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Benefits Decision Was Not Arbitrary Because It Was Supported By Evidence Inconsistent With Insured

Benefits Decision Was Not Arbitrary Because It Was Supported By Evidence Inconsistent With Insured's Claim

Howard v. Hartford Life & Accident Ins. Co., 563 F. App'x 658 (11th Cir. 2014)

ERISA and Life Insurance News
(August 29, 2014)

Howard sued Hartford to recover additional long-term disability benefits, based on subjective diagnoses of lupus and fibromyalgia, among other ailments. The district court granted summary judgment to Hartford, and the Eleventh Circuit affirmed.

Hartford initially approved benefits based on a treating physician’s report that Howard could not perform her occupation as a business strategy manager. To further assess Howard’s capabilities, Hartford obtained surveillance, which showed Howard engaging in activities that were starkly inconsistent with her self-reports and those of her treating physicians.

Hartford consulted an independent physician and an independent psychologist, and both opined that Howard should be able to perform her occupation full-time. Hartford terminated benefits.

On appeal, Howard complained that Hartford’s conflict of interest affected its benefits determination, and that the district court erred in failing to consider extra-record exhibits attached to her summary judgment motion (some of which did not even exist when Hartford made its decision).

The Eleventh Circuit confirmed that it is the claimant’s burden to prove disability, to prove an abuse of discretion by the claim administrator, and to prove that the decision was affected by the conflict of interest. Because Howard’s allegedly disabling conditions were subjective (i.e., fibromyalgia and a lupus diagnosis without corroborating labwork), the Eleventh Circuit found that “credibility in this case is of the utmost importance.” Howard’s credibility was “seriously called into question by the surveillance which show[ed] her engaging in activities grossly inconsistent with her description of her abilities, and in stark contrast to her own treating physicians’ assessments” based on her “subjective complaints.”

The court reiterated that a review of a claimant’s records by an independent consultant is not arbitrary and capricious. Moreover, despite submitting 30 extra-record exhibits with her summary judgment motion, “Howard failed to submit evidence showing the reviewing health care providers were tainted or biased,” such that “Hartford’s reliance on their opinions was not arbitrary or capricious.” With conflict being just one factor to consider, “the district judge appropriately deferred to Hartford’s decision regarding benefits ....”

It was not necessary for the court to resolve whether the district “erred in failing to consider” Howard’s various exhibits, because the judge “did examine all exhibits Howard tendered but concluded these exhibits did not justify another result.”

Click here to view the full August 2014 Edition of the ERISA and Life Insurance News.

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