David Carr v. John Hancock Life Insurance Company (USA)

703 F. App'x 733
CourtCourt of Appeals for the Eleventh Circuit
DecidedJuly 12, 2017
Docket16-17134 Non-Argument Calendar
StatusUnpublished
Cited by1 cases

This text of 703 F. App'x 733 (David Carr v. John Hancock Life Insurance Company (USA)) is published on Counsel Stack Legal Research, covering Court of Appeals for the Eleventh Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
David Carr v. John Hancock Life Insurance Company (USA), 703 F. App'x 733 (11th Cir. 2017).

Opinion

PER CURIAM:

Plaintiff-appellant David Carr appeals pro se from the district court’s grant of summary judgment' in favor of defendant-appellee John Hancock Life Insurance Company (“John Hancock”) on his claim for wrongful denial of benefits under the Employee Retirement Income Security Act (“ERISA”). Carr contends that the district court erred by determining th^t John Hancock was “not wrong” in terminating Carr’s benefits under its long-term care insurance policy effective July 2013. After careful review of the record and the parties’ briefs, we affirm.

I. FACTUAL BACKGROUND

A. The John Hancock Plan and Policy

Carr worked for Shell Oil Company and participates in Shell Oil Company’s pension and welfare-benefits plan (the “Plan”), which is governed by ERISA. As part of the Plan, John Hancock issued a Group Long-Term Care Policy to Shell Oil Company (the “Policy”). Carr is insured under the Policy.

To be eligible for benefits under the Policy, an insured must be “[cjhronically [ijll.” This means that the insured must be “unable to perform at least two Activities of Daily Living due to the loss of functional capacity for a period expected to last 90 days.” 1 Similarly, the Policy defines “Benefit Trigger” as being “unable to perform (without Substantial Assistance from another individual) at least 2 Activities of Daily Living for a period of at least 90 days due to a loss of functional capacity.”

The Policy delineates six Activities of Daily Living (“ADLs”): (1) Bathing (defined as washing oneself in either a tub or shower, including the task of getting into and out of the tub or shower); (2) Continence (meaning the ability to maintain control of bowel or bladder function and the ability to perform associated personal hygiene); (3) Dressing (defined as putting on and taking off all items of clothing and any necessary braces, fasteners, or artificial limbs); (4) Eating (defined as feeding oneself by getting food into the body from a receptacle such as plate, cup or table or by a feeding tube or intravenously); (5) Toileting (defined as getting to and from the toilet, getting on and off the toilet, and performing associated personal hygiene); and (6) Transferring (defined as moving into or out of a bed, chair or wheelchair, or moving from place to place either via walking or wheelchair or other means).

“Substantial Assistance” means “[sjtand-by or hands-on assistance by another person needed to perform the Activity of Daily Living.” “Stand-by” assistance means the presence of another person nearby who can prevent injury as the insured *736 performs the ADL himself, while “hands-on” assistance means the physical assistance of another person, without which the insured could not perform the ADL.

The Policy provides that John Hancock will “only pay benefits if’ it is provided with “Proof of Claim satisfactory to Us that confirms that You are receiving covered services and You continue to meet all eligibility requirements.”

B. Carr Was Paid Benefits from July 7, 2011 until July 19, 2013

According to Carr’s filings in the district court, by January 2011, he was legally blind and had been diagnosed with muscle atrophy, peripheral neuropathy, anemia, fatty liver, tobacco abuse, anxiety and depression, prostate cancer, and hypertension. The parties agree that Carr filed a claim for benefits under the Policy in May 2011, and that John Hancock detérmined that Carr met the requirements for payment of benefits from July 7, 2011 until July 19,2013.

C. The February 2012 On-Site Assessment

In February 2012, John Hancock ordered what it characterizes as an “independent on-site assessment” of Carr’s condition. The assessment was performed by a registered nurse for Univita. The Univita nurse reported that Carr was “intoxicated and not feeling well” during her visit. Carr told the-nurse that he had been drinking for three weeks and had not bathed in three weeks. The nurse reported that Carr needed assistance (either stand-by or hands-on) in all of the listed ADLs except for eating.

Beginning in April 2012, a nurse employed by Maxim Healthcare Services (“Maxim”) provided Carr with home health care services. According to “weekly notes” completed by Maxim between April 2012 and February 2013, the Maxim home health care nurse typically assisted Carr with housekeeping, meals, and two ADLs — bathing and transferring. 2 The Maxim home health care nurse and Carr reviewed and signed each weekly note.

D. The February 2013 On-Site Assessment

In February. 2013, John Hancock ordered another on-site assessment of Carr by Univita. The report from the February 2013 assessment stated that Carr received home health services because he was “unstable on [his] walker, blind, [and] weak.” The report also stated that Carr worked out three times a week on his home gym. As to Carr’s functional capacity, the Univi-ta nurse concluded that Carr needed assistance with bathing, toileting, transferring, and “rare” bowel incontinence. The Univita nurse noted that, although Carr struggled with his balance and strength, his mobility had improved to the point that he could use a walker. Accordingly, John Hancock approved Carr for further benefits.

E. Documentation from May 2013 to August 2013

According to the Maxim weekly notes from May to mid-June 2013, the Maxim home health care nurse typically assisted Carr with only showering, housekeeping, and meal preparation. In mid-June 2013, the Maxim home health care nurse assisting Carr stopped working for Maxim and began working as an “independent care provider” to Carr. Thus, she began submitting “independent care provider service bills” (the “ICP bills”) to John Hancock. Again, both the home health care nurse and Carr reviewed and signed the ICP *737 bills, certifying that the information provided therein “is a complete and accurate representation of the care provided and received.”

According to those ICP bills, no ADLs were checked off from June 16, 2013 to August 10, 2013. However, beginning on August 11, 2013, and continuing through at least November 22, 2014, the ICP bills began checking off all, or nearly all, of the six ADLs every day.

F. The July 2013 On-Site Assessment

In July 2013, John Hancock ordered another on-site assessment of Carr by Univi-ta. The Univita nurse stated that Carr did not need any assistance with eating, transferring, toileting, bathing, continence, or dressing. The Univita nurse noted that he walked with a “steady gait” and “erect posture” while using his walker, could get in and out of a chair by himself, could bathe himself while seated in a shower seat, and could dress himself. Further, the nurse’s report states that Carr told her he was “very pleased” with his recent gains in mobility. The Univita nurse also reported that she saw Carr walk with the aid of his walker, and that Carr used his Bowflex exercise machine “regularly.”

G. John Hancock Terminated Carr’s Benefits Effective July 18, 2013

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703 F. App'x 733, Counsel Stack Legal Research, https://law.counselstack.com/opinion/david-carr-v-john-hancock-life-insurance-company-usa-ca11-2017.