ERISA-Second Circuit Upholds Administrator’s Denial Of Claim For Long Term Disability Benefits

In Testa v. Hartford Life Insurance Company, No. 11-974-cv (2nd Cir. 2012) (Summary Order), the plaintiff, Josphine Testa (“Testa”), was a participant in several employer-provided health care plans (the “Plans”). The Plans were governed by ERISA, and were administered by the defendant, Hartford Life Insurance Company (“Hartford”). Testa brought suit against Hartford , as plan administrator, for denying her claim under the Plans for long term disability (“LTD”) benefits. The district court granted summary judgment to Hartford, and Testa appealed. On the appeal, Testa argued that Hartford’s denial of the claim was not supported by substantial evidence, and Hartford failed to provide her a full and fair review of her claim as required by ERISA.

In analyzing the case, the Second Circuit Court of Appeals (the “Court”) said that where, as here, written plan documents confer upon a plan administrator the discretionary authority to determine eligibility, the Court will not disturb the administrator’s claim denial unless it is arbitrary and capricious. Under the arbitrary and capricious standard, a decision to deny benefits will be overturned only if it is without reason, unsupported by substantial evidence or erroneous as a matter of law. Here, Hartford’s decision to deny the claim for LTD benefits was reasonable and supported by substantial evidence, and thus not arbitrary or capricious. Hartford relied on the opinions of three independent physicians and one independent psychologist, all of whom reviewed Testa’s medical record and independently determined that there was insufficient evidence to support a finding of total disability. Specifically, those doctors found–and the record on appeal demonstrates–virtually all of Testa’s symptoms were self-reported and supported by little, if any, objectively verifiable evidence. Moreover, that Hartford chose to credit the independent doctors it selected over Testa’s treating physicians is not, in and of itself, grounds for reversing its decision.

The Court noted that Testa also contended that several procedural irregularities evidence that Hartford failed to provide a “full and fair review” of her claim as required by ERISA (See 29 U.S.C. ยง 1133(2)). After reviewing the record, the Court found that these contentions had no merit. As such, the Court affirmed the district court’s summary judgment in Hartford’s favor.

Posted in:
Updated:

Comments are closed.