Pylant v. Hartford Life and Acc. Ins. Co.

• Decision Date: 20 August 2007
• Docket Number: No. 06-11370 Summary Calendar.,06-11370 Summary Calendar.
• Citation: 497 F.3d 536
• Parties: Andrea D. PYLANT, Plaintiff-Appellant, v. HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY, and The First American Corporation Group Life, Medical, Dental, Disability Benefits Trust No. 502, Defendants-Appellees.
• Court: U.S. Court of Appeals — Fifth Circuit

497 F.3d 536

Andrea D. PYLANT, Plaintiff-Appellant, v. HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY, and The First American Corporation Group Life, Medical, Dental, Disability Benefits Trust No. 502, Defendants-Appellees.

No. 06-11370 Summary Calendar.

United States Court of Appeals, Fifth Circuit.

August 20, 2007.

Bernard A. Guerrini, James M. Klancnik, Law Offices of James M. Klancnik, Dallas, TX, for Pylant.

Thomas E. Sanders, Jessica S. Taylor, Akin, Gump, Strauss, Hauer & Feld, San Antonio, TX, Megan M. O'Laughlin, Akin, Gump, Strauss, Hauer & Feld, Dallas, TX, for Defendants-Appellees.

Carrie Beth Hoffman, Gardere Wynne Sewell, Dallas, TX, for First Am. Corp.

Appeal from the United States District Court for the Northern District of Texas.

Before DAVIS, WIENER, and BENAVIDES, Circuit Judges.

BENAVIDES, Circuit Judge:

Plaintiff-Appellant Andrea Pylant appeals the district court's grant of summary judgment in favor of Defendants-Appellees Hartford Life and Accident Insurance Co. ("Hartford") and The First American Corporation Group Life, Medical, Dental, Disability Benefits Trust No. 502 ("Plan"). This case arises from the termination of long-term disability benefits ("LTD benefits") by the administrator of an employee welfare benefit plan governed by the Employee Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. § 1001, et seq. We AFFIRM.

We review a grant of summary judgment de novo, using the same criteria as the district court. Hanks v. Transcont. Gas Pipe Line Corp., 953 F.2d 996, 997 (5th Cir.1992). Summary judgment is appropriate if the record reflects "that there is no genuine issue as to any material fact and that the moving party is entitled to a judgment as a matter of law." FED. R. CIV. P. 56(c); see also Celotex Corp. v. Catrett, 477 U.S. 317, 323, 106 S.Ct. 2548, 91 L.Ed.2d 265 (1986). A court's role at the summary judgment stage is not to weigh the evidence or determine the truth of the matter, but rather to determine only whether a genuine issue exists for trial. Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 249, 106 S.Ct. 2505, 91 L.Ed.2d 202 (1986). A genuine issue of material fact exists "if the evidence is such that a reasonable jury could return a verdict for the nonmoving party." Id. at 248, 106 S.Ct. 2505.

Pylant worked as a technical writer for First American Financial Corporation ("First American") from September 2000 until November 2001, when she quit because of fatigue and pain. In February 2002, Pylant filed a claim for LTD benefits after being diagnosed with chronic fatigue, Epstein Barr, cytomegalovirus, and psoriatic arthritis. Her claim was approved on May 30, 2002, and she began receiving LTD benefits. In October 2002, Hartford reevaluated her eligibility for LTD benefits and, based upon an Attending Physician Statement ("APS") and Physical Capabilities Form ("PCF") completed by Pylant's doctor, and her own self-completed questionnaire, determined that Pylant continued to qualify for benefits.

Hartford again reviewed Pylant's eligibility for LTD benefits in June 2003. This time, Pylant's claimant questionnaire and the APS and PCF presented divergent accounts of Pylant's abilities. While the questionnaire stated that she could perform almost all activities of daily living without assistance, and occasionally attended church and her children's sporting activities, the APS and PCF stated that she could never drive a vehicle and could only sit, stand, or walk for less than fifteen minutes at a time. Based upon this discrepancy, Hartford's claims examiner referred Pylant's claim to Hartford's Special Investigations Unit ("SIU") for further fact-gathering.

Hartford's SIU conducted video surveillance of Pylant's daily activities for two days in August 2003. During that time, the SIU observed and recorded Pylant engaged in various activities that contradicted assessment in the APS and PCF of her condition, including driving her children to school, removing a child weighing in excess of twenty pounds from the rear of her car, carrying that child with both hands into her home, and holding an infant for eighteen minutes while standing. Based on this surveillance, SIU conducted an in-person interview with Pylant. Pylant admitted that she was readily capable of performing the observed activities and conceded that she had absolutely "no limitations or restrictions" on how long she could sit.

In September 2003, Hartford requested that Pylant submit another claimant questionnaire and have her treating physician complete another APS and PCF. Pylant's revised questionnaire reiterated her disabilities and contradicted her interview admissions by stating that she could not sit for more than fifteen minutes. Her doctor's APS and PCF opined that she could sit, stand, walk, and drive for approximately an hour at a time. Upon receiving these documents, Hartford sent Pylant's doctors copies of the surveillance video and in-person interview, and asked them, based on their contact with Pylant and those materials, whether she could return to work subject to various, specified limitations. One doctor left a voice mail stating that she agreed that Pylant could return to work with those limitations. The other doctor responded to Hartford's request by stating that Pylant could return to work on a full-time basis with the restrictions stated. Hartford then notified Pylant that further benefits would not be payable beyond January 31, 2004.

Pylant appealed Hartford's discontinuation of her LTD benefits. Hartford referred her claim to another doctor, Dr. David Trock, for independent medical review. Dr. Trock reviewed Pylant's medical records and surveillance video and contacted her previous doctors. Dr. Trock subsequently concluded that Pylant was able to return to work in a sedentary capacity with restrictions. Hartford decided to uphold its termination of Pylant's LTD benefits and sent Pylant a letter on January 7, 2005, advising her that the appeal had been denied. Pylant filed this lawsuit on February 24, 2005, and the district court granted summary judgment for Hartford.

In analyzing a claim for benefits allegedly due under an ERISA plan, the district court reviews the plan administrator's determination for abuse of discretion when the plan expressly gives the administration discretionary authority. Vercher v. Alexander & Alexander Inc., 379 F.3d 222, 226 (5th Cir.2004). If an administrator's decision is supported by substantial evidence, the court must affirm that decision. Ellis v. Liberty Life Assurance Co. of Boston, 394 F.3d 262, 273 (5th Cir.2004). However, if there is a potential conflict of interest, the abuse of discretion inquiry is altered. Vega v. National Life Ins. Services, Inc., 188 F.3d 287, 297 (5th Cir. 1999). Here, because Hartford is both the insurer and the administrator, but Pylant has not produced evidence showing any greater conflict, Hartford's decision is afforded "only a modicum less deference" than it would receive in other circumstances. Id. at 301.

As a preliminary matter, Pylant argues Hartford incorrectly defined the Plan term "your...