Bloom, a participant in an ERISA-governed disability plan, claimed benefits due to frequent seizures. According to Bloom and her treating physician, the seizures were unpredictable, and, among other things, they made it unsafe for Bloom to drive an automobile.
Hartford’s review of the claim included two days of surveillance, during which Bloom was observed driving an automobile approximately 90 miles. Hartford denied the claim, and upheld its decision on appeal. The district court held that Hartford’s denial of Bloom’s claim was not arbitrary and capricious.
On appeal, the Eleventh Circuit affirmed, noting that the surveillance video provided “substantial evidence” to support Hartford’s claim decision. “[T]he fact that she drove an automobile approximately 90 miles during that two-day period is significantly inconsistent with her account of her condition and that of the opinion of her treating physician, which seems to have been based upon her self-reported symptoms,” the court said.
The court rejected Bloom’s argument that Hartford was arbitrary and capricious because it did not sua sponte attempt to obtain a copy of an ambulatory EEG report mentioned by the treating physician for the first time in a letter supporting Bloom’s appeal. “Although it is true that the administrator acts in a fiduciary capacity,” the court said, “the case law in this Circuit clearly establishes that the plaintiff has the burden of proving her claim for disability benefits.”
While noting that under certain circumstances a claims administrator might have “a fiduciary duty to seek out the location of and consider omitted documents referred to in the record where it is apparent that the document would provide significant support for the claimant’s claim,” those circumstances were not present. Instead, the treating physician “referred to the document only in passing,” and he “gave no indication that it provided any significant support for a disabling seizure disorder.”
Finally, Bloom argued that Hartford’s failure to comply with its claims manual was evidence that its decision was arbitrary and capricious. The Eleventh Circuit disagreed, stating that “our careful review leads us to agree with the district court that deviations in this case, if indeed there were any at all, were de minimis,” and they did not affect the fullness and fairness of the review.
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