Flowers v. Hartford Life and Accident Insurance Company

Background

Kerri Flowers sought judicial review under the Employee Retirement Income Security Act (ERISA) after Hartford Life and Accident Insurance Company stopped her long-term disability benefits. Flowers had worked as a Regional Human Resources Manager for Duane Reade and was covered by a group long-term disability policy issued and administered by Hartford.

The policy defined disability in stages. After the initial period and a further 24 months, benefits were available if the claimant could not perform “Any Occupation,” meaning an occupation for which the claimant was qualified by education, training, or experience. The policy also gave Hartford discretion to decide eligibility for benefits and interpret the policy’s terms.

Flowers stopped working in September 2008 after being diagnosed with a seizure disorder and bipolar disorder. Hartford approved her claim beginning in December 2008 and later determined that she remained unable to perform any occupation. Flowers received benefits for nearly a decade. During that time, she was also diagnosed with fibromyalgia and several musculoskeletal conditions, including cervical degenerative disc disease, lumbar degeneration, and bilateral carpal tunnel syndrome.

Hartford’s review and denial

Hartford began reviewing Flowers’s continuing-benefits claim in 2019. Dr. Jeffrey Liva conducted an independent medical examination concerning Flowers’s musculoskeletal conditions. He concluded that she could sustain activity for eight hours per day and 40 hours per week. He did not give an opinion about her psychiatric disorders. Flowers’s treating internist, Dr. Pintauro, agreed with Dr. Liva’s conclusions; two other treating physicians did not respond to Hartford’s request for comments.

Hartford’s vocational rehabilitation case manager, Lisa Screen Housley, prepared an employability analysis identifying five occupations that Flowers was qualified and functionally able to perform with minimal learning. The occupations were Personnel Manager, Employment Manager, Employee Relations Specialist, Equal Opportunity Officer, and Employment Agency Manager. The report stated that these occupations existed in reasonable numbers in the national economy.

Hartford denied Flowers’s claim for continuing benefits effective April 8, 2020. Flowers appealed and argued that fibromyalgia, cervical radiculopathy, lumbar degeneration, bilateral carpal tunnel syndrome, and related conditions prevented her from performing any full-time work. She submitted medical records, a functional-capacity evaluation stating that she could not work at that time or in the near future, and a vocational report concluding that she could not perform any occupation under the policy.

Hartford referred the medical records to Dr. Diana Hussain and Dr. Alfred Becker for independent review. Dr. Hussain concluded that Flowers could work 40 hours per week without restrictions or limitations. Dr. Becker similarly concluded that the records did not establish medically necessary restrictions and that Flowers could work 40 hours per week from a rheumatological standpoint. Flowers’s treating physicians did not respond to requests to discuss or comment on those reports. Hartford upheld its denial on appeal.

Legal standard

Because Hartford’s policy gave it discretionary authority to determine eligibility and interpret the policy, the court reviewed Hartford’s decision under the “arbitrary and capricious” standard rather than reviewing the benefits claim from the beginning. Under that standard, the court would not disturb Hartford’s decision if it had a reasonable basis, was supported by substantial evidence, and was not legally erroneous. Substantial evidence means more than a small amount of evidence, although it need not be more likely than not to prove the conclusion.

The court’s review was limited to the administrative record—the materials considered during Hartford’s benefits review. The court considered the parties’ cross-motions for summary judgment, which ask whether the evidence shows that there is no genuine dispute over a material fact and that one party is entitled to judgment under the law.

Court’s analysis

The court held that Hartford’s denial was supported by substantial evidence. It relied on Dr. Liva’s examination and conclusion that Flowers could work full time; Dr. Pintauro’s agreement with Dr. Liva; medical notes from Dr. Barone and Dr. Andrus; Flowers’s statement that she had not seen a mental-health provider since 2018; Housley’s vocational analysis; and the reports of Drs. Hussain and Becker.

The court rejected Flowers’s argument that the evidence supporting her disability required judgment in her favor. The relevant question was whether substantial evidence supported Hartford’s decision, not whether some evidence supported Flowers’s position. The court also rejected her challenges to Dr. Liva’s examination, including her argument that the examination was too brief or did not adequately address fibromyalgia. The court noted that Dr. Liva conducted multiple physical and neurological tests, credited Flowers’s fibromyalgia diagnosis, and explained why he concluded that the condition did not prevent full-time work.

The court further ruled that Hartford could rely on the opinions of independent medical reviewers who had not personally examined Flowers and could give greater weight to those opinions than to conflicting opinions from treating physicians. The court found that Drs. Hussain and Becker explained their conclusions and considered Flowers’s reported pain rather than disregarding it without explanation.

The court also rejected Flowers’s argument that Hartford acted unreasonably because it had previously approved her benefits and because she continued to receive Social Security Disability Insurance. The court stated that Hartford could change its determination based on updated medical information, that Flowers continued to bear the burden of showing entitlement to benefits, and that a Social Security benefits decision did not bind Hartford or the court. The court found that the Social Security letter Flowers submitted did not explain the basis for that award or show that the Social Security Administration had reevaluated her condition using newer medical evidence.

Finally, the court rejected Flowers’s vocational arguments. It interpreted the policy’s use of “or” to mean that Flowers could be qualified for an occupation through education, training, or experience. Because Flowers had a bachelor’s degree, the court found that she was qualified by education for the five occupations identified by Housley. The court also found that Hartford considered, but was not required to accept, Flowers’s vocational report and functional-capacity evaluation.

Ruling

Judge Mary Kay Vyskocil granted Hartford’s motion for summary judgment and denied Flowers’s cross-motion for summary judgment. The court concluded that Hartford’s denial of continuing long-term disability benefits was supported by substantial evidence and was not arbitrary and capricious. The clerk was directed to terminate the relevant docket entries and close the case.