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Burris v. Hartford Life and Accident Co.

March 20, 2007


The opinion of the court was delivered by: Leon Jordan United States District Judge


This civil action is brought pursuant to the Employee Retirement Income Security Act ("ERISA"), 29 U.S.C. § 1001, et seq. It is now before the court for consideration of "Plaintiff's Motion for Judgment on the Administrative Record" [doc. 10] and the "Motion for Judgment on the Record" [doc. 11] filed by defendant, Hartford Life and Accident Company ("Hartford"). Hartford has responded to plaintiff's motion [doc. 14], and plaintiff, Glenna Burris ("Burris"), has responded to Hartford's motion [doc. 13]. For the reasons stated herein, Burris's motion will be denied, Hartford's motion will be granted, and judgment will be entered in favor of Hartford.

I. Procedural Background

Hartford issued to Wal-Mart Stores, Inc. an insurance plan (the "Plan" or "Policy") that provides short term disability ("STD") benefits. [A.R. 002, 048, 082].*fn1 Wal-Mart is the Plan administrator. [A.R. 048]. Hartford is the claims administrator. [A.R. 086].

Burris worked at Wal-Mart as a salesfloor associate from 1999 until July 2004. She filed a claim for STD via telephone on July 27, 2004, advising that she could not work due to a cyst on her back. [A.R. 144].

Hartford denied Burris's STD claim by letter dated August 6, 2004, stating that she was not "Totally Disabled" under the terms of the Policy but allowing her to submit additional documentation for reconsideration of her claim. [A.R. 151]. For STD purposes, the Plan defines "Totally Disabled" as unable to do the material and substantial duties of your occupation. Your occupation includes similar job positions with the employer which may be offered to you with a rate of pay 60% or greater of your predisability earnings. [A.R. 090].*fn2

Burris submitted additional information, but Hartford denied her claim a second time by letter dated August 12, 2004. [A.R. 670]. Hartford again upheld its claim via a letter dated September 17, 2004 [A.R. 661], and on February 4, 2005, Hartford acknowledged receipt of Burris's appeal. [A.R. 646]. Hartford informed Burris on June 17, 2005, that it was affirming its decision to deny her STD benefits. [A.R. 154]. Burris filed this lawsuit on August 2, 2005.

II. Standard of Review

In Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101 (1989), the United States Supreme Court held that "a denial of benefits challenged under § 1132(a)(1)(B) is to be reviewed under a de novo standard unless the benefit plan gives the administrator or fiduciary discretionary authority to determine eligibility for benefits or to construe the terms of the plan." Id. at 115. However, if a plan grants the administrator or fiduciary the appropriate discretionary authority, this court must review the decision at issue under the "highly deferential arbitrary and capricious standard of review . . . ." Yeager v. Reliance Standard Life Ins. Co., 88 F.3d 376, 380 (6th Cir. 1996). A plan's grant of discretionary authority to the administrator or fiduciary must be "express." Perry v. Simplicity Eng'g, 900 F.2d 963, 965 (6th Cir. 1990); see also Wulf v. Quantum Chem. Corp., 26 F.3d 1368, 1373 (6th Cir. 1994) (requiring "a clear grant of discretion") (emphasis in original).

Decisions concerning eligibility for ERISA benefits are not arbitrary and capricious if they are "rational in light of the plan's provisions." Daniel v. Eaton Corp., 839 F.2d 263, 267 (6th Cir. 1988). "Before concluding that a decision was arbitrary and capricious, a court must be confident that the decisionmaker overlooked something important or seriously erred in appreciating the significance of evidence." Marchetti v. Sun Life Assurance Co. of Canada, 30 F. Supp. 2d 1001, 1008 (M.D. Tenn. 1998) (citing Wahlin v. Sears, Roebuck & Co., 78 F.3d 1232, 1235 (7th Cir. 1996)). The Policy contains the following provision:


The Hartford has full discretion and authority to determine eligibility for benefits and to construe and interpret all terms and provisions of the Group Insurance Policy. [A.R. 086]. Burris acknowledges the existence of this language but argues that a de novo review is required because the grant of discretion is to the claims administrator and not to the Plan administrator, Wal-Mart. The court does not agree.

In Garst v. Wal-Mart Stores, Inc., 30 F. App'x 585 (6th Cir. 2002), the Sixth Circuit stated that the plan before it "designated Hartford as its claims administrator, giving Hartford discretionary authority to resolve all questions concerning the administration, interpretation or application of the Plan." Id. at 588. The Court then noted it would review "the district court's grant of summary judgment to determine if there is any genuine issue of material fact whether the insurance company's decision to deny benefits was arbitrary or capricious." Id. (citation and quotation omitted). This court concludes that, like in Garst, the grant of discretion to the claims administrator in this case is sufficient to trigger the arbitrary or capricious standard of review. The court will apply that standard in its review of Hartford's decision. See also Bruch, 489 U.S. at 115 (considering the amount of discretion given to "the administrator or fiduciary") (emphasis added); Miller v. Metro. Life Ins. Co., 925 F.2d 979, 984 n.2 (6th Cir. 1991) (applying arbitrary or capricious standard where discretion was granted to the insurer/claims administrator).

Plaintiff does correctly note that there is an inherent conflict of interest in this case because Hartford is the decision maker for disability benefits claims as well as the entity that pays benefits. However, the existence of such a conflict does not alter the standard of review. Marchetti, 30 F. Supp. 2d at 1007. Rather, the administrator's conflict of interest is a factor considered by the court in its review of the administrative decision. See id.; Miller, 925 F.2d at 984. The court will accordingly consider this inherent conflict of interest as a factor in determining whether Hartford's decision was arbitrary or capricious.

III. Administrative Record

Beginning in at least 2002, Burris reported periodically to Drs. Howard McNeeley and Ronald Wray with abdominal and stomach complaints. [A.R. 203-10, 354, 357]. On June 30, 2004, Burris complained of knee pain secondary to playing tennis. [A.R. 211]. Two weeks later, she continued to report abdominal problems and had a temperature of 102. ...

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