Hung v. Guardian Life Ins

UNPUBLISHED
UNITED STATES COURT OF APPEALS
FOR THE FOURTH CIRCUIT
MEI-JONG HUNG,
Plaintiff-Appellant,
v.
No. 99-2117
THE GUARDIAN LIFE INSURANCE
COMPANY OF AMERICA,
Defendant-Appellee.
Appeal from the United States District Court
for the District of Maryland, at Baltimore.
Frederic N. Smalkin, District Judge.
(CA-99-104-S)
Argued: May 5, 2000
Decided: August 7, 2000
Before WILKINSON, Chief Judge, NIEMEYER, Circuit Judge,
and Jerome B. FRIEDMAN, United States District Judge
for the Eastern District of Virginia, sitting by designation.
_________________________________________________________________
Reversed and remanded by an unpublished per curiam opinion
_________________________________________________________________
COUNSEL
ARGUED: Mark John Hardcastle, BLAIR, HARDCASTLE &
O'CONNOR, P.A., Baltimore, Maryland, for Appellant. James
Forbes Taylor, FUNK & BOLTON, P.A., Baltimore, Maryland, for
Appellee. ON BRIEF: Terry B. Blair, BLAIR, HARDCASTLE &
O'CONNOR, P.A., Baltimore, Maryland, for Appellant. Bryan D.
Bolton, FUNK & BOLTON, P.A., Baltimore, Maryland, for Appel-
lee.
_________________________________________________________________
Unpublished opinions are not binding precedent in this circuit. See
Local Rule 36(c).
_________________________________________________________________
OPINION
PER CURIAM:
On December 28, 1997, Mei-Jong Hung found her husband, Dr.
Chao-Huang Hung, passed out in the kitchen of their Maryland home.
Mrs. Hung called for an ambulance and Dr. Hung was transported to
the hospital where he underwent substantial treatment and diagnoses.
On January 11, 1998, Dr. Hung died. Between December 28 and the
time of Dr. Hung's death, Mrs. Hung discovered certain evidence in
her home which caused her to believe that Dr. Hung suffered from an
accidental death, rather than as a result of a stroke, as had been previ-
ously suspected. Mrs. Hung presented her findings and opinions to
Guardian Life Insurance (hereinafter Guardian), Dr. Hung's provider
for group insurance, and requested coverage under Dr. Hung's acci-
dental death plan. Guardian reviewed the file and denied coverage.
Claiming that Guardian wrongfully denied coverage under the acci-
dental death plan, Hung filed this action seeking review of Guardian's
decision. The district court reviewed the administrative record, con-
cluded that the plan administrator had not abused his discretion, and
granted summary judgment.
Because we conclude that the plan administrator did abuse his dis-
cretion by failing to submit an adequate record to the reviewing phy-
sicians for a determination as to Dr. Hung's cause of death, we
reverse and remand to the district court.
I.
On December 28, 1997, Dr. Hung collapsed on the kitchen floor
of his home, and was later discovered by his wife, Mei-Jong Hung.
2
She called "911" and suggested that Dr. Hung might have suffered
from a stroke. The paramedics arrived at Dr. Hung's residence and he
was taken by an emergency team to a hospital where he was diag-
nosed with a brain hematoma and a rear skull fracture. He was there-
after transferred from the local hospital to the University of Maryland
Shock Trauma Center. While Dr. Hung was hospitalized, Mrs. Hung
allegedly found a fallen ladder and Dr. Hung's flip-flop sandals in the
basement of their home and some rearranged Christmas decorations
on a shelf six feet above the ground. She additionally found drips of
blood on the ground and she discovered that Dr. Hung's eye glasses
were missing a lens. Mrs. Hung claims that during Dr. Hung's hospi-
talization he used hand motions to communicate to her the fact that
he slipped and fell in the basement. Based on her findings and com-
munications with Dr. Hung, Mrs. Hung personally determined that
Dr. Hung was injured as a result of an accidental fall from the ladder,
and not from a stroke. Many tests were done between the time of Dr.
Hung's hospitalization and the time of his death, January 11, 1998.
In March 1998, Dr. Hung's previous employer, Patuxent Medical
Group, filed a "Proof of Death" form with Guardian claiming acciden-
tal death coverage. Pursuant to Dr. Hung's group plan with Guardian,
if he suffered an "accidental death" his beneficiaries would be entitled
to "two hundred percent of [his] annual earnings, rounded to the next
higher one thousand dollars." Some confusion surrounds what Mrs.
Hung originally understood as Guardian's response regarding her
request for accidental coverage. However, Guardian ultimately noti-
fied Mrs. Hung that it would conduct an investigation into the cause
of Dr. Hung's death. In April 1998, Guardian paid Mrs. Hung for
"basic life benefits" and notified her that it would continue to investi-
gate the accidental death claim. At that point Guardian's nurse, Ms.
McCafferty, and doctor, Dr. Dennison, reviewed Dr. Hung's file. Dr.
Dennison concluded that Dr. Hung suffered from hypertension caus-
ing a subarachnoid hemorrhage, which resulted in a head injury and
eventually a stroke while he was hospitalized. Based on his conclu-
sions, on July 20, 1998, Guardian denied Mrs. Hung's request for
accidental death benefits and notified her of her right to request a
review of the decision.
On September 18, 1998, Mrs. Hung requested that Guardian recon-
sider its denial decision and provided Guardian with her affidavit; an
3
affidavit of her daughter, Ching-Li Mera; a letter from Dr. Srinivas
Mandava, the doctor who pronounced Dr. Hung dead; an affidavit of
Dr. Schilder, an outside neurologist; and a letter from her attorney.
Mrs. Hung's and her daughter's affidavits essentially explained their
opinions that Dr. Hung fell from a ladder in his basement while wear-
ing flip-flop sandals. Dr. Mandava's September 20, 1998, letter
explained his opinion that the "probable cause of death was probably
due to the head trauma and intracranial hemorrhage with subsequent
cerebral swelling, leading to his coma and death, and not directly to
his underlying condition of hypertension." Dr. Schilder explained his
opinion, based on records provided to him by Mrs. Hung, that Dr.
Hung died as a result of head trauma, not hypertension.
In considering Mrs. Hung's appeal, Dr. Dennison reviewed the
medical file for a second time, and also reviewed the new information
submitted by Mrs. Hung. Guardian additionally sought an outside
medical review of its previous determination. Specifically, Dr.
Schuster, an outside neuroradiologist, was directed to review the med-
ical records. Notably, Dr. Schuster was not provided with the affida-
vits and letters submitted by Mrs. Hung. However, based on the
medical records supplied to him by Guardian, Dr. Schuster concluded
that Dr. Hung's cause of death was a stroke.
On November 30, 1998, Guardian notified Mrs. Hung that it had
completed its review of her appeal. Guardian explained that based on
its review and the review of Dr. Schuster, the independent physician,
it concluded that its original denial of accidental death benefits was
appropriate, as Dr. Hung's death was a result of an underlying dis-
ease, hypertension, and not a result of an accident.
Following Guardian's denial of the appeal, Mrs. Hung filed suit in
Maryland State Court. Guardian removed the action to federal court
under Employment Retirement Income Security Act (ERISA). The
district court determined that review was appropriate on the adminis-
trative record before the decisionmaker at the time of the challenged
decision. The court concluded based on the record that the administra-
tor had not abused its discretion in denying the claim, and as a result
it granted the defendant's motion for summary judgment. Based on
the district court's rulings, Mrs. Hung filed this appeal.
4
II.
A District Court's grant or denial of summary judgment is
reviewed de novo. Haley v. Paul Revere Life Ins. Co., 77 F.3d 84, 89
(4th Cir. 1996); see also Ellis v. Met. Life Ins. Co., 126 F.3d 228, 232
(4th Cir. 1997). ERISA plans, as contractual documents, must be
reviewed de novo by the Court to determine the degree of discretion
afforded to the plan administrator. Booth v. Wal-Mart Stores, Inc.
Associates Health and Welfare Plan, 201 F.3d 335, 341 (4th Cir.
2000). When the plan confers discretion on a fiduciary and the fidu-
ciary acts with the scope of that conferred discretion, the principles
of trust law apply, and a fiduciary's "exercise of power is not subject
to control by the court except to prevent an abuse by the trustee of
his discretion." Id. (citing Firestone Tire and Rubber Co. v. Bruch,
489 U.S. 101, 111 (1989)). Thus, the fiduciary's"discretionary deci-
sion will not be disturbed if reasonable, even if the court itself would
have reached a different conclusion." Booth , 201 F.3d at 341; Elliott
v. Sara Lee Corp., 190 F.3d 601 (4th Cir. 1999); Haley, 77 F.3d at
89. In general, "a decision is reasonable if it is the result of a deliber-
ate, principled reasoning process and if it is supported by substantial
evidence." Ellis, 126 F.3d at 233 (citations omitted). "[A] denial deci-
sion must be reviewed for abuse of discretion." Elliott, 190 F.3d at
606; see also Booth, 201 F.3d at 341-42 (distinguishing the abuse of
discretion standard and arbitrary and capricious standard of review).
The fact that a fiduciary acts under a conflict of interests must be
considered in reviewing the decision and determining whether the dis-
cretion was abused. Booth, 201 F.3d at 342 (citing Firestone, 489
U.S. at 115). In addition to many factors relevant to determining
whether an abuse of discretion occurred, the court must determine
whether the record before the decisionmaker was adequate, and
whether the materials before the fiduciary support the challenged
decision. Booth, 201 F.3d at 342 (citing Bernstein v. CapitalCare,
Inc., 70 F.3d 783, 788 (4th Cir. 1995)) (listing factors to be consid-
ered when reviewing a fiduciary's discretionary decision).
With these standards in mind, the Court must review the Guardian
plan, and Guardian's decision to deny accidental death benefits. The
Court reviews the fiduciary's decision, as the district court did, to
determine whether the fiduciary abused its discretion. The Court
5
applies the "modified abuse of discretion standard," which requires
the court to weigh the factor of the conflict in its decision to deter-
mine whether the administrator abused its discretion. Ellis, 126 F.3d
at 233. The Court must determine based on its review of the adminis-
trative record before the fiduciary at the time of decisionmaking
whether the administrator's decision is consistent with a decision that
might have been made by a fiduciary acting free of the interests which
conflict with those of the beneficiaries. Id. (quoting Bedrick v. Travel-
ers Ins. Co., 93 F.3d 149, 152 (4th Cir. 1996)).
Additionally, the District Court properly limited its review to the
administrative record before the administrator at the time of decision-
making. See Elliott, 190 F.3d at 606 (limiting scope of review to
administrative record); Quesinberry v. Life Ins. Co. of N. Am., 987
F.2d 1017, 1026 (4th Cir. 1993) (limiting scope of review to adminis-
trative record and applying de novo review standard).1 To determine
whether an abuse of discretion occurred, the court must consider the
facts before the decisionmaker at the time of decisionmaking. Elliott,
190 F.3d at 606; Sheppard & Enoch Pratt Hosp., Inc. v. Travelers Ins.
Co., 32 F.3d 120, 124-25 (4th Cir. 1994).
III.
From the record before the Court, it appears that Guardian's initial
decision was based on the following facts: (1) Dr. Hung's death cer-
tificate indicated stroke as the immediate cause of death, JA 239; (2)
the CT scan performed on Dr. Hung while he was hospitalized prior
to his death (reported by Dr. Moss) concluded that Hung had three
hemorrhage lesions, at least two of which were not commonly associ-
ated with trauma, and as a result, Dr. Moss suspected that the lesions
were present at the time Dr. Hung fell, JA 389-90; (3) Dr. Hung's
hospital records indicate that Dr. Hung was hypertensive, and that he
_________________________________________________________________
1 The plaintiff contends that"it is difficult to discern" what modifica-
tions the District Court made to compensate for the conflicted adminis-
trator regarding the medical evidence presented by both parties and that
the district court should have made a de novo review of the medical evi-
dence. However, this Circuit does not require de novo review by the dis-
trict court. See Doe v. Group Hospitalization and Med. Serv., 3 F.3d 80,
87 (4th Cir. 1993).
6
suffered from high blood pressure and headaches prior to falling (all
indicators for a stroke); and finally, (4) Dr. Dennison, a physician for
Guardian, reviewed the records and concluded that"[h]ypertension
caused a hypertensive subarachnoid hemorrhage that subsequently
lead to a fall to the floor resulting in head injury-- contusion and
hematoma -- a major in-hospital stroke days later was the termi-
nal/final event." He further concluded that in his opinion, "the fall was
the result of a neuro insult, i.e., the hypertensive subarrachnoid
bleed."
On Mrs. Hung's appeal, Dr. Dennison, Guardian's physician,
reviewed the evidence outlined above, and additionally reviewed the
information submitted by Mrs. Hung (the affidavits and letters). Dr.
Dennison acknowledged that the information provided by Mrs. Hung
supported a conclusion that head trauma was the"direct cause" of
Hung's death, but noted that hypertension was the cause of the head
trauma; not an accidental fall. Nevertheless, Dr. Dennison recom-
mended an outside medical review. As a result, Guardian contracted
with an independent neuroradiologist, Dr. Schuster, to review Dr.
Hung's medical records.
It is Dr. Schuster's review and Guardian's failure to provide Dr.
Schuster with the documentation submitted by Mrs. Hung that makes
Guardian's review of Mrs. Hung's appeal incomplete. Specifically,
Dr. Schuster was provided with only the "medical records." Guardian
did not provide Dr. Schuster with the affidavits and letters submitted
by Mrs. Hung.
Based on the medical records alone, Dr. Schuster concluded that
Dr. Hung had an "underlying process in the cerebral hemispheres of
his brain" that resulted in hemorrhages and that the hemorrhages
caused Hung to lose consciousness and collapse. Dr. Schuster con-
cluded that the impact of the fall caused a fracture to the occipital
bone in Hung's head. However, he further concluded that the hemor-
rhages were unrelated to the fall, but likely caused the fall, and that
the skull fracture resulting from the fall was the direct cause of death.
Based on Dr. Schuster's opinion, Guardian confirmed its initial deci-
sion to deny accidental death coverage.
Because Dr. Schuster's opinion was the primary basis for Guard-
ian's decision on appeal, and because Dr. Schuster was not provided
7
an entire set of facts and circumstances surrounding Dr. Hung's death,
under the modified abuse of discretion standard applicable in this
case, the Court cannot find that the record contains adequate informa-
tion to support Guardian's decision. Cf. Booth , 201 F.3d at 343(upholding finding of the Administrative Committee in part based on
thorough review of numerous independent doctors' opinions and let-
ters); Ellis, 126 F.3d at 230-31 (considering evidence submitted by
independent doctors). It is not an abuse of discretion for an adminis-
trator to come to one decision, rather than another, where there is con-
flicting medical evidence in the record. Elliott , 190 F.3d at 606 (citing
Ellis, 126 F.3d at 234) (affirming summary judgment decision where
there was conflicting medical evidence as to whether there was a dis-
ability). Rather, decisions are often upheld where there is conflicting
medical evidence and it is clear from the administrative record that
the administrator fully considered both opinions. See Booth, 201 F.3d
at 345 (citing Elliott, 190 F.3d at 606); Brogan v. Holland, 105 F.3d
158, 163 (4th Cir. 1997) (affirming district court's grant of summary
judgment where medical evidence was inconsistent as to whether
stroke occurred during course of employment).
However, in this case, the problem arises because the allegedly
conflicting evidence was not presented to the independent medical
expert employed to review the file and offer an opinion as to Dr.
Hung's cause of death. Because a substantial portion of the relevant
evidence was withheld from the independent reviewing neurora-
diologist, Guardian's conclusions based on Dr. Schuster's opinion is
necessarily called into doubt and unreliable. While Guardian may
have considered the information submitted by Mrs. Hung in its reas-
sessment of her claim, its consulting physician undisputedly did not.2
This obvious flaw in Guardian's review process and decisionmaking
regarding Mrs. Hung's claim requires remand to Guardian for a new
determination based on a complete record, which necessarily includes
the information submitted by Mrs. Hung. See Elliott, 190 F.3d at 609(citations omitted); see also Sheppard, 32 F.3d at 125. Guardian's
referral of Dr. Hung's medical record to Dr. Schuster was incomplete
_________________________________________________________________
2 Mrs. Hung's other arguments on appeal related to the alleged impro-
priety of Guardian's review of her claim and the district court's denial
of the motion to amend need not be specifically addressed herein based
on the decision of the Court that the record reviewed was incomplete.
8
in the absence of the documentation submitted by Mrs. Hung, and as
a result, reconsideration is required. See Elliott, 190 F.3d at 609.
Accordingly, we reverse the grant of summary judgment by the
district court and remand for further proceedings consistent with this
opinion.
REVERSED AND REMANDED
9