Opinion
Case No. 3:02-CV-192-J-25HTS.
March 15, 2005
ORDER
THIS MATTER came on for bench trial on February 10, 2004. The Court has jurisdiction over the parties and over the subject matter of the action. The Court, having heard the argument of counsel, and having reviewed the administrative record, now finds as follows:
At trial, the parties made oral argument and otherwise relied on the administrative record by way of evidence. Nothing beyond the administrative record was submitted for the Court's consideration.
I. FINDINGS OF FACT
From 1974 until October 21, 1997, Plaintiff was employed as a medical technologist at Lake City Medical Center in Lake City. Florida; during the last several years of her employment. she was working at that hospital for Columbia/HCA Healthcare Corporation (Columbia). In her position. Plaintiff's duties included supervising technical and clerical employees in clinical laboratories, staffing and quality control in clinical laboratories, assisting in collection of laboratory specimens and performance of laboratory tests. A. Disability Plan Terms
During her employment, Godbolt was a participant in the Columbia Long Term Disability Plan (the "Plan"). The Plan is an employee welfare benefit plan governed by the Employee Retirement Income Security Act of 1974, 29 U.S.C. § 1001 et seq. ("ERISA"). Defendant Hartford Life Accident Insurance Corporation ("Defendant" or "Hartford") is the claims administrator of the Plan. The group insurance policy ("Policy") provides that Hartford has "full discretion and authority to determine eligibility for benefits and to construe and interpret all terms and provisions of the [Policy]."
Additionally, the Policy provides that participants will receive disability benefits if they are totally disabled and submit proof of loss satisfactory to Hartford. Those benefits include 60% of pre-disability earnings as an income replacement benefit. (Admin. Rec. H. 13.) The Policy defines "totally disabled" as follows:
Total Disability or Totally Disabled means that:
(1) during the Elimination Period; and
(2) for the next 24 months, you are prevented by:
(a) accidental bodily injury;
(b) sickness;
(c) mental illness;
(d) substance abuse; or
(e) pregnancy,
from performing the essential duties of your occupation, and as a result you are earning less than 20% of your pre-disability earnings, unless engaged in a program of rehabilitative employment approved by us.
After that, you must be so prevented from performing the essential duties of any occupation for which you are qualified by education, training, or experience.
(emphasis in original).
B. Plaintiff Terminated for Falsifying Time Records
On October 21, 1997, Plaintiff was dismissed from her employment with Columbia for falsifying time records (Admin. Rec. H 210). The Court finds that the records are clear that at the time of her termination, falsifying time records was the reason given — records dated the same day as the termination list that as the reason for termination. She worked full-time until the date of her termination. At no time during her employment with Columbia did any physician restrict her work activities in any manner. Moreover, Plaintiff did not seek disability benefits at any time during her employment.
C. Purported Disability Claim Ensues
Two days after her termination, on October 23, 1997, Plaintiff apparently sought to claim total disability. "Apparently" is used because according to Plaintiff's timeline, that is the date she first returned to work to fill out the needed paperwork to make that claim; there is no evidence of this in the record other than Plaintiff's self-report. (Admin Rec. H 164-66.)
The question arises: What was Plaintiff's disability? Plaintiff's medical records preceding her termination reveal a variety of ailments:
idiopathic thrombocytopenia purpura: this is a medical condition where the sufferer has a low platelet count in her blood, which will cause patient to have trouble with blood clotting;
edema: body swelling because of excessive salt retention
chronic pancreatitis: bouts of pain over long term in the upper gastric area of the abdomen
osteoarthritis: progressive breakdown of the cartilage in the jointshypertension: high blood pressure
hypersplenomegaly: related to spleen; medical record indicated spleen may be removed in response (Admin. Rec. H. 103);
lupus: autoimmune disease, the body attacks the DNA in one's healthy cells.
migraine headaches
(Admin. Rec. H. 102-106.) Additionally. Plaintiff claims she suffered from Hodgkin's Lymphoma, although there is nothing in the record to substantiate this diagnosis prior to her termination. None of her medical records, however, indicated that Plaintiff should take time off from work due to any or all of the conditions. Moreover, prior to her termination, there is no evidence that Plaintiff took time off from work due to any or all of these conditions.
On November 13, 1997, less than one month after she was terminated, she drafted a letter to Columbia's Human Resources Director; in that letter she complained that she had "repeatedly tried to reach your office to speak to you regarding my long-term disability claim. Please contact me to setup a date to meet with you at your earliest convenience. . . ." (Admin. Rec. H 166.) A later letter included in the claim file relates in detail the measures Plaintiff took in seeking to receive her long term disability benefits: from two days after her termination through April 1, 1998, Plaintiff was repeatedly given the runaround by the Lake City Medical Center, and the Human Resources Director refused to take her phone calls or meet with her, despite Plaintiff having filled out paperwork the day after her termination to claim her long-term disability benefits. (Admin. Rec. H. 164-66.)
D. Denial of Benefits and Appeals
On January 10, 2000, Lake City Medical Center/Columbia submitted its Employer's Statement regarding Plaintiff's disability claim on January 10, 2000. Hartford received the form on January 21, 2000. Where the employer is asked to describe why the employee ceased work, the form has a handwritten note reading "XXXXXX Medical advise lupus. ITP termenat" and underneath it reads "Employee was discharged." (Admin. Rec. H 233.) Along with the Employer's Statement, Plaintiff was likewise required to fill out a form making her request for benefits: in this form. Plaintiff lists two disabling conditions: "Lupus and ITP [idiopathic thrombocytopenia purpura]." (Admin. Rec. H 234.) She also claimed in filling out that form that her disability began on October 21, 1997 — the date she was terminated. (Admin. Rec. H 234.)
On October 3, 2000, Hartford notified Plaintiff that she failed to submit proof of loss satisfactory to The Hartford which supports total disability at any time on or after 10/21/97. Accordingly. [long-term disability] benefits are not payable to you." (Admin Rec. H 179.) Hartford invited Plaintiff to submit additional information not previously submitted (including certain records it suggested should have been previously filed) and gave Plaintiff sixty days to submit the new information. Hartford agreed to review the additional information, along with the previously-submitted information, and notify Plaintiff of the results of that review.
On October 31, 2000, Plaintiff appealed Hartford's denial. Plaintiff also submitted new records for review, specifically records detailing the severity of her nearly lifelong migraine headache suffering, which made Plaintiff "drowsy . . . dizzy . . . tired, weak and worn-out." (Admin. Rec. H 139.)
After this appeal but before it was denied, Plaintiff produced a note from a nurse employed by Hartford, dated May 16, 2001, which indicates the nurse believed Plaintiff's claim was legitimate:
Medical records before 10/97 and after appear to support severity of medical conditions to support no work capacity. The insured ha[d] multiple medical conditions at that time idiopathic thrombocytopenia, severe low platelet count, up to 15 but as low as 0 in the months that followed, insured has osteoarthritis noted, severe w/Prednisone at 30 mg per day, severe headaches with Vistaril and Talwin ordered, with Demerol and Phenergan used later. Lupus noted in 12/97 with Prednisone increased up to 35 mg/day. Later insured noted to have Hodgkins Lymphoma and Hep C with colon resection two years later.
Medical records in the file at the dod up until 2/9/01. Medical records in 10/00 indicated that the insured was in the hospital for 20 days for a colon resection. She had Hodgkin's Lymphoma, CHF, Colon resection, Lupus, osteoarthritis, Hep. C and hypertension. Appears reasonable no work from last day of work up until current and most likely permanently given the multitude of serious dx's w/symptomotology. Most likely the insured had severe impairment in functionality before 10/97 according to the medical records.
(Admin Rec. H 46.) (emphasis added).
On June 14, 2001, Plaintiff's appeal was denied. (Admin. Rec. H 80-92.) The decision was based on: (1) her termination on October 21, 1997, for falsifying time records, which would render her not covered under the policy for any disability arising after that date because she was no longer employed by Columbia; (2) the fact that Plaintiff worked full-time with no medical restrictions until the date of her dismissal by Columbia; and (3) the absence of any references in the medical records to any disability as defined in the policy, or to any condition sufficiently incapacitating to constitute a disability as defined in the policy. (Admin Rec. H. 80-92.) The denial letter also referenced Plaintiff having sought unemployment benefits following her termination; to obtain unemployment benefits, Plaintiff would have had to advise the state she had work capacity. (Admin Rec. H 81.)
On August 6, 2001, Plaintiff appealed the second denial. Plaintiff complained that the second denial letter was the first time she had been told that her request for unemployment benefits was being used against her for purposes of denying her disability benefit request. She asked that Hartford provide her documentation from Columbia regarding the unemployment claim, but Hartford refused to grant that request, stating that Columbia forbade them from doing so.
Finally, on September 14, 2001, Hartford issued its "final determination with respect to this matter," and advised Plaintiff that because she was terminated on October 21, 1997, she was no longer a full-time employee when she made her demand for disability insurance coverage, per the terms of the policy. The provision Hartford relied upon reads:
When does your coverage terminate?
You will cease to be covered on the earliest to occur of the following dates:
(1) the date the Group Insurance Policy terminates;
(2) the date the Group Insurance Policy no longer insures your class;
(3) the date premium payment is due but not paid by the Employer;
(4) the last day of the period for which you make any required premium contribution, if you fail to make any further required contribution;
(5) the date you cease to be an active full-time Employee in an eligible class including:
(a) temporary layoff;
(b) leave of absence; or
(c) a general work stoppage (including a strike or lockout). If you are granted a leave of absence due to illness, the employer may continue your insurance for 6 months following the month coverage would have terminated subject to the following:
(a) the required premium must be paid: and
(b) the Employer must not discriminate unfairly among employees in similar situations.
(Admin. Rec. H 25) (Emphasis added). Hartford took the position that the date Plaintiff ceased to be an active employee was the last date for which she would have been entitled to make a claim for coverage as a full-time employee in the eligible class.
In making this determination, Hartford rejected the language of a one-page `summary plan description,' ostensibly produced by Hartford, Plaintiff had relied upon in making her claim for coverage. The `summary plan description suggested that insurance coverage ended "the last day of the month your employment ends." (Admin Rec. H 66.) In denying summary judgment, the Court had concluded that this document created a genuine issue of material fact regarding when the Plaintiff's coverage would end. Having heard from each side at bench trial, however, the Court finds that this one-page document is too unreliable to be accorded any weight by the Court in making its final conclusions of law. Defendant has no idea where this document came from, and Plaintiff had no idea when she received this document. The document is not even necessarily reflective of the Plan at issue; there is simply no way for the Court to determine what this document is, based on the evidence Plaintiff produced in the administrative record.
"Summary plan description" is the name the Court uses for this document, although it is not titled as such. The one-page document does not have a title.
Plaintiff appeals Hartford's denial of her claim for disability benefits.
II. CONCLUSIONS OF LAW A. ERISA Standards of Review
In Firestone Tire Rubber Co. v. Bruch, 489 U.S. 101, 109 (1989), the Supreme Court stated that, generally, courts should review claims challenging an ERISA claims administrator's denial of benefits under a de novo standard. The Supreme Court adopted the de novo standard because the arbitrary and capricious, or abuse of discretion, standard, is too lenient. The Supreme Court explained that the arbitrary and capricious standard of review is appropriate, however, when the plan documents at issue explicitly grant the claims administrator discretion to determine eligibility or construe terms of the plan. See id. at 115; see also Florence Nightingale Nursing Serv., Inc. v. Blue Cross/Blue Shield, 41 F.3d 1476, 1481 (11th Cir. 1995). The arbitrary and capricious deference is diminished, though, if the claims administrator was acting under a conflict of interest. Florence Nightingale, 41 F.3d at 1481. If the claims administrator was acting under a conflict of interest, the burden shifts to the administrator to prove that its interpretation of the plan provisions committed to its discretion was not tainted by self interest. Brown v. Blue Cross Blue Shield, 898 F.2d 1556, 1566 (11th Cir. 1990). Accordingly, the Eleventh Circuit has adopted the following standards for reviewing administrators' plan interpretations: (1) de novo where the plan does not grant the administrator discretion; (2) arbitrary and capricious [where] the plan grants the administrator discretion; and (3) heightened arbitrary and capricious where there is a conflict of interest. See Buckley v. Metropolitan Life, 115 F.3d 936, 939 (11th Cir. 1997).
"The distinction between a plan administrator and a fiduciary is unimportant because the standard of review, as set forth by the Court in Firestone, `applies equally to the decision of fiduciaries and the plan administrator.'" Marecek v. BellSouth Telecommunications, Inc., 49 F.3d 702, 705 n. 1 (11th Cir. 1995).
See Jett v. Blue Cross Blue Shield, 890 F.2d 1137, 1139 (11th Cir. 1989) (stating that the arbitrary and capricious standard is used interchangeably with an abuse of discretion standard).
In the instant case, Plaintiff submits that the Court must review Hartford's decision to deny Plaintiff benefits under a heightened arbitrary and capricious standard. This is so because the Plan in this case is insured by an insurance policy sold to the sponsor by Defendant and administered by Defendant. Further, Defendant pays claims from its own funds via this insurance policy. Defendant disagrees, and submitted that the Court should apply the more deferential arbitrary and capricious standard of review. The Court agrees with Plaintiff that heightened arbitrary and capricious review is the proper standard to use when reviewing Hartford's decision to deny Plaintiff ERISA benefits, because Hartford is the administrator and pays claims from its own funds. See Torres v. Pittston Co., 346 F.3d 1324, 1331 (11th Cir. 2003); Brown v. Blue Cross Blue Shield of Ala., 898 F.2d 1556, 1562 (11th Cir. 1990).
Regardless of whether arbitrary and capricious or heightened arbitrary and capricious review applies, the Court evaluates the claims administrator's interpretation of the plan to determine whether it is "wrong." See Godfrey v. BellSouth Telecommunications, Inc., 89 F.3d 755, 758 (11th Cir. 1996) ("we first conduct a de novo review to decide if the [claims administrator's] determination was wrong."); Brown, 898 F.2d at 1566 n. 12 ("[i]t is fundamental that the fiduciary's interpretation first must be `wrong' from the perspective of de novo review before a reviewing court is concerned with the self-interest of the fiduciary."); see also Marecek v. BellSouth Telecommunications, Inc., 49 F.3d 702, 705 (11th Cir. 1995) (explaining that when the district court agrees with the ultimate decision of the administrator, it will not decide whether a conflict exists. Only when the court disagrees with the decision does it look for a conflict and, when it finds such a conflict, it reconsiders the decision in light of this conflict).
"Wrong" is the label used by Eleventh Circuit precedent to describe the conclusion a court reaches when, after reviewing the plan documents and disputed terms de novo, the court disagrees with the claims administrator's plan interpretation. See Yochum v. Barnett Banks, Inc., 234 F.3d 541 (11th Cir. 2000); see also Marecek v. BellSouth Telecommunications, Inc. 49 F.3d 702, 705 (explaining a court must decide if the administrator correctly interpreted the plan).
Hartford determined that Plaintiff's termination on October 21, 1997, precluded her from coming forward two days later and making a disability benefits claim, because she was no longer an employee and thus not covered by the policy at that point. Was that decision correct? The Policy states that coverage terminates on the earliest to occur of several dates, and one of those dates is "the date you cease to be an Active Full-Time Employee." (Admin Rec. H 25.) Having disregarded the summary plan description Plaintiff produced because of its unreliability, the Court concludes that on October 21, 1997, Plaintiff ceased to be covered for disability under the Policy because she was terminated from work on that date.
Under the terms of the Policy, a participant is totally disabled if she is unable to perform the essential duties of her occupation. There is little, if any, evidence that while Plaintiff was employed that she was unable "to perform the essential duties of her occupation." Although there is a note from a nurse in the administrative record which states that it would be "likely" that Plaintiff would have had trouble working prior to her termination date because of her variety of medical conditions, the fact remains that Plaintiff worked continuously up until the date she was terminated from work for falsifying time records. Prior to her dismissal, Plaintiff had been continuously employed for more than two decades without ever seeking disability benefits. Restrictions were never put on Plaintiff's ability to work during her employment by Columbia. As such, the far greater weight of the evidence leads to the inescapable conclusion that Plaintiff was not disabled during her term of employment, even on October 21, 1997, the day she was terminated.
Most of the medical information in the Administrative Record, and all of the information from prior to Plaintiff's termination, consists of the treatment records of Dr. David Fanney, Plaintiff's treating physician. Although Fanney treated Plaintiff for the variety of conditions described supra, at no time do those records reflect Fanney ever prescribing, suggesting, or even mentioning any limitation or restriction on Plaintiff's ability to work. The records reflect that Plaintiff had been living, and working, for a long time with the conditions for which she now claims a disability. Additionally, the records do not reflect any sudden change in her condition in the weeks leading up to her termination. Although the Court recognizes that there may be circumstances where a disabled employee may continue to work full-time despite a disability that should preclude the individual from working, see, e.g., Perlman v. Swiss Bank Long Term Disability Plan, 195 F.3d 975, 983 (7th Cir. 1999), the Court concludes that this is not the situation before the Court in the instant case.
There, the Seventh Circuit stated:
"We can imagine circumstances under which it would be unreasonable to demand proof of a change in condition. Some disabled people manage to work for months, if not years, only as a result of superhuman effort, which cannot be sustained. Sometimes work beyond one's limitations is essential to maintain one's standard of living, or is the result of an effort to disguise one's limitations from friends and coworkers. Reality eventually prevails, however, and limitations that have been present all along overtake even the most determined effort to keep working. Perlman, 195 F.3d at 193. Nevertheless, the Court held in Perlman that the plaintiff was not that type of employee, and reversed the district court's award of ERISA benefits.
Because she was not disabled during her employment with Columbia, and because her coverage ceased on the date she was terminated, which cuts Plaintiff off from coverage for any disability which may have arisen after she was terminated, the Court concludes that Defendant's decision to deny benefits to Plaintiff was correct.
2. Analysis Ends With Conclusion That Administrator Was Correct.
Since the Court has concluded that Defendant was correct to deny Plaintiff's claim for disability coverage, the Court need go no further in its analysis.
III. CONCLUSION
Plaintiff was terminated from work for malfeasance, and then sought to make a claim for disability coverage after her coverage had expired due to her termination, as per the Policy. Defendant was correct to deny her claim.
Accordingly, it is
ORDERED:
The Clerk is DIRECTED to enter JUDGMENT in favor of DEFENDANT and CLOSE THIS CASE.