Lee v. Hartford Life & Accident Ins. Co.

• Decision Date: 05 March 2013
• Docket Number: Civil Action No. 11–2083 (RC).
• Citation: 928 F.Supp.2d 51
• Court: U.S. District Court — District of Columbia
• Parties: Debra LEE, Plaintiff, v. HARTFORD LIFE & ACCIDENT INSURANCE COMPANY et al., Defendants.

928 F.Supp.2d 51

Debra LEE, Plaintiff,

v.HARTFORD LIFE & ACCIDENT INSURANCE COMPANY et al., Defendants.

Civil Action No. 11–2083 (RC).

United States District Court, District of Columbia.

March 5, 2013.

Scott Bertram Elkind, Elkind & Shea, Silver Spring, MD, for Plaintiff.

Brian Patrick Downey, Pepper Hamilton LLP, Harrisburg, PA, Joleen Okun, Ogletree, Deakins, Nash, Smoak & Stewart, P.C., Washington, DC, Vance E. Drawdy, Ogletree, Deakins, Nash, Smoak & Stewart, P.C., Greenville, NC, for Defendants.

MEMORANDUM OPINION

RUDOLPH CONTRERAS, District Judge.

I. INTRODUCTION

Debra Lee brings this action under the Employee Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C. § 1001 et seq., claiming that her insurance company—The Hartford Life and Accident Insurance Company—wrongfully denied her claim for disability benefits. In her motion for partial summary judgment, the plaintiff asks whether she may supplement the record with documents that were not in the record at the time Hartford denied her claim. Ordinarily, the record is confined to “the evidence presented to the plan administrators, not ... a record later made in another forum.” Heller v. Fortis Benefits Ins. Co., 142 F.3d 487, 493 (D.C.Cir.1998). This case is no different. Accordingly, the court will deny the plaintiff's motion.

II. FACTUAL ALLEGATIONS AND PROCEDURAL BACKGROUND

Through her former employer, Debra Lee was enrolled in an insurance plan that covered claims for disability benefits. Am. Compl. ¶ 6. Hartford is the claims administrator ¹ and insurer for the plan. Id. ¶ 7. Ms. Lee alleges that she suffers from several medical conditions that render her disabled under the insurance contract, thereby entitling her to receive disability benefits. Id. ¶¶ 10–11. She began receiving such benefits in 2007. Id. Two years later, based on a change in the contractual definition of “disabled,” Hartford concluded that Ms. Lee no longer met the policy's definition of “disabled” and thus denied her claim for continued payments. See id. ¶¶ 9, 12; Pl.'s Mot., Ex. 1. In early 2010, Ms. Lee internally appealed Hartford's decision. Am. Compl. ¶ 12; Pl.'s Mot., Ex. 3. When reviewing her appeal, Hartford solicited the views of a medical professional, Dr. Ephraim Brennan. Def.'s Opp'n at 2. After reviewing the evidence, Hartford denied Ms. Lee's appeal. Pl.'s Mot., Ex. 3. Hartford did not give Ms. Lee the opportunity to review or rebut Dr. Brennan's report before deciding her appeal. Pl.'s Mot. at 3; Def.'s Opp'n at 3.

Ms. Lee brought suit under 29 U.S.C. § 1132(a), alleging that Hartford's internal appeals process was unfair and that Hartford suffers from a conflict of interest. Now before the court is the plaintiff's motion for partial summary judgment, in which she asks the court to supplement the record with additional documents (rather than for partial judgment in her favor). See Pl.'s Reply at 14, 15 (requesting an opportunity to respond to Dr. Brennan's report). Accordingly, the court construes the motion as a motion to supplement the record.

III. ANALYSIS

A. Legal Framework

“ERISA is a comprehensive statute designed to promote the interests of employees and their beneficiaries in employee benefit plans.” Shaw v. Delta Air Lines, Inc., 463 U.S. 85, 90, 103 S.Ct. 2890, 77 L.Ed.2d 490 (1983); see also29 U.S.C. § 1001(b) (noting that ERISA was enacted “to protect ... employee benefit plans and their beneficiaries”). Among those plans regulated by ERISA are employer-sponsored welfare plans that provide “benefits in the event of ... disability,” 29 U.S.C. § 1002(1), such as the plan that Hartford administered for Ms. Lee's benefit.

ERISA requires that a plan administrator follow certain procedures if it denies a claim for benefits. Wade v. Hewlett–Packard Dev. Co. LP Short Term Disability Plan, 493 F.3d 533, 539 (5th Cir.2007). “These procedures are set forth in 29 U.S.C. § 1133 and the regulations promulgated by the Department of Labor thereunder.” Id.

After the administrator denies the individual's claim, the administrator must provide the claimant with notice of the decision. 29 C.F.R. § 2560.503–1(g)(1) (“[T]he plan administrator shall provide a claimant with written or electronic notification of any adverse benefit determination.”). Thereafter, the claimant must be provided with a “full and fair opportunity” to appeal the decision internally. See29 U.S.C. § 1133(2) (requiring that employee benefit plans must “afford a reasonable opportunity to any participant whose claim for benefits has been denied for a full and fair review by the appropriate named fiduciary of the decision denying the claim.”); 29 C.F.R. § 2560.503–1(h)(1) (“Every employee benefit plan shall establish and maintain a procedure by which a claimant shall have a reasonable opportunity to appeal an adverse benefit determination to an appropriate named fiduciary of the plan, and under which there will be a full and fair review of the claim and the adverse benefit determination.”).²

If the administrator ultimately denies the appeal, the regulation requires a second round of disclosures. Thus, the administrator must disclose the specific reason for the decision, the specific plan provisions upon which the decision is based, an indication that the claimant is entitled to receive all records that are relevant to the claim, and a notification that the claimant has a right to file another internal appeal (if the policy so provides) or to bring a civil action under 29 U.S.C. § 1132(a). Id. § 2560.503–1(j)(1)–(4).

In sum, the relevant regulation mandates the disclosure of relevant documents at two discrete points: (1) “relevant documents generated or relied upon during the initial claims determination must be disclosed prior to or at the outset of an administrative appeal,” Metzger v. UNUM Life Ins. Co. of Am., 476 F.3d 1161, 1167 (10th Cir.2007) (citing 29 C.F.R. § 2560.503–1(h)(2)(iii)), and (2) “relevant documents generated during the administrative appeal—along with the claimant's file from the initial determination—must be disclosed after a final decision on appeal,” id. (citing 29 C.F.R. § 2560.503–1(i)(5)).

B. Section 2560.503–1(h)—Which Requires Administrators to Provide Claimants with a “Full and Fair Review of the Claim”—Did not Require Hartford to Provide the Plaintiff with a Copy of Dr. Brennan's Report Before It Decided Her Internal Appeal

The plaintiff's motion presents a narrow legal question. The parties agree that Hartford was required to provide Ms. Lee with a copy of Dr. Brennan's report, which was generated during her appeal of Hartford's initial denial of her claim to benefits. But they disagree on the timing: the plaintiff argues that she was entitled to receive a copy before her internal appeal was decided so that she could respond, otherwise the appeal cannot be considered “full and fair.” Hartford argues that it was required to turn over the report after it denied Lee's appeal. The court agrees with Hartford.

Any discussion of the timing of the disclosure issue would be incomplete without first mentioning Pettaway v. Teachers Insurance and Annuity Association of America, 644 F.3d 427, 436 (D.C.Cir.2011). Like Ms. Lee, the plaintiff in Pettaway argued that her claim to disability benefits was unfairly terminated. Pettaway v. Teachers Insurance and Annuity Association of America, 699 F.Supp.2d 185, 207 (D.D.C.2010). The plaintiff pursued an internal appeal with the company, but was unsuccessful. The policy administrator denied her appeal, in part due to a doctor's report that was generated during the internal appeals process. Id. Like Ms. Lee, the plaintiff in Pettaway argued that she should have been provided with an opportunity to rebut the report's findings before the appeal was decided. The district court rejected this argument, concluding that she had no right to review the medical report before the administrator ruled on her appeal. Id. (“[B]ecause Dr. Lindquist's report was the last report completed before her claim was denied in March 2005, the plaintiff contends that she never had the opportunity to respond to that report with her own evidence and therefore should have been afforded another appeal. This argument has been rejected by a number of courts.”). The Circuit affirmed the decision, although it provided an analysis that is slightly different than the arguments in this case. ³

Although the D.C. Circuit's opinion in Pettaway is not directly on point to Ms. Lee's claim—that she was entitled to review and rebut Dr. Brennan's report before her appeal was decided—every other circuit to consider the issue has squarely rejected her argument. See Shedrick v. Marriott Intern., Inc., 500 Fed.Appx. 331, 339 (5th Cir.2012) (“Further, there does not appear to be relevant case law or regulations for the proposition that Aetna violated ERISA's full and fair review requirement by failing to consider evidence submitted after Shedrick's appeal was closed or by not allowing Shedrick to rebut the report by Dr. Wallquist.”); Midgett v. Wash. Group Int'l Long Term Disability Plan, 561 F.3d 887, 896 (8th Cir.2009) (“[T]he full and fair review to which a claimant is entitled ... does not include reviewing and rebutting, prior to a determination on appeal, the opinions of peer reviewers solicited on that same level of appeal.”); ⁴Glazer v. Reliance Std. Life Ins. Co., 524 F.3d 1241, 1245 (11th Cir.2008) (“Glazer argues that the failure of Reliance to provide her with a copy of the report produced by Hauptman during the pendency of the review of the initial denial of benefits deprived her of a ‘full and fair review.’ Reliance responds that it was not required to produce the documents it relied upon while it reviewed the initial denial of benefits; the production occurs after a final decision is reached. We agree with Reliance.”); Metzger, 476 F.3d at 1166 (“In light of the sum procedural requirements of 29 C.F.R. § 2560.503–1 and the Department's explanation of those...