David Carr v. John Hancock Life Insurance Company (USA)
703 F. App'x 733
| 11th Cir. | 2017Background
- David Carr, insured under a John Hancock group long-term care policy through Shell, received benefits from July 7, 2011 until John Hancock terminated benefits effective July 18, 2013.
- The Policy pays only if insured is “chronically ill”: unable to perform ≥2 Activities of Daily Living (ADLs) without substantial assistance for ≥90 days; substantial assistance = stand-by or hands-on help.
- Independent on-site assessments: Feb 2012 (Univita) found need for assistance in most ADLs; Feb 2013 assessment found assistance needed for several ADLs but noted improved mobility; July 2013 Univita assessment found Carr could perform all six ADLs without assistance.
- Care documentation (Maxim weekly notes and later independent care provider bills) showed assistance with at most one ADL from May–mid‑Aug 2013; ICP bills showed no ADLs checked 6/16–8/10/2013 and then many ADLs checked beginning 8/11/2013.
- Carr submitted multiple appeal records, including Certifications by treating physicians asserting ADL dependency; John Hancock reviewed those but found them inconsistent with contemporaneous assessments and records and upheld denial in its final decision on October 2, 2014.
- District court granted summary judgment for John Hancock; Eleventh Circuit affirmed, applying the Williams multi-step framework and concluding John Hancock’s denial was correct or, alternatively, reasonable under arbitrary-and-capricious review.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Proper standard of review | District court should not apply deferential review | Plan grants discretionary authority; deferential Williams framework applies | Williams framework/arbitrary-and-capricious review is correct |
| Scope of record | Court should consider evidence from Carr’s April 2015 new claim | Review limited to materials before administrator when final decision issued (Oct 2, 2014) | Administrative record closed as of Oct 2, 2014; later claim excluded |
| Burden of proof | (implicit) administrator must prove termination proper | Policy and precedent place burden on insured to prove entitlement | Carr bore burden to prove inability to perform ≥2 ADLs |
| Merits: termination of benefits July 18, 2013 | Treating physicians’ certifications show Carr needed assistance with ≥2 ADLs | July 2013 independent assessment and contemporaneous care notes showed no more than one ADL needing help; physician certifications conflicted with those records | John Hancock’s denial was correct; alternatively reasonable under arbitrary-and-capricious review |
Key Cases Cited
- Blankenship v. Metro. Life Ins. Co., 644 F.3d 1350 (11th Cir. 2011) (sets out multi-step Williams framework for reviewing discretionary ERISA benefit denials)
- Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101 (U.S. 1989) (courts apply deferential review when plan grants discretion)
- Metro. Life Ins. Co. v. Glenn, 554 U.S. 105 (U.S. 2008) (conflict of interest as plan administrator/payor is a factor, not dispositive)
- Williams v. BellSouth Telecomms., Inc., 373 F.3d 1132 (11th Cir. 2004) (framework elements for ERISA review)
- Doyle v. Liberty Life Assur. Co. of Boston, 542 F.3d 1352 (11th Cir. 2008) (discusses discretion and review standard)
- Glazer v. Reliance Standard Life Ins. Co., 524 F.3d 1241 (11th Cir. 2008) (insured bears burden to prove disability)