Burmania v. Hartford Life and Accident Insurance Company, The
1:12-cv-01244
W.D. Mich.Dec 12, 2013Background
- ERISA action challenging Hartford's denial of plaintiff Burmania's LTD benefits.
- Plaintiff was employed by YRC and covered by the YRC Group LTD Plan insured by Hartford.
- Policy defines disability as own-occupation for first 24 months, then any-occupation thereafter.
- Plaintiff began STD in 2009 and LTD January 2010 under own-occupation definition; SSA disability also awarded.
- Provider notes and various physicians showed multiple serious conditions; Hartford denied continued LTD on Jan 1, 2012 under any-occupation standard.
- Court applies arbitrary-and-capricious review due to discretionary authority granted to plan administrator; Michigan discretionary-clause rules not applicable to this plan.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Proper standard of review given discretionary clause and Michigan rules. | Burmania argues de novo review per Michigan rules. | Hartford contends discretionary review applies; MS rules do not govern this plan. | Arbitrary and capricious standard applies. |
| Whether the denial was supported by substantial evidence over treating physicians. | Treating doctors' opinions show disability. | Non-treating reviews considered more objective; opinions credited. | Decision upheld; credited Huver/Taylor opinions over treating doctors. |
| Role of independent medical reviewers and potential conflicts of interest. | Independent reviewers paid by defendant may be biased. | No proven bias; independent reviews considered valid. | Conflict of interest acknowledged but not shown to have influenced outcome. |
| Impact of SSA disability decision on ERISA denial. | SSA determination should control outcome. | SSA findings are not binding; only one factor. | SSA determination given weight as one factor, not controlling. |
Key Cases Cited
- Am. Council of Life Insurers v. Ross, 558 F.3d 600 (6th Cir. 2009) (preemption of discretionary clauses; post-2007 rules apply in Michigan)
- Tracy v. Pharmacia & Upjohn Absence Payment Plan, 195 F. App’x 511 (6th Cir. 2006) (SSA disability as a factor in ERISA review; not binding)
- Calvert v. Firstar Fin., Inc., 409 F.3d 286 (6th Cir. 2005) (differences between SSA and ERISA; weight given to SSA findings)