Post v. Hartford Insurance

501 F.3d 154, 41 Employee Benefits Cas. (BNA) 1943, 2007 U.S. App. LEXIS 21911, 2007 WL 2669825
CourtCourt of Appeals for the Third Circuit
DecidedSeptember 13, 2007
Docket05-4927
StatusPublished
Cited by108 cases

This text of 501 F.3d 154 (Post v. Hartford Insurance) is published on Counsel Stack Legal Research, covering Court of Appeals for the Third Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Post v. Hartford Insurance, 501 F.3d 154, 41 Employee Benefits Cas. (BNA) 1943, 2007 U.S. App. LEXIS 21911, 2007 WL 2669825 (3d Cir. 2007).

Opinions

[157]*157OPINION OF THE COURT

AMBRO, Circuit Judge.

Carol Post believes that she is entitled to long term disability benefits under her former employer’s disability plan. Her treating physicians maintain that she is disabled. On the other hand, Hartford Insurance Company, the plan administrator (who also happens to fund the plan), has hired reviewing physicians who maintain that Post is not disabled. In other words, the central issue in this case— whether Post is disabled — is a “battle, of the experts.”

“Battle-of-the-experts” cases are often easy for a reviewing court. If the trial court’s standard of review is arbitrary and capricious, then Hartford usually wins when it has produced sufficient evidence supporting its position. It cannot be said to have acted arbitrarily, and summary judgment in its favor is appropriate. On the other hand, if the standard is de novo, then summary judgment for either party must be vacated because there is credible evidence on both sides of the key fact question.

But this case, a claim that ERISA benefits were improperly denied, is anything but easy, for the trial court’s standard of review is neither arbitrary and capricious (at least in its traditional form) nor de novo. In these cases, district courts must select a standard of review that accords with the extent to which the plan administrator operates under a conflict of interest. Here we conclude that the District Court did not select the proper standard of review, and so we vacate and remand for consideration under the standard we deem to apply.

We affirm, however, the Court’s grant of summary judgment on Post’s claim for breach of fiduciary duty because it is barred by res judicata.

I. Facts and Procedural History

Carol Post was in a serious car accident in November 1993, just a few days after having major dental surgery. At the time, she was employed as a dentist by Overlook Hospital in Summit, New Jersey. She sustained a whiplash injury in the accident, but she nonetheless attempted to return to work soon afterward. After six days of working, she was forced to stop because of intractable pain. Overlook, however, offered for her to try working as a pharmacist for a while (as she has both dentistry and pharmacy degrees), and she accepted. She returned to work in December 1993, but was forced to take nearly a day off each week because of pain. After nine months of off-and-on working, she resigned due to pain in September 1994. During this period, she tried numerous physical therapy treatments, none of which significantly improved her condition. She returned to work again in January 1995, but resigned four months later because of continuing pain. She has not worked since.

Post’s medical record is voluminous. Between 1993 and 2003, she visited 14 doctors. Her pain management regimens ranged from traditional treatments like prescription drug combinations, trigger-point injections, and various forms of physical therapy, to more exotic treatments like acupuncture and biofeedback. She reports that none has given her significant relief. Her primary treating physician is currently Dr. Carolyn Britton, a professor of neurology at Columbia University. According to Dr. Britton, Post suffers from chronic post-traumatic pain syndrome characterized by severe myofacial pain; regular, debilitating headaches accompanied by sensitivity to light, nausea, and vomiting; irritable bowel syndrome; and insomnia. Dr. Britton believes that this syndrome is [158]*158directly attributable to Post’s car accident and that it renders her disabled from any sustained employment.

In keeping with Dr. Britton’s determination, Post’s view of the record is that it indicates that she sustained a traumatic whiplash injury that sensitized her central nervous system, thus triggering the development of chronic pain syndrome. This is Dr. Britton’s diagnosis, and it is supported by a number of other evaluations in the record.

Hartford, on the other hand, believes that the record indicates that Post suffered no more than a whiplash injury that has now healed. While it concedes that Post continues to report pain, it contends that the record contains no reliable diagnosis of a recognized debilitating condition. In support of its view, Hartford primarily relies on the reports of Dr. Ekaterina Mal-ievskaia, its reviewing physician, and Dr. Christopher Lynch, who performed an independent medical examination. Hartford also cites the opinions of Drs. Michael John Fiore and Joel Harris,1 who evaluated Post in 1994 and 1996, respectively.

This ease is governed by the Employee Retirement Income Security Act (“ERISA”), 29 U.S.C. §§ 1001-1461, because Overlook Hospital’s disability plan (the “Plan”) is an “employee welfare benefit plan” as defined by 29 U.S.C. § 1002(1). Post filed a disability claim with Hartford, Overlook’s disability carrier, soon after she ceased working in 1995. Hartford approved her claim, subject to periodic renewal. To be considered “totally disabled” under the Plan after December 6, 1997, she had to be “prevented by [disability from doing any occupation or work for which [she was] or could become qualified.”

From 1995 until 2002, Hartford paid out benefits. In August 1998, the Social Security Administration approved Post’s application for disability benefits, citing intractable cervical pain, chronic pain syndrome, and fibromyalgia2 as the relevant diag[159]*159noses. Soon after Post was approved for Social Security benefits, Hartford asked her to submit a copy of the administrative decision so that it could offset her benefits. She responded through counsel that 'Hartford was not entitled to an offset under the plain language of the Plan, but she did provide Hartford with a copy of the decision. Hartford eventually relented and accepted Post’s reading of the Plan.

For reasons not apparent from the record, sometime in late 1999 Hartford took a renewed interest in Post’s claim. The company surveilled her and reported in its claim notes that surveillance was unsuccessful, as she was not seen leaving her house. Hartford also began requesting copies of Post’s tax records, ostensibly to take a non-Social Security income offset, as the Plan allowed. It provides that “Hartford has the right to require, as part of Proof of Loss: (1) your [Post’s] signed statement identifying all Other Income Benefits, and (2) [satisfactory proof to the Hartford that you and your Dependents have duly applied for all Other Income Benefits which are available. The Hartford reserves the right to determine if proof of loss is satisfactory.” Hartford contends that the “proof ... that you ... have duly applied for all Other Income Benefits” language gives it the right to demand tax returns, though it is not clear how a tax return would reflect whether Post had applied for other income benefits. The plain language of this provision does not authorize the review of tax returns. (Incidentally, the tax returns confirm that Post was not receiving any income during the disputed period.)

In June 2001, Hartford determined that Post should submit to an independent functional capacity evaluation to confirm her disability. This was permissible under the Plan.

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Bluebook (online)
501 F.3d 154, 41 Employee Benefits Cas. (BNA) 1943, 2007 U.S. App. LEXIS 21911, 2007 WL 2669825, Counsel Stack Legal Research, https://law.counselstack.com/opinion/post-v-hartford-insurance-ca3-2007.