Administrator's Benefit Denial Upheld After Participant Failed to Provide Records

Pension & Benefits Daily™ covers all major legislative, regulatory, legal, and industry developments in the area of employee benefits every business day, focusing on actions by Congress,...

A plan administrator's decision denying a participant's claim for disability benefits based on a suspected disqualifying pre-existing condition and the participant's failure to provide requested documentation was not an abuse of discretion, the U.S. District Court for the Southern District of Mississippi ruled Aug. 3 (Scott v. Hartford Life and Accident Insurance Co., S.D. Miss., No. 2:10-cv-00220-KS -MTP, 8/3/12).

The plan administrator requested additional medical evidence after the participant's medical records indicated that the participant's injuries were related to a pre-existing condition.

Judge Keith Starrett determined that the administrative record supported the plan administrator's decision to request additional medical records and concluded its benefit denial was not unreasonable after the participant failed to provide the records.

Dispute Over Disability Benefits Claim.

Tonya Scott worked for the Hattiesburg Clinic from March 10, 2007, through June 6, 2007, and participated in its Employee Retirement Income Security Act-governed group long-term disability plan, which was insured by Hartford Life and Accident Insurance Co.

Scott suffered a slip-and-fall injury in April 2007 and began experiencing lower back pain. Scott was treated by a doctor for the injury and continued seeking medical care. Scott allegedly filed a disability claim with Hartford and sued in Mississippi state court in April 2010 after Hartford failed to respond.

Hartford removed the suit to federal court in September 2010 based on ERISA preemption. Hartford then filed a motion for summary judgment in June 2011 and argued that Scott had failed to exhaust her administrative remedies because she did not file a benefit claim until June 2010.

The court granted a motion to stay in August 2011 to allow Hartford time to evaluate Scott's disability claim. The stay was lifted in November 2011 after Hartford denied Scott's claim. Another stay was granted in January 2012 after Scott filed an administrative appeal. Hartford upheld its decision in April 2012 and filed another motion for summary judgment.

Participant Failed to Provide Records.

The court noted that Hartford had sole discretionary authority to interpret the plan's terms and to determine Scott's benefit eligibility. Additionally, the plan excluded coverage for pre-existing conditions, which were defined as “a condition for which medical treatment or advice was rendered, prescribed or recommended within 3 months prior to [Scott's] effective date of insurance,” the court said.

The court noted that Hartford's investigation into Scott's disability claim “produced medical records which prompted [Hartford] to inquire whether her disability” was caused by a preexisting condition. According to the court, medical documentation from two physicians indicated that Scott's fall at the Hattiesburg Clinic caused her lower back pain, in addition to “congenital problems” and “pre-existing spondylolysis.”

Hartford asked Scott to submit additional medical records as a result of the physician statements, the court said. According to the court, Hartford denied Scott's disability benefit claim after she failed to provide the requested documentation. Scott argued that she submitted evidence “that she [was] disabled, that she does not have a pre-existing condition, that her injury was work-related, and that no reasonable person would have demanded further information.”

The court determined that Scott's alleged disability was irrelevant because Hartford based its benefit denial on Scott's “failure to provide information regarding the alleged pre-existing condition.” The court, quoting Holland v. International Paper Co. Retirement Plan, 576 F.3d 240, 47 EBC 2753 (5th Cir. 2009) (136 PBD, 7/20/09; 36 BPR 1721, 7/21/09), concluded that the “pertinent issue” was whether Hartford's “decision to request further information and to deny coverage for [Scott's] failure to provide it were 'made without a rational connection' to the known facts.”

According to the court, “the Administrative Record contain[ed] evidence supporting [Hartford's] denial” and “it was reasonable for [Hartford] to seek further information from [Scott] as to whether she had received medical treatment during the three months prior to the policy's effective date.” Hartford “did not abuse its discretion by denying [Scott's] claim for benefits” after Scott failed to submit the requested medical records, the court said.

Scott was represented by Chester B. McSwain of Petal, Miss. Hartford was represented by Steven H. Begley and Lana E. Gillon of Wells Marble & Hurst, Jackson, Miss.

The full text of the opinion is at