:: District Court Applies Tenth Circuit Weber Opinion In Affirming Benefit Denial

Although Plaintiff does not address whether Defendant’s conflict of interest influenced its decision, Plaintiff argues in its motion for summary judgment that Defendant failed to provide a full and fair hearing. Plaintiff states that there is no indication that any of the review team was a health care professional, and there is no indication what documentation the appeal team considered. Plaintiff’s contention, however, is not supported by the evidence.

Dove v. Prudential Ins. Co. of Am., 2009 U.S. Dist. LEXIS 41896 (D. Kan. May 18, 2009)

The district court in Dove v. Prudential  applied its interpretation of  post-Glenn Tenth Circuit authority in evaluating a denial of benefits under an accident policy.  The important aspect of the opinion is framed by the excerpt quoted above.   When faced with a conflict of interest by a plan adminstrator, what factors should it evaluate in determining whether the conflict affected the benefits denial decision.

Facts

In this case, the plaintiff suffered an severe injury to his eye from the rim of a basketball goal.  

On April 2, 2005, Dove had an accident that resulted in damage to his right eye. The attending physician, Dr. Lee, characterized the accident as “rim of basketball goal ruptured globe and collapsed eye-right eye.” Dr. Lee stated that there was no disease or condition prior to the date of the accident that might have served as a contributing cause. Dr. Lee also stated that the last observation of the vision in the right eye on May 31, 2005 was “Lt @ 2ft.”

The plaintiff had had eye problems in that eye previously, however, and this formed the basis of the insurer’s denial of benefits.

Plan Provisions

The plan provisions were as follows:

The Plan provides: “If, while insured for this benefit, you or your dependents suffer accidental bodily injury, which independently of all other causes, results in any losses described herein, we will pay the benefits stated in the Plan Summary.” The policy defines “Accidental Bodily Injury” as an “injury that results solely and directly from a Covered Accident and which occurs while the coverage is in force.”

“Dismemberment” is defined as “Accidental Bodily Injury that, directly and independently of all other causes, results in the loss of . . . (5) sight.” The Plan states that “Loss of sight means total and permanent loss of sight.” The policy also provides that it “will not pay any benefits if the loss directly or indirectly, results from any of the following: sickness, mental illness, disease of any kind, or medical or surgical treatment for any sickness, illness or disease . . . .”

Rationale For Benefit Denial

In denying Plaintiff’s claim, Defendant found that based on Plaintiff’s medical records, he was permanently blind prior to the accident and that his vision problems were not all due to the accident but from his previous medical condition.

Defendant relied on the Plan’s language that the injury must result “solely and directly” from a covered accident. Defendant stated that while an accident did occur that did not make Plaintiff’s vision any better, it did not create a new circumstance because Plaintiff was already blind.

The Principal Issue

The district court framed the issue as being “whether Plaintiff’s loss of sight resulted from an accidental bodily injury.”

The facts bearing on this issue were the state of Plaintiff’s sight in the eye before the accident and the significance of the accident in contributing to futher loss of sight.

The court stated:

Plaintiff does not address the issue except to state that he had further vision loss after his accident. Plaintiff also does not address this language in the Plan. The Plan’s language is unambiguous when it defines “accidental bodily injury” as an injury resulting “solely and directly from a covered accident.”

The court evidently viewed the causation factor as the key:

Prudential, in denying Plaintiff’s claim, stated that Plaintiff suffered from loss of sight prior to the accident. As such, Plaintiff’s loss of sight was not covered by the language in the Plan.

Frame Of Reference

The Plaintiff had sight in the eye before the accident, but he had problems with the eye:

It appears to the Court that Defendant relied on the evidence in Plaintiff’s file which indicated that he had numerous problems with his right eye, including cataract removal surgery, retinal detachment surgery, and 20/400 vision, prior to the accident.

The causation argument seemed to weigh as a more substantial factor than application of the definition of “permanent loss of vision” :

This evidence indicated that Plaintiff suffered permanent loss of vision prior to the accident and that the loss of sight in his right eye did not result from an accidental bodily injury that was independent of all other causes. Because the Plan language specifically requires that the loss of sight occur from an accidental bodily injury independent of all other causes, it appears that Prudential’s determination was reasonable and supported by substantial evidence. Accordingly, the Court cannot find that Defendant’s decision to deny Plaintiff benefits was arbitrary and capricious. 

Note:  The district court took the “minimalist” view of MetLife v. Glenn.    The Court appears to have considered the use of physician review as a procedure adequate to offset any possible effects of a conflict of interest:

In Glenn, the Supreme Court noted that the conflict of issue “should prove less important (perhaps to the vanishing point) where the administrator has taken active steps to reduce potential bias and to promote accuracy . . . .”

Here, it appears that Prudential has taken active steps to reduce potential bias in that it had three different physicians review the claims file at each stage of the proceeding. In addition, it appears that each physician was given all of Dove’s medical records and the additional documentation on review. As such, each physician was given all of the pertinent information to make an informed evaluation about Dove’s claim. From the evidence in front of the Court, the Court cannot conclude that the inherent conflict of interest tainted Prudential’s decision. Accordingly, the conflict of interest is a factor that will be less important in determining whether Prudential’s determination was arbitrary and capricious. 

This view is somewhat amusing and, I submit, a distortion of Glenn’s notion of procedures that may eliminate bias.

Argument On Bias –  The opinion does not reflect whether any discovery was sought on the question of bias.  The Plaintiff appeared to have couched the bias argument in terms of the regulatory requirement of a full and fair hearing.  Once again, the court found the reviewing physicians’ opinions very influential:

Although Plaintiff does not address whether Defendant’s conflict of interest influenced its decision, Plaintiff argues in its motion for summary judgment that Defendant failed to provide a full and fair hearing. Plaintiff states that there is no indication that any of the review team was a health care professional, and there is no indication what documentation the appeal team considered. Plaintiff’s contention, however, is not supported by the evidence. The administrative record indicates that a physician was involved in each stage of the review. In addition, each appeal letter stated that Defendant thoroughly evaluated the documentation in the file as well as the documentation received for the appeal.  As such, the undisputed facts do not support Plaintiff’s contention that Defendant failed to provide a full and fair hearing.

Tenth Circuit Authority – The Tenth Circuit had occasion to reflect on its standard after the Glenn case in Weber v. GE Group Life Assurance Co., 541 F.3d 1002 (10th Cir. 2008).  There the Court interprested its prior opinion in Fought v. UNUM Life Ins. Co., 379 F.3d 997 (10th Cir. 2004)):

As both the insurer and the plan administrator, GE operates under a conflict of interest in this case. See Glenn, 128 S. Ct. at 2349-50. Accordingly we will still employ the arbitrary and capricious standard, but we will weigh GE’s conflict of interest as a factor in determining the lawfulness of the benefits denial.

The Tenth Circuit appears to have taken a more expansive role in evaluating the possible effect of conflict that the district court in Dove, however.   Consider this excert from Weber:

If the language is ambiguous, then we “must take a hard look and determine” whether GE’s decision was arbitrary in light of its conflict of interest. Fought, 379 F.3d at 1008.   As part of this review, we “typically consider whether: (1) the decision was the result of a reasoned and principled process, (2) is consistent with any prior interpretations by the plan administrator, (3) is reasonable in light of any external standards, and (4) is consistent with the purposes of the plan.” Flinders, 491 F.3d at 1193 (internal quotations omitted); see also Geddes v. United Staffing Alliance Employee Med. Plan, 469 F.3d 919, 929 (10th Cir. 2006). Neither party addresses these questions specifically and the record reveals little about GE’s claims assessment process, so we are left to our own analytic devices.

The Dove court really did not meaningfully engage these factors in reaching its decisino.

Retrospective – The causation defense is a silver bullet for insurers when it comes to accident claims.   Causation appears rather mundane in everyday life, but the subject has a metaphysical component that can become quite confusing in the context of a claim for benefits.  Argument directed at the factors suggested above is the only recourse the plaintiff really has as a countermeasure.

Paradox –  The focus on degrees of blindness suffered by this poor fellow reminds me of the sorites paradox.  You may know it as the “paradox of the heap”.   This is really off-topic, so if  you were reading for legal information, you can stop here.

Is a million grains of sand a heap of sand?  It would appear so.  But what if you remove a single grain?1,000,000 grains of sand is a heap of sand. (Premise 1)A heap of sand minus one grain is still a heap. (Premise 2)

Repeated applications of Premise 2 (each time starting with one less number of grains), eventually forces one to accept the conclusion that a heap may be composed of just one grain of sand (and if you follow premise 2 again, composed of no grains at all!).

These are “little by little” arguments and they come in several forms.  They do point up a logical problem that results whenever we take an incremental view toward outcomes.  The excerpt above and related discussion may be found here.