Freeman v. Hartford Life & Accident Ins. Co.

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KURT FREEMAN v. HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY

Civil Action No. 21-342-SDD-RLB

United States District Court, M.D. Louisiana

March 22, 2023

RULING

SHELLY D. DICK, CHIEF DISTRICT JUDGE

In this ERISA case, before the Court are the cross Motions for Judgment on the Administrative Record filed by Defendants, Hartford Life and Accident Insurance Company and Aetna Life Insurance Company (“Defendants” or “Hartford”)^[1] and Plaintiff, Kurt Freeman (“Plaintiff” or “Freeman”).^[2] The Court has considered the Parties' respective Oppositions^[3] and Replies.^[4] For the following reasons, Defendants' motion shall be granted, and Plaintiff's motion shall be denied.

I. BACKGROUND FACTS

Plaintiff's claimed disability stems from an injury he sustained to his left rotator cuff on June 26, 2016, outside of work, which was subsequently surgically repaired.^[5] Plaintiff filed this lawsuit following the denial of his claim for Long Term Disability (“LTD”) benefits under a group LTD benefit plan (“the Plan”)^[6] governed by the Employee Retirement Income Security Act of 1974 (“ERISA”).^[7] The Plan was sponsored by Plaintiff's former employer, Praxair, Inc., and was insured by a group policy of insurance originally issued by Aetna under Policy No GP-656164 (the “LTD Policy”).^[8]

Defendants administered LTD claims under the LTD Policy, including Plaintiff's. The terms of the LTD Policy expressly granted Defendants the full discretion and authority to determine eligibility for benefits and to construe and interpret the LTD Policy.^[9] The Parties stipulated that the LTD Policy vests Defendants with discretionary authority to determine eligibility for benefits, to construe and interpret its terms, that ERISA governs the LTD Policy, that the Administrative Record (“AR”) is complete, and that ERISA preempts any state law claims.^[10]

The LTD Policy and Plan provide that, during the first 24 months after a claim is made, the test for disability is the “Own Occupation” test.^[11] The “Own Occupation” test requires that the claimant must be unable perform the material duties of his “own occupation” solely because of illness or injury.^[12] To remain eligible for LTD benefits after the first 24 months, a claimant must satisfy the “Any Reasonable Occupation” test for disability.^[13] The “Any Reasonable Occupation” test requires that a claimant be unable to work at “any reasonable occupation” solely because of illness or injury.^[14] The Plan defines “reasonable occupation” as “any gainful activity for which [the claimant is], or may reasonably become, fitted by education, training, or experience ”^[15] Plaintiff received LTD benefits for the initial 2-year period governed by the “Own Occupation” definition; Hartford denied continuation of LTD benefits under the “Any Reasonable Occupation” definition.

Plaintiff seeks review of Hartford's May 25, 2021 appeal decision affirming its October 6, 2020 claim decision finding that Plaintiff, a former Safety Specialist, is ineligible for LTD benefits under the “Any Reasonable Occupation” test.^[16] Defendants argue Plaintiff's lawsuit must be dismissed because Hartford's appeal decision was neither an abuse of discretion nor arbitrary and capricious. Hartford maintains it conducted a full and fair review of Plaintiff's claim before affirming its October 6, 2020 claim decision.^[17]

In upholding its October 6, 2020 claim decision, Hartford noted that, although the medical documentation supported some functional deficits impacting Plaintiff's use of his left shoulder and arm, Plaintiff is right hand dominant and capable of performing sedentary work on a full-time basis with certain restrictions on the use of his left arm.^[18]Hartford contends this conclusion was supported by Plaintiff's own evidence.^[19]

Hartford maintains it gave Plaintiff's claim a full and fair review after evaluating the entire claim file, including, “without limitation,”^[20] Plaintiff's submissions and records from his treating physicians, Dr. Kelly Boussert (“Dr. Boussert”) and from Dr. Wame Waggenspack, Jr. (“Dr. Waggenspack”).^[21] Dr. Waggenspack practices with Dr. Boussert and examined Plaintiff on October 28, 2020, at Plaintiff's request, specifically to ascertain Plaintiff's work capacity.^[22]

At the time of Plaintiff's appeal, Dr. Boussert opined that Plaintiff could work twenty-five (25) hours a week with restrictions on the use of his left arm.^[23] Further, contrary to Plaintiff's claims, Dr. Boussert reported that Plaintiff did not suffer significant side effects from his medication, and he was not cognitively impaired or sedated by his medication.^[24] Dr. Boussert noted that Plaintiff was able to drive and was driving himself to his appointments.^[25] While restricting Plaintiff to part-time work, Dr. Boussert nevertheless approved Plaintiff for light capacity work rather than purely sedentary work.^[26]

Hartford claims Plaintiff sought an examination by Dr. Waggenspack to support Dr. Boussert's part-time work restriction;^[27] however, Dr. Waggenspack disagreed with Dr. Boussert's conclusion and, rather, agreed with the determination of an Independent Medical Examination (“IME”) performed by Dr. Beau Bagley (“Dr. Bagley”), a Board Certified Specialist in Physical Medicine and Rehabilitation retained by Hartford.^[28] Dr. Bagley concluded that Plaintiff was capable of full-time, sedentary duty work with restrictions on his left upper extremity.^[29] Dr. Waggenspack also determined, based on his review of Plaintiff's medical records, that any pain complaints were well controlled by Plaintiff's medication.^[30] Hartford commissioned an Employability Analysis Report (“EAR”), dated August 27, 2020, which identified at least two (2) full-time, sedentary positions in the applicable labor market for Plaintiff: Safety Manager and Department Manager.^[31]

Following Plaintiff's appeal of the initial claim decision, Hartford obtained a Physician's Review from William Barreto, M.D. (“Dr. Barreto”) and from Dr. Jamie L. Lewis (“Dr. Lewis”), both Board Certified in Pain Medicine and Physical Medicine & Rehabilitation.^[32] Notably, Plaintiff's treating physician, Dr. Boussert, is also Board Certified in the same field.

Dr. Barreto found Plaintiff capable of full-time, sedentary work with the restrictions noted.^[33] Dr. Lewis found Plaintiff capable of performing at a sedentary demand level “at least,” with restricted use of his left arm and unrestricted use of his right arm.^[34] Based on the above medical opinions, with were in agreement with Dr. Bagley's opinion, Hartford concluded that there was substantial evidence to support its decision that Plaintiff was capable performing full-time, sedentary work with restrictions on the use of his left arm. Hartford also considered the finding by the Social Security Administration (“SAA”) that Plaintiff was “not disabled” and that he was capable of performing light duty work on a full-time basis.^[35]

For the above reasons, Hartford maintains it is entitled to judgment on the administrative record because there is substantial evidence supporting its claim decision.

Plaintiff also moves for judgment on the administrative record, arguing that Hartford disregarded key evidence and relied on flawed evidence in reaching its decision. Plaintiff contends that Dr. Bagley's notes from his July 10, 2020 IME demonstrate that Plaintiff's physical capacity is “less than sedentary.”^[36] Plaintiff relies on the following notes from Dr. Bagley in support of this interpretation:

He could not push, pull, or carry with the left arm... He guards the left upper extremity; therefore, it would be difficult for claimant to lift/carry/push/pull with the left upper extremity, but because of claimant's motor exam, he could lift/carry/push/pull 2 lbs. with the left upper extremity rarely.With the left upper extremity, he can never reach above the shoulder. With the left upper extremity he can reach at desk/bench level rarely. He can handle finger and feel with the left upper extremity occasionally..Because of the limitations of ROM of the left upper extremity, claimant cannot perform climbing and crawling..There were no inconsistencies on today's exam..Because there are chronic changes noted on EMG/NCV testing and it has been greater than two years since the original injury, claimant's prognosis for improvement in function of the left upper extremity at the shoulder without further intervention is poor.given the above restrictions. and a position that would let claimant be on current pain medication regimen, claimant can work 8 hours per day, 5 days per week.^[37]

Plaintiff concedes that, on July 12, 2020, Dr. Boussert, his treating physician, evaluated Plaintiff and concluded that he could work on a part-time basis, at light capacity with restrictions.^[38]

Plaintiff maintains that Hartford's initial denial and appeal denial were faulty in several ways. Plaintiff claims that Hartford erroneously credited the SSA determination of May 8 2019, which concluded that Plaintiff was at a greater physical capacity than even Dr. Bagley determined.^[39] Plaintiff argues that Hartford disregarded “objective evidence” of his nerve conduction studies showing permanent nerve damage, including the “chronic changes noted n EMG/NCV” identified by Dr. Bagley.^[40] Plaintiff contends Hartford limited the scope of Dr. Bagley's findings as to Plaintiff's necessary restrictions.^[41]Plaintiff attacks the vocational analysis performed for a variety of reasons, primarily because the two available jobs identified do not take into account Plaintiff's pain regimen.^[42] In sum, Plaintiff contends Hartford's denial was arbitrary and capricious in the following ways: (1) the Plan's vocational analysis was flawed and...