In Carr v. John Hancock Life Insurance Co., plaintiff David Carr, a former Shell employee, suffered from a number of illnesses including anxiety, hypertension and prostate cancer. Additionally, he was legally blind. While employed at Shell, he was covered by a Group Long-Term Care Insurance policy.
According to the written terms of the policy, Carr was eligible for benefits if, due to “a loss of functional capacity” he needed “substantial assistance” in performing at least two “activities of daily living” for a period of 90 days. Six activities of daily living were listed in the policy:
- Maintenance of bowel or blacker function and associated personal hygiene.
- Toileting, including getting on and off the toilet.
- Transferring, meaning moving from one place to the other.
Housework or housekeeping are not activities of daily living according to Hancock Life. Substantial assistance means either “hands-on” or “standby.” The burden is on the insured to prove he qualifies for benefits.
Initial Claim Approval and Subsequent Denial
Carr submitted his first claim for benefits in May 2011. He needed assistance with bathing, dressing, eating, toileting and transferring. A review of his medical records confirmed he qualified and benefits were awarded. Reevaluations were periodically conducted and benefits extended.
His condition improved. From May 2013 to the middle of June 2013, his nurse reported that he only needed assistance with housekeeping and bathing. According to nursing notes from the middle of June to the middle of August 2013, Carr had not required any assistance with any of the enumerated activities of daily living. Hancock ordered another assessment, which concluded Carr did not need any help at all. His claim for further benefits was denied effective July 2013.
Carr’s Appeal of the Denial of Continued Benefits
After Hancock denied his claim for continuing benefits, Carr appealed. Hancock informed him that he could submit additional records to support his claim. Although Carr submitted medical records, he did not submit any new record that supported his claim that he needed assistance with at least two of the enumerated covered activities of daily living. Records were presented by a neurologist and a urologist. The urologist certified that Carr “is a chronically disabled individual” without any discussion of any activities with which he needed help. After exhausting his administrative remedies, Carr filed this ERISA lawsuit.
Florida District Court Analysis
The District Court confirmed that Carr failed in his burden of proving that he needed hands-on or standby assistance with at least two activities of daily living as enumerated in the policy. Carr’s argument that he was not allowed to “amend the paperwork” was also erroneous. The Court noted that there was a 14-month period of time from the first denial to the end of the final appeal. During that entire time, Hancock encouraged Carr to provide more information. “Despite ample opportunity, Carr failed to correct the purported deficiency” therefore “John Hancock correctly denied Carr’s claim.”
This case was not decided by our firm, but we think it can be instructive to those who are given an opportunity to supplement the record during the administrative appeals process. For questions about this case, or any other question about your disability benefits, contact one of our disability attorneys at Dell & Schaefer for a free consultation.