Arko v. Hartford Life & Accident Insurance Co.
672 F. App'x 693
9th Cir.2016Background
- Plaintiff Fred Arko sued under ERISA § 502(a) challenging Hartford Life & Accident Ins. Co.’s denial of long-term disability benefits for alleged disability beginning in 2000.
- Hartford conceded Arko had multiple sclerosis (MS) in 2000 but denied benefits for lack of proof that MS rendered him unable to perform essential job functions.
- The administrative record contained large gaps in medical documentation (no records for 5 of the 11 years claimed), and some medical statements conflicted with Arko’s assertion of continuous disability.
- The parties filed cross-motions for judgment under Fed. R. Civ. P. 52; the district court ruled for Hartford after applying the abuse-of-discretion standard and making factual findings.
- On appeal, the Ninth Circuit reviewed de novo the choice of standard (affirming abuse-of-discretion was proper) and reviewed the district court’s factual findings for clear error.
- The court affirmed Hartford’s denial of benefits as not an abuse of discretion because Arko failed to provide sufficient evidence of continued disability through the policy’s elimination period and beyond.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Appropriate standard of review | District court should apply a less deferential standard | Abuse-of-discretion applies (plan administrator) | Abuse-of-discretion was properly applied by district court |
| Sufficiency of evidence of ongoing disability | Arko argued MS diagnosis and submitted records show disability from 2000 onward | Hartford argued record gaps and contradictory evidence made disability unsupported | Hartford did not abuse discretion; evidence insufficient to prove continuous disability |
| Effect of gaps in medical records | Arko: available records plus diagnosis suffice to meet burden | Hartford: long gaps (5 of 11 years) make proving continuous disability impossible | Gaps justified denial; similar gaps upheld in prior Ninth Circuit precedent |
| Procedural/regulatory challenge (failure to have medical reviewer) | Arko: Hartford violated 29 C.F.R. § 2560.503-1(h)(3)(v) by not having medical professional review records | Hartford: issue was not raised below; procedural defense | Court declined to address because Arko waived issue by not raising it in district court |
Key Cases Cited
- Abatie v. Alta Health & Life Ins. Co., 458 F.3d 955 (9th Cir.) (standard-of-review framework for ERISA benefit denials)
- Kearney v. Standard Ins. Co., 175 F.3d 1084 (9th Cir.) (bench-trial/Rule 52 review of ERISA benefit denial; clear-error standard for factual findings)
- Jordan v. Northrop Grumman Corp. Welfare Benefit Plan, 370 F.3d 869 (9th Cir.) (diagnosis alone insufficient; claimant must show inability to perform essential job functions)
- Alford v. DCH Found. Grp. Long-Term Disability Plan, 311 F.3d 955 (9th Cir.) (upholding denial when there are significant gaps in medical records)
- Easley v. Cromartie, 532 U.S. 234 (United States Supreme Court) (definition of clear-error standard of review)
- United States v. U.S. Gypsum Co., 333 U.S. 364 (United States Supreme Court) (quoted definition of clear-error/firm conviction standard)
- Pfingston v. Ronan Eng’g Co., 284 F.3d 999 (9th Cir.) (issues not raised in district court are waived on appeal)
- Salomaa v. Honda Long Term Disability Plan, 642 F.3d 666 (9th Cir.) (noting prior decisions and scope of medical-disability proof)