In Easter v. Hartford Life and Accident Insurance Company, No. 21-4106, 2023 WL 3994383 (10th Cir. June 14, 2023), an unpublished opinion, the Tenth Circuit affirmed the district court’s grant of summary judgment to Defendant-Appellee Hartford Life and Accident Insurance Company, in this dispute involving the denial of Audrey Easter’s long-term disability (“LTD”) benefits under an ERISA-governed disability plan. The court found that Hartford’s decision was entitled to deference despite the procedural irregularities alleged by Easter and that its decision was supported by substantial evidence.
Easter alleged that de novo review should apply because Hartford: (1) failed to address her primary disabling condition of Chronic Fatigue Syndrome; (2) failed to inform her of additional information it required to determine her claim; (3) failed to address the evidence provided by Easter’s primary care provider or Easter’s self-reported evidence of work limitations when Hartford initially denied her claim; and (4) failed to provide Easter’s doctors with the opportunity to respond to its medical reviews on appeal. The court found that there were no procedural irregularities in Hartford’s review process that would warrant changing the standard of review from abuse of discretion to de novo. The court declined to decide whether procedural irregularities—beyond an administrator failing to decide an appeal or deciding an appeal substantially late—would call for an alternation of the standard of review where the ERISA plan grants discretionary authority to the administrator. The court found that nothing in Hartford’s review process would justify changing the standard of review and that Hartford conducted a full and fair review of the claim which satisfied ERISA’s procedural requirements. With respect to the post-appeal evidence, the court assumed, “without deciding, a plan administrator’s reliance on appeal on new factual information or evidence could require a claimant to be provided an opportunity to respond to the new material.” The court also assumed that Hartford’s additional medical reports constituted “new evidence” requiring Hartford to provide Easter with an opportunity to respond. With these assumptions, the court found that “substantially complied with ERISA regulations and the result of the appeal would not have been different had such an opportunity to respond been provided.”
Finding that abuse of discretion review applies, the court found that Hartford’s decision was supported by sufficient evidence. Harford obtained and reviewed all of Easter’s medical records. One of Easter’s providers stated in a form letter that Easter could perform sedentary and light activity, which called Easter’s symptoms into question. Hartford’s decision was also supported by a peer-review report and a neuropsychological evaluation, which found extreme symptom exaggeration. There was evidence suggesting that Easter’s severe fatigue was likely caused by her mental health issues, which were not covered under the policy’s pre-existing condition exclusion. The court found that the evidence reasonably supported Hartford’s conclusion that Easter was not disabled.
*Please note that this blog is a summary of a reported legal decision and does not constitute legal advice. This blog has not been updated to note any subsequent change in status, including whether a decision is reconsidered or vacated. The case above was handled by other law firms, but if you have questions about how the developing law impacts your ERISA benefit claim, the attorneys at Roberts Disability Law, P.C. may be able to advise you so please contact us.
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