA’s definition of disability, she was not disabled pursuant to the LTD Plan’s definition. The Court rejects this statement because Hartford failed to explain why Plaintiff may be disabled under the SSA definition but not Hartford’s, especially when it appeared that the SSA’s definition was more restrictive.

Conclusion

The Court determined that Hartford wrongfully terminated Plaintiff’s long term disability benefits and that its conduct was arbitrary and capricious in finding that she was no longer disabled. Accordingly the appropriate remedy is retroactive reinstatement of benefits.

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