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ERISA Short-Term Disability Claim Remanded to Insurer Due to Overall Failure to Consider Claimant’s Purported Cognitive Impairments Resulting from Pain Medications

Doty v. Hartford Life & Accident Insurance Co.
Civil Case No.: CCB-11-2008 (U.S. Dist. Ct. for D. Md., July 27, 2012)
by Colleen K. O’Brien, Associate (www.semmes.com)

Plaintiff Kimberly Doty brought this action under the Employee Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C. §§ 1001–1461, to appeal the denial of short-term disability benefits by her employer’s insurer, Defendant Hartford Life and Accident Insurance Company (“Hartford”).On Cross-Motions for Summary Judgment, Judge Catherine C. Blake denied the Defendant’s motion, granted the Plaintiff’s motion in part, and remanded the case to Hartford with instructions to perform a full and fair review of Doty’s claim.

Doty claimed short-term disability due to ongoing back problems and pain.She underwent several spinal surgeries, and then later, her back problems were exacerbated by a motor vehicle accident. Hartford denied Doty’s application for benefits. The denial letter acknowledged Doty’s self reported symptoms of pain, but stated that it did not receive any objective findings to support her complaints. After receiving certain outstanding medical records, Hartford forwarded a second denial letter to Doty, concluding that the information provided did not support Doty’s inability to perform her job duties.

Doty appealed Hartford’s decision.  In the letter advising Hartford of her appeal, Doty included the description of her job requirements, listing several she could not meet. Doty claimed she worked with top secret documents and data and that being heavily medicated to deal with her ongoing back pain put her at risk of failing to identify or defend security breaches at her job. As part of the review of Doty’s appeal, Hartford referred her case file to Michael Errico, M.D., a Board-Certified Orthopedic Surgeon. Dr. Errico concluded that there were “no clinical findings to substantiate [her self-reported] complaints” and that there was no clinical evidence to support her restrictions on functional ability. Hartford denied Doty’s appeal.

Having exhausted her administrative remedies, Doty filed suit. The parties filed Cross-Motions for Summary Judgment based on the administrative record.  The Court applied an abuse of discretion standard to the case. Doty contended that Hartford was unreasonable in relying on Dr. Errico’s report because it did not consider significant portions of the administrative record. Notably, Dr. Errico’s report did not address Ms. Doty’s central argument in her appeal—that the side effects of her medications prevented her from working. Rather, Hartford relied on Dr. Errico’s report, did not properly consider statements by Doty’s treating providers that supported her claim of decreased cognitive abilities, and did not otherwise base its denial of benefits on substantial evidence.

More problematic, for the Court, however, was the fact that Dr. Errico’s report nowhere acknowledged having reviewed the specific job requirements that Doty submitted with her appeal—and in particular the cognitive requirements that she alleged she could not meet while taking her prescribed medications.  At least in some circumstances, where a reviewing physician does not discuss a plaintiff’s job duties, it may be inferred that “he did not conduct a reasoned evaluation of her condition to determine whether she could perform those duties.” (citing Elliot v. Metropolitan Life Ins. Co., 473 F.3d 613, 619 (6th Cir. 2006)).  As a result, Hartford could not reasonably rely on Dr. Errico’s report for the proposition that Doty’s medications did not prevent her from performing her job.

Because of the “defective” independent medical review, Hartford’s argument therefore needed to rest on its conclusion that Doty lacked any evidence of decreased cognitive abilities.  However, the Court remarked that the only discussion of Doty’s complaints about her medications in Hartford’s three separate denial letters was a single conclusory statement, while, as Doty pointed out, the record contained “significant” evidence of her drug regimen.

While the Court noted that it may be that the evidence put forth by Doty was insufficient to overcome the reasoned opinion of an independent medical professional, Hartford offered nothing in its denial of benefits to explain the conclusory statement that the medical record was insufficient.  The Court therefore could not find that Hartford followed a reasoned decision-making process or presented substantial evidence to support its determination on the question of medication side effects. Consequently, remand was appropriate so Hartford could give proper attention to Doty’s complaints about the secondary effects of her drug regimen and the intellectual demands of her job.