James Connelly v. Standard Ins. Co.
663 F. App'x 414
| 6th Cir. | 2016Background
- James Connelly, a former staff attorney, applied for long-term disability (LTD) benefits under his employer’s ERISA plan, claiming inability to work beginning July 25–26, 2011; his coverage ended July 26, 2011.
- Connelly has long-standing Crohn’s disease and several other chronic conditions (diabetes, hypertension, depression); contemporaneous 2011 records (CT, colonoscopy, routine notes) showed no significant active Crohn’s flare or work-restricting findings.
- Treating physicians later (2012–2013) submitted statements asserting they had recommended Connelly stop working in July 2011 due to an acute Crohn’s flare and related depression; those treating notes from 2011, however, did not document such recommendations.
- The SSA awarded Social Security disability benefits with an onset date of February 17, 2012, not July 2011; Standard relied on that and independent file reviews in denying LTD benefits.
- Standard’s claims reviewers (three independent physicians, including a psychiatrist) found no objective evidence of work-impairing conditions before July 26, 2011; Standard denied benefits and affirmed on appeal after accepting additional records.
- Connelly sued under ERISA; the district court granted summary judgment to Standard; the Sixth Circuit reviewed whether the denial was arbitrary and capricious and affirmed.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Whether Standard’s denial was arbitrary and capricious under ERISA discretionary-review standard | Connelly: treating physicians recommended stopping work in July 2011 and their corroborating statements should carry weight; Standard failed to contact treating doctors or perform an exam and ignored comorbidity | Standard: contemporaneous medical records and independent reviewers show no disabling condition before July 26, 2011; SSA’s later finding of disability began in 2012; reviews were reasoned and documented | Denial was not arbitrary and capricious; substantial evidence supports finding that disability began after coverage ended |
| Weight to give after-the-fact treating physicians’ statements vs contemporaneous records | Connelly: treating doctors’ 2012 statements should not be dismissed; treating opinions deserve deference | Standard: contemporaneous records are more probative than later recollections; reviewers considered treating records and explained disagreement | Court credited contemporaneous records over post hoc treating statements given lack of contemporaneous corroboration |
| Need for physical examination or contact with treating doctors | Connelly: file review insufficient; exam or communication could resolve discrepancies | Standard: file review reasonable here because significant time had elapsed and claimant’s condition worsened after coverage ended | Failure to examine or contact doctors did not render denial arbitrary given claim was about past disability and lack of contemporaneous evidence |
| Consideration of comorbidity and SSA finding | Connelly: Standard failed to evaluate combined effects of multiple conditions and should give weight to SSA | Standard: reviewers considered all conditions; SSA’s later onset supports Standard’s conclusion | Court found comorbidity unsupported by 2011 records; SSA’s 2012 onset weighed in favor of Standard |
Key Cases Cited
- Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101 (1989) (establishes standard of review for ERISA benefit denials)
- Metropolitan Life Ins. Co. v. Glenn, 554 U.S. 105 (2008) (insurer-administrator conflict of interest is a factor in review)
- Javery v. Lucent Techs., Inc. Long Term Disability Plan for Mgmt. or LBA Emps, 741 F.3d 686 (6th Cir. 2014) (applying arbitrary-and-capricious review to LTD claims)
- Killian v. Healthsource Provident Adm’rs, Inc., 152 F.3d 514 (6th Cir. 1998) (denial not arbitrary if based on deliberate, principled reasoning and substantial evidence)
- Elliott v. Metropolitan Life Ins. Co., 473 F.3d 613 (6th Cir. 2006) (administrator may not summarily reject treating physicians’ opinions without explanation)
- DeLisle v. Sun Life Assurance Co. of Canada, 558 F.3d 440 (6th Cir. 2009) (examines factors making post hoc treating statements persuasive and when file reviews are inadequate)
- Evans v. UnumProvident Corp., 434 F.3d 866 (6th Cir. 2006) (failure to conduct a physical exam can render a denial arbitrary when current condition is at issue)
- Rochow v. Life Ins. Co. of N. Am., 482 F.3d 860 (6th Cir. 2007) (progressive conditions and contemporaneous documentation can make later manifestations evidence of pre-coverage disability)
- Calvert v. Firstar Financial, Inc., 409 F.3d 286 (6th Cir. 2005) (reviewing physician must address key evidence in the record; failure to do so can be arbitrary)