Clark v. Hartford Life & Accident Insurance

[DO NOT PUBLISH]
IN THE UNITED STATES COURT OF APPEALS
FOR THE ELEVENTH CIRCUIT FILED
________________________ U.S. COURT OF APPEALS
ELEVENTH CIRCUIT
September 14, 2006
No. 06-12552
THOMAS K. KAHN
Non-Argument Calendar CLERK
________________________
D. C. Docket No. 05-00067-CV-T-23-MAP
MICHAEL CLARK,
Plaintiff-Appellant,
versus
HARTFORD LIFE AND ACCIDENT
INSURANCE COMPANY,
Defendant-Appellee.
________________________
Appeal from the United States District Court
for the Middle District of Florida
_________________________
(September 14, 2006)
Before MARCUS, WILSON and PRYOR, Circuit Judges.
PER CURIAM:
Michael Clark appeals the summary judgment in favor of the Hartford Life
and Accident Insurance Company against Clark’s complaint for long-term
disability benefits under the Employee Retirement Income Security Act, 29 U.S.C.
§ 1001 et seq. (ERISA). Clark argues that the refusal of the district court to treat
language in Hartford’s correspondence with Clark as a binding interpretation of
the policy was reversible error. We affirm.
I. BACKGROUND
Clark was employed by Publix Super Markets, Inc. as a store manager.
Publix obtained group long-term disability insurance, administered by Hartford,
for its employees, and Clark received coverage under the Hartford plan.
Following leg surgery in 1999, Clark began experiencing painful symptoms
of what would eventually be diagnosed as reflex sympathetic dystrophy, also
referred to as complex regional pain syndrome. Because of the pain, numbness,
and cramping in his leg, Clark reduced his workweek to 40 hours and continued
working at this level until he was placed on medical leave in April 2001. He
began receiving disability benefits from Hartford on July 19, 2001.
Hartford began to investigate Clark’s claim on January 22, 2003. A year
later, Hartford notified Clark that he was no longer eligible for long-term disability
benefits because its investigation revealed that he was not totally disabled. Clark
2
appealed the denial of benefits to Hartford. After a second investigation that
included consultation with four physicians, an interview with Clark, and
surveillance of his activities, Hartford found that Clark was capable of full-time,
light-duty work, which rendered Clark ineligible for continuing benefits.
Clark then filed a complaint for benefits under the Hartford long-term
disability plan. The parties filed cross-motions for summary judgment. The
district court referred the matter to a magistrate judge, who recommended granting
summary judgment in favor of Hartford. Over Clark’s objection, the district court
adopted the Report and Recommendation and entered summary judgment for
Hartford.
II. STANDARD OF REVIEW
We review a grant of summary judgment de novo. Wright v. Aetna Life Ins.
Co., 110 F.3d 762, 764 (11th Cir. 1997). We review denials of benefits under
ERISA as follows:
(1) Apply the de novo standard to determine whether the claim
administrator’s benefits-denial decision is “wrong” (i.e., the court
disagrees with the administrator’s decision); if it is not, then end the
inquiry and affirm the decision.
(2) If the administrator’s decision is in fact “de novo wrong,” then
determine whether he was vested with discretion in reviewing claims;
if not, end judicial inquiry and reverse the decision.
(3) If the administrator’s decision is “de novo wrong” and he was
vested with discretion in reviewing claims, then determine whether
3
“reasonable” grounds supported it (hence, review his decision under
the more deferential arbitrary and capricious standard).
(4) If no reasonable grounds exist, then end the inquiry and reverse
the administrator’s decision; if reasonable grounds do exist, then
determine if he operated under a conflict of interest.
(5) If there is no conflict, then end the inquiry and affirm the decision.
(6) If there is a conflict of interest, then apply heightened arbitrary
and capricious review to the decision to affirm or deny it.
Williams v. BellSouth Telecomms., Inc., 373 F.3d 1132, 1137-38 (11th Cir. 2004)
(footnotes omitted).
III. DISCUSSION
Clark urges us to start with the sixth step of our standard of review and hold
that Hartford’s denial of benefits was “arbitrary and unreasonable.” Precedent
demands otherwise. “Regardless of whether arbitrary and capricious or
heightened arbitrary and capricious review applies, the court evaluates the claims
administrator’s interpretation of the plan to determine whether it is ‘wrong.’”
HCA Health Servs. of Ga., Inc. v. Employers Health Ins. Co., 240 F.3d 982, 993
(11th Cir. 2001). If we do not conclude that Hartford’s denial of benefits was
“wrong,” our inquiry ends.
Clark’s appeal is notable as much for what he does not argue as for what he
argues. Clark does not argue that Hartford’s ruling was factually wrong; instead,
he “accepts . . . Hartford’s determination that he is capable of working in a light-
4
duty job.” Clark contends that the district court was “wrong” in accepting its
interpretation of the Hartford plan.
ERISA requires that “plans be administered, and benefits be paid, in
accordance with plan documents.” Egelhoff v. Egelhoff, 532 U.S. 141, 150
(2001). The Hartford long-term disability plan Booklet-Certificate, a plan
document, provides this definition of “total disability”:
After [the first 24 months of disability], and for as long as you remain
Totally Disabled, you are prevented by Disability from doing any
occupation or work for which you are, or could become, qualified by:
(1) training;
(2) education; or
(3) experience.
The Summary Plan Description further explains:
Benefits will continue after that 24 month period until you are 65
provided you were Disabled prior to age 60 and you are prevented by
Disability from performing the essential duties of any occupation that
you are or could become qualified for by training, education, or
experience.
Clark does not dispute the meaning or application of any of this language.
Clark argues that language in his communications with Hartford supplied an
additional policy term. According to Clark, the definition of total disability, as
interpreted by Hartford, includes a minimum income requirement; for the claimant
not to be totally disabled, the claimant must be able to perform the duties of an
5
occupation that pays at least 60 percent of his predisability earnings.
Clark’s argument fails. “When plan documents unambiguously address the
substantive rights of the parties at issue, the plan language controls, absent a
showing of intentional fraudulent promises by the insurer in informal
communications with the insured.” Meadows v. Cagle’s, Inc., 954 F.2d 686, 691
(11th Cir. 1992). Clark cites no contrary authority to support his position that
informal communications may impose binding interpretations of the policy in the
absence of fraud or ambiguity in the policy terms. The decision upon which Clark
most heavily relies is inapposite, because it discusses the review of denials based
on the interpretation of ambiguous policy terms. See King v. Hartford Life &
Accident Ins. Co., 414 F.3d 994, 998-99 (8th Cir. 2005) (en banc).
Clark does not allege that he would have been entitled to benefits but for the
alleged additional term. He concedes that he is capable of light-duty work. Under
the terms of the policy, Clark is not “totally disabled” and not entitled to benefits.
The decision of Hartford that Clark was not totally disabled was not wrong.
IV. CONCLUSION
The summary judgment in favor of Hartford is
AFFIRMED.
6