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PAESE v. HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY

April 8, 2004.

DENNIS PAESE, Plaintiff, -against- HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY, Defendant


The opinion of the court was delivered by: DENNY CHIN, District Judge

OPINION

In this case, plaintiff Dennis Paese sues under the Employee Retirement Income and Security Act of 1974 ("ERISA"), 29 U.S.C. § 1001 et seq., to challenge the decision of defendant Hartford Life and Accident Insurance Company ("Hartford") to terminate his long term disability benefits under his former employer's group disability insurance plan. The parties agreed to submit this dispute to the Court for a summary trial on the documentary evidence and written submissions, waiving their right to call witnesses.

  As discussed more fully below, the record shows unequivocally that Paese was totally disabled when Hartford decided to terminate his long term disability benefits. The numerous physicians who examined and treated Paese concluded that he suffered serious spine, shoulder, and hand injuries as the result of a motor vehicle accident. MRIs and other tests and studies objectively confirmed the existence of significant injuries. Indeed, Paese had two surgeries — first on his elbow and forearm, and second, months later, on his cervical spine as a disc was removed and bone was engrafted. Even the Social Security Administration determined that Paese was totally disabled and awarded him Social Security benefits. Instead of evaluating Paese's claim in a fair and open-minded manner, Hartford largely ignored this evidence and relied instead on entries taken out of context from the medical records and the opinions of two physicians who never even examined Paese and who were hardly unbiased.

  Accordingly, judgment will be entered in favor of Paese. My findings of fact and conclusions of law follow.

  STATEMENT OF THE CASE

 A. The Facts

  1. Plaintiff

  Paese is a 53-year old, 300-pound, 6'l" man. (A 02-229, 02-410).*fn1 He was employed by Sequa Corporation ("Sequa") from March 7, 1977, until September 21, 1999, when his department was reorganized, his position was eliminated, and his employment was terminated. (A 02-503, 02-503A).

  From January 5, 1987, until the termination of his employment, Paese was Sequa's Director of Labor Relations in Hackensack, New Jersey. (A 02-503). Paese was responsible for labor relations at Sequa, including formulating and implementing labor and employee relations policies, serving as the chief negotiator for collective bargaining agreements and labor contracts, and maintaining relations with unions. (A 02-501). His position required extensive traveling, throughout the United States and Europe, and he often had to travel to plant and division locations and various government agency offices throughout the United States, at times working long and odd hours. (A 02-209-10; see A 02-395 (Sequa human resources manager reporting that Paese's position "required extensive travel" and that travelling was "definitely considered an essential function of the occupation")).

  On August 30, 1999, Paese was involved in an automobile accident. He sustained injuries, but was not hospitalized. (A 02-364, 02-594-95). He returned to work until September 8, 1999, when he stopped working and applied for disability benefits. (See A 02-503). As of September 8, 1999, Paese's salary was $137,254 per annum and he had earned $151,822 for the year, consisting of $93,006 in base pay and $58,816 in bonus. (A 02-018, 04-081).

  2. The Plan

  As of January 1, 1998, Paese was covered, as a Sequa employee, under Sequa's employee benefit plans, which included a group "plan of Long Term Disability Insurance" under Group Insurance Policy GLT-208141 (the "Plan"), issued by Hartford as insurer. (A 001, 041, 0043). Under the Plan, claims and appeals from the denial of claims were to be submitted to Hartford. (See A 056-57).

  The Plan provides "income protection" for Sequa employees who "become disabled from a covered accidental bodily injury, sickness or pregnancy." (A 043). "Disabled" means "Totally or Residually Disabled." (A 045). A "Residual Disability" is a partial disability (A 047) and is not at issue here, as Paese applied for Total Disability benefits only. "Total Disability" and "Totally Disabled" are defined to mean:
(1) during the Elimination Period; and
(2) for the next 24 months, you are prevented by:
(a) accidental bodily injury;
(b) sickness;
(c) mental illness;
(d) substance abuse; or
(e) 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.
After that, you must be so prevented from performing the essential duties of any occupation for which you are qualified by education, training, or experience.
(Id.). For Paese, the "Elimination Period" was 180 days. (A 044; A 02-390). " [Y] our occupation" refers to the defined term "Your (Own) Occupation," and means the employee's occupation as recognized in the "general workplace" rather than his or her specific job for a specific employer or at a specific location. (A 048).

  Monthly benefits under the Plan are payable if an employee becomes "Disabled" while insured under the Plan, remains Disabled throughout and beyond the Elimination Period, is and has been under the regular care of a physician, and "submit [s] proof of loss satisfactory to . . . Hartford." (A 052; See also A 056 (discussing "proof of Disability")). Payments are to be adjusted for inflation. (A 045 (applying a formula based on a consumer price index)). An employee who became disabled was also entitled to a waiver of life insurance premium benefits. (A 3-031).

  3. Paese'S Disability Benefits

  Paese applied for and was granted short term disability benefits, which he received until March 8, 2000. (Def. Mem. at 2; see A 02-500). On March 10, 2000, Sequa submitted to Hartford on Paese's behalf an application for long term total disability benefits. (A 02-500-06). On April 12, 2000, a Hartford representative noted in an internal worksheet that Paese was engaging in physical therapy, was scheduled for hand and elbow surgery, and was hoping to avoid spinal surgery. (A 02-486). Noting that Paese's job required travel, the representative recommended approval of the application. (A 02-485-86).

  On May 4, 2000, Hartford advised Paese that his claim for long term disability benefits had been approved and he began receiving long term disability benefits, at the rate of $6,862.70 per month, or 60% of his base earnings. (A 02-49, 02-390). On October 11, 2001, however, Hartford advised Paese that it was terminating his benefits, writing:
We have completed our review of your claim for benefits and have determined medical documentation no longer establishes a total disability beyond October 11, 2001 from Your Own Occupation as a Director of Labor Relations. Accordingly, LTD [long term disability] benefits are not payable to you beyond October 11, 2001.
(A 02-218).

  On November 7, 2001, Paese wrote to Hartford, challenging its decision to terminate his benefits. (A 02-207). By letter dated November 19, 2001, Hartford responded, stating that it had received Paese's "appeal," as set forth in his November 7, 2001, letter, and advising that it was referring the claim to its Appeals Unit. (A 02-205). Paese and Hartford thereafter engaged in an extended exchange of correspondence. (See, e.g., A 02-179 (Paese letter dated 12/6/01); A 02-59 (Hartford letter dated 12/13/01); A 02-204 (Hartford letter dated 1/9/02); A 02-51 (Paese letter dated 1/27/02); A 02-54 (Paese letter dated 2/16/02); A 02-131 (Paese letter dated 2/28/02)).

  By letter dated March 20, 2002, Hartford rejected Paese's appeal and adhered to its decision to terminate his benefits, writing:
Our determination has remained that the documentation on file, taken as a whole, supports our original decision. Therefore, we must uphold our decision to terminate your claim for LTD benefits.
(A 02-33). 4. Plaintiff's Medical Condition
  In the accident on August 30, 1999, Paese was driving when his car was rear-ended by another vehicle. He was wearing his seatbelt (A 02-410), but both hands impacted into the steering wheel. (A 02-364). He went to work after the accident, but later in the day he began to experience severe neck pain, shoulder pain, headache, and tingling in the arms. (A 02-410, 02-413).

  Paese was seen by Dr. Gudimal, an orthopedic surgeon at N.Y.U., and began physical therapy. He had severe pain and limitation of both shoulders and was unable to internally rotate either shoulder without severe pain and limitation. (A 02-410).

  Paese had an MRI on September 9, 1999, just ten days after the accident. (A 02-400). The clinical diagnosis was "[c]ervical spine injury sustained in a motor vehicle accident." (Id.). The MRI showed anterior bulging of the discs at all levels from C4/5 through C6/7, straightening of the normal cervical lordosis, paravertebral muscle spasm, dessiccation of the C5/6 disc, and ...


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