Griffin v. Hartford Life & Accident Ins. Co.

• Decision Date: 31 July 2018
• Docket Number: No. 17-1251,17-1251
• Citation: 898 F.3d 371
• Parties: Scott GRIFFIN, Plaintiff-Appellant, v. HARTFORD LIFE & ACCIDENT INSURANCE COMPANY, Defendant-Appellee.
• Court: U.S. Court of Appeals — Fourth Circuit

898 F.3d 371

Scott GRIFFIN, Plaintiff-Appellant,

v.HARTFORD LIFE & ACCIDENT INSURANCE COMPANY, Defendant-Appellee.

No. 17-1251

United States Court of Appeals, Fourth Circuit.

Argued: May 9, 2018

Decided: July 31, 2018

ARGUED: Michael D. Grabhorn, GRABHORN LAW OFFICE, PLLC, Louisville, Kentucky, for Appellant. John Cowles Neiman, Jr., MAYNARD COOPER & GALE, P.C., Birmingham, Alabama, for Appellee. ON BRIEF: Andrew M. Grabhorn, GRABHORN LAW OFFICE, PLLC, Louisville, Kentucky, for Appellant. William B. Wahlheim, Jr., Grace R. Murphy, Braxton S. Thrash, MAYNARD COOPER & GALE, P.C., Birmingham, Alabama, for Appellee.

Before WILKINSON and NIEMEYER, Circuit Judges, and Richard M. GERGEL, United States District Judge for the District of South Carolina, sitting by designation.

Affirmed by published opinion. Judge Niemeyer wrote the opinion, in which Judge Wilkinson and Judge Gergel joined.

NIEMEYER, Circuit Judge:

Scott Griffin commenced this action under the Employee Retirement Income Security Act ("ERISA") against Hartford Life and Accident Insurance Company ("Hartford Life") as the administrator of his employee welfare benefit plan, seeking a continuation of the long-term disability benefits that Hartford Life had terminated based on its conclusion that Griffin was no longer "disabled," as that term is used in the plan.

The district court granted summary judgment to Hartford Life, and Griffin filed this appeal, contending that the district court erred (1) in reviewing the administrator’s decision for abuse of discretion, rather than de novo , and (2) in concluding that Griffin failed to provide evidence sufficient to support a conclusion that Hartford Life’s decision to terminate the long-term disability benefits was unreasonable. For the reasons that follow, we affirm.

I

Scott Griffin became employed by MedQuist Transcriptions, Ltd., as a medical transcriptionist in April 2010. As an employee, he enjoyed the benefits of MedQuist’s employee welfare benefit plan, which included life insurance, short-term disability benefits, and long-term disability benefits. MedQuist provided these benefits through group policies that it purchased from Hartford Life, which was also the administrator of the plan.

As relevant to this appeal, Griffin’s long-term disability benefits were governed by a long-term disability policy that defined disability as follows:

Disability or Disabled means You are prevented from performing one or more of the Essential Duties of:

(1) Your Occupation during the [180-day] Elimination Period;

(2) Your Occupation , for the 24 month(s) following the Elimination Period, and as a result Your Current Monthly Earnings are less than 80% of Your Indexed Pre-disability Earnings; and

(3) after that, Any Occupation .

(Emphasis added). The policy also stated that it was the claimant’s responsibility to submit continuing proof of disability and provided that "[b]enefit payments will stop on the earliest of: (1) the date You are no longer Disabled; (2) the date You fail to furnish Proof of Loss; [or] (3) the date You are no longer under the Regular Care of a Physician," among other limiting events. Finally, the policy vested Hartford Life with "full discretion and authority to determine eligibility for benefits and to construe and interpret all terms and provisions of The Policy."

In September 2011, Griffin stopped working due to pain in his forearm and wrist, which prevented him from typing. He submitted a claim for short-term disability benefits to Hartford Life, and Hartford Life approved his claim, paying him short-term disability benefits until March 2012, when those benefits were exhausted. Griffin then applied for long-term disability benefits, adding to his claim complaints of pain not only in his forearm and wrist but also in his neck and right shoulder. After Hartford Life obtained medical records from Griffin’s medical providers, it approved Griffin’s claim for long-term disability benefits in May 2012. In its letter informing Griffin of its decision, Hartford Life explained that his benefits would continue as long as he continued to meet the definition of "disabled" in the long-term disability benefits policy.

Thereafter, Hartford Life periodically contacted Griffin to monitor his condition and periodically requested updated medical records from his attending physicians. During this period, Griffin had been seeing Dr. Jonathan Carmouche, a neck and spine specialist, who concluded that Griffin’s pain was caused by a herniated disc

and recommended surgery. In March 2013, Dr. Carmouche performed the recommended surgery. A month later, he reported to Hartford Life that Griffin "ha[d] done well thus far." And again in June 2013, he completed an "attending physician’s statement" form for Hartford Life indicating that Griffin had "[i]mproved." But Dr. Carmouche did not complete the functionality section of the form, consistent with his earlier statements to Hartford Life that he does not provide physical functionality assessments.

Because Hartford Life did not have information regarding Griffin’s functionality post-surgery, it referred his claim to a medical case manager, who reviewed Griffin’s file and concluded that it was not clear whether Griffin had any limitations on his functionality. This prompted her to recommend that additional information be obtained from Griffin. Thereafter, Hartford Life repeated its efforts to obtain functionality opinions from Griffin’s medical providers, but again unsuccessfully. When, in August 2013, Hartford Life told Griffin that it was unable to obtain functionality opinions, he stated that he had not visited Dr. Carmouche since June 2013 and that he could no longer afford to see his primary care physician. He did indicate, however, that he had recently visited Dr. Cesar Bravo to treat tendonitis

in his right elbow. When Hartford Life inquired of Dr. Bravo, he reported that he had found no "significant bone or joint abnormality" in Griffin’s elbow and concluded that Griffin’s soft tissues were "unremarkable." Dr. Bravo, however, would not give Hartford Life a functionality opinion. Moreover, neither Dr. Carmouche’s nor Dr. Bravo’s records indicated any imposition of restrictions on Griffin’s activities at that time.

In response to Hartford Life’s further inquiry in December 2013 about Griffin’s functionality, Dr. Carmouche told Hartford Life that he disagreed with a suggestion that Griffin was then "currently able to perform Sedentary Work on a full-time basis," but he added, "Not until [r]eleased by Dr. Bravo who is treating his tendonitis

." But Dr. Bravo refused to provide Hartford Life with any functionality opinion, stating that he had seen Griffin only once. In further followups, both Dr. Bravo and Dr. Carmouche were consistently unwilling or unable to provide Hartford Life with a functionality opinion.

In February 2014, Hartford Life decided to send Griffin to another doctor to conduct an in-person medical examination to assess his functionality, but it was unable to locate an appropriate examiner close enough to Griffin at a reasonable cost. Accordingly, it decided to seek a peer-review assessment from Dr. Ronald Teichman based on Griffin’s existing medical records. Dr. Teichman conducted the assessment and provided Hartford Life with a report in which he recounted that he had spoken to Dr. Carmouche and that Dr. Carmouche told him that he was "not convinced that Mr. Griffin w[ould] be able to tolerate working, even in a sedentary position," noting that Griffin had claimed that he could not "sit for more than 10 minutes." Dr. Carmouche added, however, "[T]he likelihood is that the patient can actually do more than he thinks he can do." Thus, Dr. Teichman concluded in his report:

I cannot recommend any restrictions or limitations [on Griffin] based on the very limited information that was sent to me. That does not mean that the client does not need restrictions. I just cannot recommend any based on this information.... Further, in discussion with Dr. Carmouche, he was, as I indicated at the beginning of this report, very hesitant to commit to any specific restrictions or limitations. He was, in fact, sufficiently hesitant that he declined to make any statements about what he thought the patient could perform, but rather, opted to order a functional capacity evaluation.

The case manager followed up with Dr. Teichman to obtain a more detailed assessment, but Dr. Teichman indicated that his only choice was to defer to Dr. Carmouche, who had stated that his patient reported being unable to sit for more than 10 minutes at a time. Dr. Teichman concluded that if that were so, it was "not compatible with functionality in a work environment."

In March 2014, Griffin reached a point when he had been receiving long-term disability benefits for two years, and, under the policy, the applicable definition of disability then changed from the inability to perform one or more of the essential duties of his prior occupation to an inability to perform one or more of the essential duties of "[a ]ny [o ]ccupation ." (Emphasis added). Nonetheless, Hartford Life continued to pay Griffin long-term disability benefits based on Dr. Teichman’s deferral to Dr. Carmouche’s statement that Griffin had claimed he was not able to sit for more than 10 minutes at a time. In reporting to Griffin its decision to continue paying benefits, Hartford Life reminded Griffin that it would periodically be seeking continued proof from him of his disability.

Several days thereafter, however, Hartford Life decided to refer Griffin’s claim to its special investigations unit to uncover more information. It decided to do so because Dr. Carmouche had stated that Griffin likely had more functionality than he realized; Griffin was rarely at home when Hartford Life called; and Griffin repeatedly insisted that Hartford Life’s policy of following up on his condition every three months was too frequent.

The investigations unit thereafter videotaped...