In Scott Griffin v. Hartford Life & Accident Insurance Company, Plaintiff was a medical transcriptionist who was initially awarded long term disability benefits in 2010 due to arm and wrist pain and a herniated cervical disc. He ultimately underwent surgery for the bad disc.
Plaintiff’s initial benefits were awarded based on his inability to perform the regular duties of his own occupation. After 24 months, the definition of disability changed to require him to be unable to perform the duties of any occupation for which he was qualified.
In May 2012, Hartford sent Plaintiff a letter informing him that his benefits would continue “as long as he continued to meet the definition of ‘disabled’ in the long-term disability benefits policy.” Hartford continued to monitor his condition and periodically requested updates from his treating physicians.
Hartford specifically asked for functionality test results, or at least a functionality opinion, but both of Plaintiff’s attending physicians informed Hartford they did not conduct these types of tests, and were not willing to offer a functionality opinion. The medical records of the two providers indicated that there were not any restrictions on Plaintiff’s activities.
Hartford repeatedly tried to get more information from Plaintiff’s medical providers to no avail. Finally, Hartford learned that Plaintiff was no longer undergoing any medical treatment and was not taking any pain medications. Based on these reasons, Hartford terminated Plaintiff’s long term disability benefits. After exhausting his administrative appeals, Plaintiff filed an ERISA lawsuit in the U.S. District Court for the Western District of Virginia.
The District Court held that Hartford did not abuse its discretion when it terminated Plaintiff’s long term disability benefits. Although Plaintiff raised several issues in his appeal, the U.S. Court of Appeals for the Fourth Circuit affirmed the district court’s decision holding that: 1) The lower court used the proper standard of review; and 2) The burden is on the claimant to prove the disability.
District Court Correctly Reviewed Hartford’s Termination of Benefits for Abuse of Discretion
Plaintiff argued that the lower court should have reviewed the termination of benefits de novo instead of for abuse of discretion. The Appellate Court affirmed the district court decision and concluded, that when the terms of the plan confer discretionary authority on the administrator to determine eligibility, “courts… decide only the contractual questions of whether the administrator exceeded its power or abused its discretion…”.
The Burden is on the Claimant to Provide Documentation of Disability
Plaintiff argued that Hartford did not provide proof that his condition had changed such that termination of his benefits was warranted. He also said Hartford should have had him submit to a medical exam before terminating his benefits.
The Appellate Court disagreed. It noted that the language of the policy explicitly stated that it is a claimant’s duty, not Hartford’s, to provide “proof of loss.” Even so, medical records from 2014 said his condition had improved. He was no longer receiving treatment and no longer taking pain medication. Plaintiff provided no proof that he was still disabled.
The Court concluded that the district court correctly agreed that Hartford did not abuse its discretion in terminating benefits and stated, that “While ERISA administrators may not deny benefits without an adequate evidentiary basis, they are ‘under no duty to secure specific forms of evidence.’”
This case was not handled by our office, but we feel it can be instructive to those who need to provide medical evidence to plan administrators in order to prove the need for continuing long term disability benefits. If you have a similar issue, or any issue concerning your disability benefits, contact one of our disability attorneys at Dell & Schaefer for a free case evaluation.