Hartford Life And Accident Insurance Company denies disability benefits and prevails in lawsuit filed by operator for Mohawk Inc.

When making a case for a claim of disability benefits, it is essential that a claimant has strong medical support from treating physicians. The disability insurance companies are not under any duty to help a claimant further his or her claim for disability benefits. It is the burden of the claimant to ensure that he or she had provided sufficient proof of his or her disability status. This case of Almetta T. Campbell Vs. Hartford Life And Accident Insurance Company is a good example of how a disability insurance company can easily win a disability denial if the administrative record does not have strong medical support. Disability claimants must anticipate and be prepared for a change of the policies definition of disability from own occupation to any occupation. ERISA governed policies can make it difficult for disability claimants to prevail.

The Facts of The Case against Hartford Filed in South Carolina Federal Court

Award of Disability benefits under the “Own Occupation” Standard

Plaintiff was a Spinning Operator for Mohawk. Her job duties required her to sit, stand, reach, and balance. On September 19th 2008, the plaintiff submitted a claim for long term disability benefits, which was received by Hartford. On October 9th 2008, Hartford informed the plaintiff that it had approved the plaintiff’s claim for long term disability benefits under the “Your Occupation” definition of disability.

Disability Change of Definition from Own Occupation to Any Occupation

On March 23rd 2009, the plaintiff was informed by Hartford that it would review the Plaintiff’s claim to determine if she will qualify for benefits under the “Any Occupation” definition of disability on and after September 17th 2009. The plaintiff was also informed of the requirements that she would have to meet to be eligible for continued benefits after September 17,

Subsequently, the plaintiff provided information for Hartford to evaluate. In filling out the Claimant Questionnaire, the plaintiff identified two attending physicians. Enclosed in the information provided was a copy of the denial notice from the Social Security Administration that her claim for disability benefits had been denied on March 24th 2009. An Attending Physician Statement (APS) was also provided by the plaintiff to Hartford.

Denial of Long Term disability Benefits by Hartford

On September 17th 2009, Hartford informed the plaintiff that it was denying the plaintiff claim for long term disability benefits under the “any occupation” standard. The plaintiff appealed this decision on September 28th 2009 and stated that all her medical records had not being reviewed by Hartford. It was stated that only then for the very first time she indentified several other attending physicians. In her appeal, the plaintiff submitted additional medical documentation to support her appeal. A peer review of the plaintiff’s claim was made on November 13th 2009 which concluded that the plaintiff was able to perform sedentary work.

On December 10th 2009, the plaintiff was informed that her appeal was unsuccessful. It was explained that Hartford arrived at the decision by evaluating the plaintiff’s claim file as a whole. On January 6th 2010, Harford was advised that the plaintiff had engaged a counsel to represent her and requested a copy of the claim file. On January 21st 2010, the plaintiff’s South Carolina disability lawyer sent a one page Physical Capacities Evaluation form completed by the plaintiff’s attending physician. Hartford acknowledged the letter but advised that the appeal was final and it would no longer consider the information sent.

The Plaintiff’s Arguments

The plaintiff accepted the fact that Hartford had discretionary authority in making claims determination but also suggested that the Court “should reduce the deference given the [Hartford’s] decisions to a de novo or, at a minimum, a modified abuse of discretion standard, in order to neutralize the untoward influence resulting from that direct conflict of interest.”

The District Court held that the United States Supreme Court had stated broadly that a conflict of interest should not lead to “special burden-of-proof rules, or other special procedural or evidentiary rules, focused narrowly upon the evaluator/payer conflict.”

Decision of Hartford was Reasonable and the Plaintiff Received a Full and Fair Review

The District Court contended that the administrative record, when viewed as whole, supported administrator’s determination that the plaintiff was not disabled based on plan’s “Any Occupation” definition. Furthermore after the initial denial, Hartford conducted an independent review of the claim file through an independent physician. During the entire decision making process, the plaintiff was kept abreast of the status of her claim. The District Court held that these facts establish that Hartford’s determination resulted from a deliberate and principled process.

Other Rulings by the District Court

The South Carolina District Court also held that a document that was not in existence when the Plan administrator made its final decision four months earlier was not relevant to reasonableness of decision

In addition, the Plan administrator did not have duty to obtain diagnostic testing or to create or supplement administrative record with “actual vocational examinations or functional capacity evaluations” before making its final determination.

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