Joanne Work v. Hartford Life and Accident Insurance Company

* The Honorable Eugene E. Siler, Jr., Senior Judge for the United States Court of
Appeals for the Sixth Circuit, sitting by designation.
NOT PRECEDENTIAL
UNITED STATES COURT OF APPEALS
FOR THE THIRD CIRCUIT
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No. 05-5350
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JOANNE WORK,
Appellant,
v.
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY,
Appellee.
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On Appeal from the United States District Court
for the Eastern District of Pennsylvania
(D.C. No. 04-CV-2565)
District Court Judge: The Honorable Thomas N. O’Neill, Jr.
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Argued March 13, 2007
BEFORE: FUENTES, VAN ANTWERPEN, and SILER, * Circuit Judges.
(Filed: August 31, 2007)
William D. Marvin (ARGUED)
Cohen, Placitella & Roth, P.C.
2001 Market Street
Two Commerce Square, Suite 2900
Philadelphia, PA 19103
Counsel for Appellant

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Kim R. Plouffe (ARGUED)
German, Gallagher & Murtagh
The Bellevue, Suite 500
200 S. Broad Street
Philadelphia, PA 19102
Counsel for Appellee
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OPINION OF THE COURT
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SILER, Circuit Judge.
Joanne Work appeals the District Court’s grant of summary judgment in favor of
Hartford Life and Accident Insurance Company (“Hartford”) on her claim under the
Employee Retirement Income Security Act (“ERISA”), 29 U.S.C. § 1132, for restoration
of her long term disability (“LTD”) benefits. Because Hartford’s termination decision
was arbitrary and capricious, we reverse.
I.
From November 1999 to May 2000, Work served as an administrative assistant for
Brandywine Realty Trust, Inc. (“Brandywine”). She stopped working because she
suffered severe back injuries as a result of a herniated disk and associated complications
including sciatica, fibrosis, and bilateral knee problems. After receiving short term
disability benefits from Brandywine, she applied, in July 2000, for LTD benefits from

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Hartford, which had contracted to administer and pay LTD benefits under Brandywine’s
ERISA plan. Hartford initially honored her claim but stopped paying benefits in January
2002, when it determined Work was no longer “disabled,” as defined by the plan. Work
exhausted her administrative remedies through Hartford’s internal appeal process, and
then brought this lawsuit to challenge the termination of her benefits. The District Court
concluded that Hartford’s termination of Work’s disability benefits was not arbitrary and
capricious, and, therefore, granted Hartford’s summary judgment motion.
II.
We review claims denials in ERISA cases under the arbitrary and capricious
standard if, as here, “the benefit plan gives the administrator or fiduciary discretionary
authority to determine eligibility for benefits or to construe the terms of the plan.”
Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989). “Under the arbitrary
and capricious standard, an administrator's decision will only be overturned if it is without
reason, unsupported by substantial evidence or erroneous as a matter of law [and] the
court is not free to substitute its own judgment for that of the defendants in determining
eligibility for plan benefits.” Pinto v. Reliance Standard Life Ins. Co., 214 F.3d 377, 387
(3d Cir. 2000) (internal quotation marks omitted).
In Pinto, we held that where an insurance company is both the plan administrator
and funder, a court must take into account the structural conflict of interest present and
apply a higher standard of review. Id. at 387-90. Under the “heightened arbitrary and
capricious review” standard, a court remains “deferential, but not absolutely deferential”

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to the decisions of a plan administrator. Id. at 393. We refined this standard by adopting
a “sliding scale” approach. Id. at 392. Under this approach, the reviewing court may take
into account “the sophistication of the parties, the information accessible to the parties, . .
. the exact financial arrangement between the insurer and the company . . . [and] the
current status of the fiduciary.” Id. We noted that the level of scrutiny applied to the
fiduciary's decision is “a range, not a point.” Id. at 392 (quoting Wildbur v. ARCO Chem.
Co., 974 F.2d 631, 638 (5th Cir. 1992)). A court should “approximately calibrat[e] the
intensity of [its] review to the intensity of the conflict.” Id. at 393.
The District Court in this case employed a standard of review at the low end of the
Pinto sliding scale because it found that Hartford had only a “moderate” conflict of
interest in determining Work’s eligibility for disability benefits. Work argues that
because Hartford’s conduct displayed bias resulting from its conflict of interest, a higher
level of scrutiny is appropriate. However, we need not consider this argument because
we conclude that even applying the standard of review used by the District Court,
Hartford’s decision was arbitrary and capricious.
III.
The District Court concluded that Hartford’s decisions to terminate Work’s
disability benefits and to uphold its judgment on appeal are supported by the evidence in
the record. We disagree. Our review of the evidence reveals that Hartford’s decision was
not based on a fair reading of Work’s medical records and contradicts the
recommendation of Work’s treating orthopedic surgeon, Dr. Mansmann.

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Following Work’s internal appeal, Hartford conducted a paper review of her
medical records. The review was completed by Dr. Elizabeth Roaf, who concluded that,
based on the medical information available, Work could resume her full-time position.
Hartford adopted Dr. Roaf’s analysis, and the District Court determined that its reliance
on this report was reasonable.
Dr. Roaf’s report was deficient. Her conclusion appears to rest entirely on Dr.
Mansmann’s report that Work could use her hands and feet; handle, finger, and feel
things; and occasionally lift weights under ten pounds, stoop, kneel, crouch, crawl, and
reach above the shoulder and at waist level. However, in a 2002 letter to Hartford, Dr.
Mansmann recommended that Work remain out of work. In his conversation with Dr.
Roaf, he told her that “it is possible that [Work] might be able to perform some part-time
position at a sedentary level,” but cautioned that “she would certainly need frequent
position changes, [and] the ability to sit and stand when needed.” He also noted that
during Work’s visits to his office, she was “clearly uncomfortable” in either a sitting or
standing position. Dr. Mansmann never suggested that Work could return to work on a
full-time basis. Because Hartford presented no other evidence in support of its
determination, its denial of benefits was arbitrary and capricious.
IV.
For the foregoing reasons, we reverse the judgment of the District Court and
remand with instructions to enter the appropriate judgment for Work.

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