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WINTER v. HARTFORD LIFE AND ACCIDENT INSURANCE CO.

March 22, 2004.

GERARD P. WINTER, Plaintiff, -against- THE HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY, Defendants


The opinion of the court was delivered by: ARTHUR SPATT, District Judge

MEMORANDUM OF DECISION AND ORDER

The plaintiff Gerard P. Winter ("Winter" or the "plaintiff") commenced this action under the provisions of the Employee Retirement Income Security Act ("ERISA"), 29 U.S.C. § 1001 et seq., alleging that the defendant The Hartford Life and Accident Insurance Page 2 Company ("Hartford" or the "defendant") improperly denied long term disability benefits to him. Presently before the Court is a motion for summary judgment by Hartford.

I. BACKGROUND

  Winter was employed as a money market broker with United News & Media and their Affiliates ("United News") from prior to July 1, 1997 until on or about December 2, 1998. Pursuant to his employment by United News, Winter was a participant in an employee welfare benefit plan (the "Plan") which was sponsored by his employer. The benefits provided under the Plan included long-term disability benefits which are provided through a group insurance policy, GL/GLT 208118 (the "Group LTD Policy"), issued by Hartford to the plaintiff's employer, United News.

  On or about December 2, 1998, the plaintiff ceased working for United News. On or about April 23, 1999, the plaintiff submitted a claim for long-term disability benefits pursuant to the terms of the Group LTD Policy (the "Claim"). In this Claim, the plaintiff indicated that his "severe back pain" made him unable to work. In particular, the plaintiff indicated that the "constant and continued sitting [and] lack of movement [was] aggravating [his] condition." Moreover, in the accompanying "Attending Physician's Statement of Disability," the plaintiff's treating physician Ralph C. Marcove, M.D. ("Dr. Marcove") indicated, among other things, that Winter suffered from Marie Strumpel Disease, which is a debilitating disease of the spine. Page 3

  On August 13, 1999, Hartford determined that it would approve the plaintiff's claim for long-term disability benefits based on a determination that he was totally disabled for his own occupation "at th[at]time." By letter dated August 17, 1999, Maryann Iannettone ("Iannettone"), a claims examiner for Hartford, advised the plaintiff that his claim for long-term disability benefits had been approved. This letter indicated, among other things, that the benefit payments would continue so long as the plaintiff met the policy definition of "total disability" which was defined:
Total Disability or Totally Disabled means that you are prevented by:
(1) accidental bodily injury;
(2) sickness;
(3) mental illness;
(4) substance abuse; or
(5) pregnancy, from performing the Essential Duties of Your Occupation and as a result you are earning less than 20% of your Pre-disability Earnings, unless engaged in a program of Rehabilitative Employment approved by us.
  Thereafter, Hartford began paying long term disability benefits to the plaintiff in the gross amount of $5,500.00 per month (minus reductions for other income benefits) effective from March 3, 1999.

  On March 22, 2000, John Acampa, M.D. ("Dr. Acampa") submitted an "Attending Physician's Statement of Continuing Disability" in which he indicated that his primary diagnosis was "Anklosing Spondylitis" which caused "limited mobility of [his] neck and Page 4 back."

  On April 12, 2000 and April 13, 2000, investigators hired by Hartford observed and monitored Winter's activities. According to the investigation report and accompanying surveillance video, Winter was observed, among other things, driving his car, doing errands, walking, bending and engaging in other physical activities at a local boat yard. Hartford attempted to contact Dr. Acampa, the plaintiff's physician, regarding the surveillance video tape but was unsuccessful.

  In a letter dated July 7, 2000, Iannettone advised Winter that Hartford had completed its review of his claim for benefits and had determined that he no longer met the definition of total disability. This letter indicated that Hartford's decision was based on, among other things, (1) the Claim; (2) the Claimant Questionnaire form dated March 1, 2000 in which the plaintiff indicated that his activities during a typical day included "some morning stretching, walking short distances, some local driving, reading and watching T.V."; (3) the Physical Aspects of the plaintiff's occupation which included "occasional standing and keyboard/repetitive hand motion and continuous sitting"; and (4) the above mentioned surveillance video and Special Investigative Reports dated April 14, 2000 and May 4, 2000. The plaintiff was informed that his long term disability benefits would be terminated as of May 1, 2000. This letter also indicated to the plaintiff that he can appeal Hartford's decision to terminate the benefits and supplement his file with additional information. Page 5

  On or about September 6, 2000, the plaintiff requested a review of Hartford's determination that he was no longer eligible for benefits and submitted additional documentation in connection with his request for review. This additional documentation included Dr. Acampa's treatment notes from a period of December 14, 1999 through May 25, 2000; a letter dated May 23, 2000 and November 15, 2000 from Catherine Swanson Giuffre, M.S.W., C.S.W.; a letter dated September 16, 2000 from Dr. Acampa; and a letter dated October 30, 2000 from Howard M. Boskey, M.D.

  On or about December 20, 2000, Shelley Worley ("Worley"), a Behavioral Healthcare Manager reviewed the plaintiff's claim file which included the original application, the surveillance tape and the material submitted through the appeal. In her "Summary Detail Report" Ms. Worley concluded, among other things, that "if [the plaintiff] were provided a simple adjustable workstation he would be able to perform his desk work and phone work while being allowed to change his position as needed. There are documents provided with the appeal that indicate limitations due to his pain and his depression but these statements are totally refuted by the physical evidence on the tape. . . ." Summary Detail Report dated Dec. 20, 2000.

  In a "Medical Report" dated January 1, 2001, Dr. George Kazda, an Associate Medical Director for Hartford, concluded that "Mr. Winter has the functional capacity to engage in sedentary occupation on full time basis." Dr. Kazda acknowledged Dr. Acampa's Page 6 letter dated September 16, 2000 in which Dr. Acampa indicated, among other things, that Winter complained of back pain which was aggravated by sitting and walking and that he could only tolerate walking half a block and with severe pain, standing for ten minutes at a time and sitting for five minutes at a time. However, Dr. Kazda concluded that "[Dr. Acampa's] information is in marked contrast to photographic and video surveillance evidence obtained on Mr. Winter in April of 2000."

  Thereafter, by letter dated January 25, 2001, Hartford indicated that it affirmed its earlier decision denying benefits to the plaintiff.

  The plaintiff commenced this action alleging that Hartford improperly denied long term disability benefits to him. Presently before the Court is Hartford's motion for summary judgment. This motion requires the Court to (1) determine the standard of review the Court must use in evaluating Hartford's decision to deny the plaintiff long term disability benefits; and (2) using that ...


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