Diane Miller v. Hartford Life & Acc. Ins Co. ( 2019 )

United States Court of Appeals
For the Eighth Circuit
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No. 19-1096
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Diane Miller
lllllllllllllllllllllPlaintiff - Appellant
v.
Hartford Life & Accident Insurance Company, also known as Hartford
lllllllllllllllllllllDefendant - Appellee
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Appeal from United States District Court
for the Eastern District of Arkansas - Little Rock
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Submitted: September 26, 2019
Filed: December 16, 2019
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Before GRUENDER, BENTON, and SHEPHERD, Circuit Judges.
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SHEPHERD, Circuit Judge.
Following the termination of disability benefits under a long-term disability
plan governed by the Employee Retirement Income Security Act (ERISA), plaintiff
Diane Miller initiated this action against plan administrator Hartford Life & Accident
Insurance Company. The district court1 dismissed Miller’s complaint with prejudice,
concluding that substantial evidence supported Hartford’s decision to terminate
benefits based on exhaustion of mental illness benefits and the lack of a disabling
physical condition. Having jurisdiction under 28 U.S.C. § 1291, we affirm.
I.
Miller was an employee of Integris Health, where she worked as a Medical
Billing Specialist. Through her employment, Miller was covered by a long-term
disability benefits plan, which was funded by a Hartford-issued group insurance
policy for Integris. On April 30, 2012, Miller ceased working and initiated claims for
long-term disability benefits under the plan and Social Security disability benefits
based on depression and non-specific psychosis. In October 2012, the Social Security
Administration approved Miller’s claim, and in November 2013, Hartford approved
Miller’s claim, effective as of November 11, 2012. Hartford’s approval of benefits
was based on evidence of Miller’s mental illness; Hartford did not find any support
for a disability due to a physical impairment at that time. Under the plan, benefits
based on mental illness were limited to a maximum of 12 months. Hartford
determined that Miller had received the 12-month benefit maximum as of November
10, 2013, and terminated Miller’s benefits as of that date.
In May 2014, Miller appealed Hartford’s decision, asserting that her mental
illness was secondary to a physical impairment and that she was thus entitled to
benefits for a physical disability. After an additional review of medical records,
including independent medical reviews, Hartford determined that Miller suffered
from a disabling physical condition. Hartford’s determination was primarily based
on the physical restrictions identified by one reviewing physician, who concluded that
1
The Honorable Brian S. Miller, Chief Judge, United States District Court for
the Eastern District of Arkansas.
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Miller did not have the capacity to do sedentary work. Hartford reminded Miller that
she was obligated to continue to submit evidence of her disabling physical condition
to continue to receive benefits.
Nearly a year later, Hartford learned that the only treatment Miller was
receiving was from a psychiatrist. Hartford requested that Miller submit information
about her claimed physical disability, reminding her that she had received all of the
available mental illness benefits. The information Miller provided from her treating
psychiatrist stated that Miller had little to no ability to work because of her mental
illness and noted that it was not known whether Miller’s limitations were the result
of a psychiatric or physical condition. Hartford then scheduled an independent
medical evaluation. After examining Miller, the independent examining physician
concluded that Miller suffered from Major Depressive Disorder with psychosis and
noted that Miller’s treating psychiatrist had previously indicated that Miller’s mental
illness was secondary to or exacerbated by a thyroid condition. The examining
physician determined that Miller had no physical impairment that precluded her from
engaging in full-time work, but could not opine as to whether her mental illness was
due to a physical or psychological condition. He did acknowledge, however, that a
possible link existed between thyroid disorders and psychotic episodes.
Based on the lack of clarity regarding Miller’s mental illness, a case manager
recommended an independent psychiatric review. Dr. Taral R. Sharma, a board-
certified psychiatrist, reviewed the records and spoke with Miller’s treating
psychiatrist, who noted improvement in Miller’s mental illness. Dr. Sharma
concluded that Miller suffered from no mental illness that required restrictions or
limitations or prevented her from maintaining full-time work. A vocational manager
later opined that, based on the functional capabilities identified by the independent
examining physician, there were numerous jobs that Miller could perform.
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On October 1, 2016, Hartford notified Miller that her benefits were being
terminated as of that date because she no longer satisfied the policy definition of
disabled. Hartford again noted that Miller’s only potential basis for receiving benefits
was physical disability because she had exhausted the mental illness benefits.
Despite the exhaustion of these benefits, Hartford also determined that Miller’s
mental illness no longer precluded her from working, noting that Miller’s own
treating psychiatrist opined that she should consider returning to work.
Miller then initiated an internal appeal to Hartford, arguing that Hartford
erroneously denied benefits, specifically noting that her anti-psychotic medications
cause her to suffer from side effects such as blurred vision, tremors, muscle stiffness,
and fatigue. Miller also asserted that when her psychotic episodes occurred, she
could not work for a period of two to three weeks. Miller did not raise any challenge
to Hartford’s discussion of the lack of evidence of a disabling physical impairment.
Based on Miller’s argument regarding the side effects of her medications, Hartford
obtained an additional review from Dr. Sharma. Dr. Sharma again communicated
with Miller’s treating psychiatrist who offered additional information about Miller’s
psychotic episodes and the effects of medications Miller took during these periods.
Dr. Sharma ultimately concluded that the medical records did not support Miller’s
inability to work during her psychotic episodes and that the evidence did not show
that Miller suffered from an impairing mental illness that precluded her from working
after September 29, 2016. Hartford notified Miller that it was denying her appeal and
upholding the termination of benefits. Miller then initiated this action, seeking
reinstatement of her benefits. Hartford opposed Miller’s request for reinstatement of
benefits and sought judgment on the administrative record. The district court granted
judgment in favor of Hartford and dismissed Miller’s complaint, concluding that
substantial evidence supported Hartford’s determination that Miller no longer
qualified for benefits. This appeal follows.
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II.
“We review the district court’s adjudication of [an ERISA] claim de novo,
applying the same standard of review to the plan administrator’s decision as the
district court.” Johnston v. Prudential Ins. Co. of Am., 916 F.3d 712, 714 (8th Cir.
2019) (alteration in original) (quoting McClelland v. Life Ins. Co. of N. Am., 679
F.3d 755, 759 (8th Cir. 2012)). “Where an ERISA plan grants the administrator
discretion to determine eligibility for benefits and to interpret the plan’s terms, courts
must apply a deferential abuse-of-discretion standard of review.” Green v. Union
Sec. Ins. Co., 646 F.3d 1042, 1050 (8th Cir. 2011).2 “However, when a conflict of
interest exists because the plan administrator is both the decision-maker and the
insurer, we take that conflict into account and give it some weight in the
abuse-of-discretion calculation.” Nichols v. Unicare Life & Health Ins. Co., 739 F.3d
1176, 1181 (8th Cir. 2014) (internal quotation marks omitted). Under this standard,
“we will reverse the plan administrator’s decision only if it is arbitrary and capricious.
To determine whether a plan administrator’s decision was arbitrary and capricious,
we ask whether the decision to deny . . . benefits was supported by substantial
evidence, meaning more than a scintilla but less than a preponderance.” Midgett v.
Washington Grp. Int’l Long Term Disability Plan, 561 F.3d 887, 896-97 (8th Cir.
2
Miller urges the Court to apply a de novo standard of review based on
Hartford’s alleged failure to “determine the claim adequately,” to obtain proper
evidence of her changed condition, to measure Miller’s disability by plan criteria, and
to engage in a meaningful dialogue with Miller. To alter the abuse-of-discretion
standard of review, a plan administrator must have committed a procedural
irregularity so significant that it “rise[s] to the level of a serious breach of the plan
trustee’s fiduciary duty to the plan beneficiary” and “leave[s] the court with serious
doubts as to whether the result reached was the product of an arbitrary decision or the
plan administrator’s whim.” Waldoch v. Medtronic, Inc., 757 F.3d 822, 830-31 (8th
Cir. 2014), as corrected (July 15, 2014) (internal quotation marks omitted). Having
reviewed the record, we see no procedural irregularity that would mandate a different
standard of review.
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2009) (alteration in original) (internal citations and quotation marks omitted). Where
the plan administrator’s decision “is supported by a reasonable explanation, it should
not be disturbed, even though a different reasonable interpretation could have been
made.” Id. at 897 (internal quotation marks omitted). “[A] decision is reasonable if
a reasonable person could have reached a similar decision, given the evidence before
him, not that a reasonable person would have reached that decision.” Id. (internal
quotation marks omitted).
Miller argues that the district court’s dismissal of her complaint was erroneous
for several reasons, including that there was insufficient evidence of improvement in
her condition and that Hartford failed to consider the potential medication side effects
and the future risk of additional psychotic episodes. But each of Miller’s arguments
ignores the primary reason for Hartford’s termination of benefits: the record medical
evidence did not support a finding of a physical disability. While Hartford engaged
in an analysis of whether Miller continued to suffer from a disabling mental illness,
this inquiry was irrelevant because Miller had exhausted her mental illness benefits.
As these arguments relate to Miller’s mental illness, they do not form a basis to
conclude Hartford erred in terminating benefits based on the absence of a physical
disability.
Miller specifically challenges Dr. Sharma’s opinion, and argues that Hartford
erroneously based its decision to terminate benefits on Dr. Sharma’s opinion alone.
But Dr. Sharma’s opinion relates only to Miller’s mental illness. Although Miller
asserts in her brief that she suffers from psychotic episodes due to an autoimmune
thyroid disorder, the medical evidence contains no record of treatment for such a
disorder since at least 2015; at best, the record recognizes the existence of a potential
link between thyroid disorders and psychiatric symptoms. Substantial evidence thus
supports Hartford’s conclusion that Miller does not suffer from mental illness as a
result of a physical condition. To the extent that Miller challenges Hartford’s reliance
on the opinions of Dr. Sharma and other examining and reviewing physicians over
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the opinions of her treating psychiatrist, it is not an abuse of the administrator’s
discretion to rely on the opinions of reviewing physicians over conflicting opinions
of treating physicians “unless the record does not support the denial.” Dillard’s Inc.
v. Liberty Life Assurance Co. of Boston, 456 F.3d 894, 899-900 (8th Cir. 2006).
Miller also asserts that Hartford’s decision was not supported by the plan
language and that she was not afforded a full and fair review of her claim. Miller first
argues that Hartford did not follow the plan language regarding the requirements for
determining when a disability ceases. Although Miller frames this argument as one
involving Hartford’s obligations under the plan, it is really a challenge to the
substantive determination Hartford made to terminate benefits. Miller alleges only
that there was not sufficient evidence that she was capable of performing work at the
requisite level, not that Hartford abandoned its obligations under the plan or reached
a conclusion that departed from the plan’s provisions or definitions. The medical
record provides substantial evidence for Hartford’s determination that Miller was
capable of full-time work. Nothing in the record suggests that Hartford’s decision
was inconsistent with the plan language.
Miller next asserts that she was not afforded a full and fair review of her claim
as required by the plan language because Hartford communicated with Miller’s
psychiatrist without notifying her and failed to consider the side effects of
medications prescribed to treat Miller’s mental illness. “ERISA’s notice provision
requires that every employee benefit plan provide adequate notice in writing of a
claim denial and afford a reasonable opportunity for a full and fair review of each
denial.” DuMond v. Centex Corp., 172 F.3d 618, 622 (8th Cir. 1999). This
requirement “provide[s] claimants with enough information to prepare adequately for
further administrative review or an appeal to the federal courts.” Id. The record
reveals that Hartford provided a reasonable opportunity for review of the denial of
Miller’s claim. It engaged in a detailed and lengthy review process, which included
consideration of voluminous medical records and opinions of treating, examining, and
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reviewing physicians, and clearly notified Miller of the reasons for termination of
benefits. Miller’s claim of one communication with a physician of which she was not
notified, even if true, did not deprive her of the necessary information to adequately
prepare for further review. And, as to Miller’s assertion that Hartford did not
consider the side effects of her medications, Hartford engaged in further review by
requesting that Dr. Sharma submit another report directly addressing this issue.
Further, as discussed above, this additional step was unnecessary in the absence of
an underlying physical disability. Hartford more than satisfied its obligation to
engage in a full and fair review of Miller’s claim.
In essence, Miller’s arguments largely amount to no more than a request for
this court to substitute its judgment for that of Hartford’s. This is inconsistent with
our role as a reviewing court, where we are tasked with determining only whether
Hartford’s decision was supported by substantial evidence. Rittenhouse v. United
Health Grp. Long Term Disability Ins. Plan, 476 F.3d 626, 632 (8th Cir. 2007)
(explaining that, where a decision is supported by the record, a court “may not
substitute its own judgment” for that of the plan administrator). Hartford engaged in
a meaningful review of Miller’s claim as it related to her complaints of both a
physical disability and a disabling mental illness, despite Miller’s exhaustion of
benefits based on mental illness alone. Finding no disabling physical condition or
mental illness based on the medical evidence and the opinions of treating, examining,
and reviewing physicians, Hartford terminated benefits. Substantial evidence
supported this determination; Hartford thus did not abuse its discretion in terminating
Miller’s benefits.
III.
For the foregoing reasons, we affirm.
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