Brooks v. Hartford Life & Accident Ins. Co.

525 F.Supp.3d 687

Andrew BROOKS, Plaintiff,

v.HARTFORD LIFE & ACCIDENT INSURANCE COMPANY, Defendant.

Civil Action No. 1:20-CV-85

United States District Court, E.D. Virginia, Alexandria Division.

Signed March 11, 2021

Benjamin Weaver Glass, III, Benjamin W. Glass, III & Associates, Fairfax, VA, for Plaintiff.

Ian R. Dickinson, Womble Bond Dickinson LLP, Charlottesville, VA, for Defendant.

MEMORANDUM OPINION

T.S. Ellis, III, United States District Judge

At issue in this Employee Retirement Income Security Act of 1974 ("ERISA") case on cross motions for judgment on the record is whether Defendant Hartford Life & Accident Insurance Company properly exercised its discretion in determining that Plaintiff Andrew Brooks was not entitled to long term disability ("LTD") benefits for disability due to both physical and mental conditions. This matter has been fully briefed and argued and is now ready for disposition. For the reasons stated below, defendant's motion for judgment on the record must be granted in part and denied in part, and plaintiff's motion for judgment on the record must be denied.¹ Specifically, because defendant's determination that plaintiff was no longer disabled due to a physical disability was the result of a deliberate, principled reasoning process and supported by substantial evidence, that decision must be upheld. However, because defendant's determination that plaintiff was not disabled due to a mental condition failed to satisfy the notice requirement of ERISA, that determination must be remanded to the plan administrator.

I.

The following findings of fact are derived from the record in this case:

• From November 2010 to September 24, 2012, plaintiff was employed by PricewaterhouseCoopers LLP ("PwC") as an "experience associate." In that position, plaintiff was "responsible for helping clients realize competitive advantage from operations, translating business strategies into operations strategies, product innovation and development, sales and operations planning, procurement and sourcing, manufacturing operations, service operations, logistics, and capital programs." Employability Analysis Report, Administrative Record ("AR") 986. Plaintiff's position was considered to be sedentary to light.

• As an employee of PwC, plaintiff participated in a group insurance policy GLT-673035 ("the Group Policy") issued by defendant. As an employer-provided insurance policy, the Group Policy is governed by ERISA, 29 U.S.C. § 1001 et seq. • As relevant to this case, the Group Policy was issued by defendant, effective July 1, 1999, to pay LTD and other related benefits to claimants who meet the conditions of the Group Policy. The Group Policy grants defendant "full discretion and authority to determine eligibility for benefits and to construe and interpret all terms and provisions." Group Policy, AR 1874.

• The Group Policy states that a claimant has a disability when the claimant is prevented by:

(1) accidental bodily injury; (2) sickness; (3) Mental Illness; (4) Substance Abuse; or (5) pregnancy, from performing one or more of the Essential Duties of Your Occupation, and as a result Your Current Monthly Earnings are no more than 80% of Your Indexed Pre-disability Earnings. After [the first 60 months], You must be so prevented from performing one or more of the Essential Duties of Any Occupation.

Id. at AR 1855.

• The Group Policy limits disability benefits for those disabled by mental illness, stating that if the claimant is disabled because of "Mental Illness that results from any cause" or "any condition that may result from Mental Illness" then "benefits will be payable a total of 24 months." Id. at AR 1866.

• The Group Policy defines mental illness as:

[A]ny psychological, behavioral or emotional disorder or ailment of the mind, including physical manifestations of psychological, behavioral or emotional disorders, but excluding demonstrable, structural brain damage.

Id. at AR 1867.

• The Group Policy further states that LTD benefits are only payable if the claimant is under the regular care of a physician and if the claimant submits satisfactory proof of loss, including, but not limited to documentation of the date, case, and prognosis of the disability medical information, and evidence that the claimant is under the regular care of a physician. Id. at AR 1861, 1865, 1871.

• On March 1, 2012, plaintiff was in a car accident in Maryland. In the accident, a vehicle ran a red light and impacted plaintiff's car at the driver's side rear window. As a result, plaintiff hit his head on the driver's side window but was otherwise uninjured.²

• Immediately after the accident, plaintiff was able to call 911, exit the vehicle, and take photographs of the scene before emergency personnel arrived. Plaintiff was then taken by ambulance to Shady Grove Adventist Hospital.

• At the hospital, plaintiff underwent tests and physical examinations. In this regard, an x-ray of plaintiff's cervical spine and an axial CT scan were performed, neither of which found evidence of a fracture or dislocation. Plaintiff was discharged a few hours later with a diagnosis of a head contusion and sprain to the neck and back.

• A month later, on March 30, 2012, plaintiff visited Jon Peters, M.D., and reported feeling "very foggy and fuzzy headed." Medical Examination of Jon Peters, M.D., AR 1679, 1687. Dr. Peters concluded that plaintiff was suffering a "closed head injury" and a "mild concussive injury to the brain," and that plaintiff was suffered from "mild post[-]concussive symptoms including headaches and cognitive difficulties." Id. Dr. Peters recommended that plaintiff have an MRI of the brain and a "sleep deprived EEG," and plaintiff did so. A review of the results of both tests were "unremarkable." Id. at AR 1686.

• In a series of appointments with Dr. Peters from March 2012 to January 2013, plaintiff reported difficulty with mood and affect control, headaches, trouble with memory and reading retention, and difficulty concentrating. Dr. Peters also noted symptoms of anxiety and difficulty with anger management, at one point finding it necessary to advise plaintiff "if he did not compose himself, [they] would have to terminate [the] meeting." AR 1681.

• During this time period, plaintiff reported seeing eight medical professionals in addition to Dr. Peters, including a neuropsychologist, a cognitive rehab therapist, and a mental health counselor, all of whom Dr. Peters recommended, as well as a neuropsychiatrist, an acupuncturist, a chiropractor, an osteopath, and a massage therapist.

• The neuropsychologist, David Hebda, Ph.D., performed an array of tests on plaintiff. From those tests, Dr. Hebda determined that plaintiff had a general cognitive ability in the superior range, but that plaintiff had deficits in processing verbal information, attention skills for visual information, and immediate verbal learning and memory. Dr. Hebda also noted an additional concern related to plaintiff's personality testing, which Dr. Hebda found to be indicative of "a person with significant thinking and concentration problems, accompanied by prominent hostility, resentment, and suspiciousness." Medical Examination of David Hebda, Ph.D., AR 1645. Dr. Hebda concluded that "it is likely that [plaintiff's] traumatic brain injury is the primary contributing factor to his processing delays and attentional deficits." Id.

• Both Dr. Hebda and Dr. Peters recommended that plaintiff visit a cognitive rehab therapist and a mental health counselor. Plaintiff did so, but afterward reported to Dr. Peters that plaintiff would not return to see either of them. Dr. Peters prescribed a mood stabilizer for plaintiff, but plaintiff expressed reluctance to take any medication.

• Despite plaintiff's continued cognitive and physical difficulties, plaintiff continued to work until September 24, 2012. At that time, plaintiff applied for short term disability with the support of Dr. Peters. Defendant approved plaintiff's application on October 24, 2012, with benefits effective starting on September 25, 2012.

• Plaintiff received short term disability benefits through March 25, 2013, and on April 1, 2013, defendant approved plaintiff's application for LTD benefits. Plaintiff was eligible for and received LTD benefits through February 5, 2019, when defendant terminated plaintiff's LTD benefits.³

• On April 22, 2016, in connection with plaintiff's workers’ compensation claim, plaintiff underwent a medical examination performed by Donald G. Hope, M.D. Dr. Hope observed that plaintiff drove himself to the examination and that, although plaintiff quantified his pain level as seven out of ten, plaintiff displayed "no evidence whatsoever of manifestation of pain." Medical Examination of Donald G. Hope, M.D., AR 1382, 1383. Dr. Hope believed that plaintiff's pain seemed staged. Based on plaintiff's medical records and an examination of plaintiff, Dr. Hope concluded that he saw "nothing" to support that plaintiff "has any residual of concussion or post[-]concussive syndrome." Id. at AR 1397.

• Beginning in March 2018, the requirements for plaintiff to continue to receive LTD benefits changed under the terms of the Group Policy. Specifically, from that point on plaintiff was required to meet a more stringent definition of disability, namely that he was unable to perform one or more of the essential duties of "any occupation," in order to continue to receive LTD benefits.⁴

• In response to that change, on March 28, 2018, Michael Porvaznik, D.O., who had been treating plaintiff since September 2012, sent a letter to defendant averring that plaintiff was totally disabled by traumatic brain injury and post-concussive syndrome resulting from the March 1, 2012 car accident, and was incapable of performing any job or occupation.

• In Dr. Porvaznik's letter to defendant, Dr. Porvaznik described plaintiff's symptoms as including: chronic debilitating pain, soft tissue injuries related to a herniated disc, knee,

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