The opinion of the court was delivered by: Garnett Thomas Eisele United States District Court
G. THOMAS EISELE, SENIOR DISTRICT JUDGE, sitting by designation*fn1
MEMORANDUM OPINION AND ORDER GRANTING SUMMARY JUDGMENT
Before the Court are Defendant's Motion for Summary Judgment and Plaintiff's Cross-Motion for Summary Judgment presenting the issue of whether Plaintiff Judy A. Tucker is entitled to long term disability benefits. After review of the parties' submissions, the record in this case and careful consideration of the issues presented thereby, the Court concludes that Defendant's Motion for Summary should be denied, and Plaintiff's Cross Motion for Summary Judgment should be granted to the extent stated herein.
This matter involves Plaintiff's claim for long term disability benefits pursuant to the Group Insurance Policy issued by Defendant Hartford Life and Accident Insurance Company ("Hartford") (Group Insurance Policy Number GLT-24256), which provided long term disability benefits for eligible employees to The Grand Union Companies.
Pursuant to the Policy, eligible employees are entitled to receive long term disability benefits so long as they are "Totally Disabled" throughout and after the Elimination Period, and as long as the claimant provides Hartford with satisfactory proof of entitlement to said benefits. The Policy states that the term "Disabled means either Totally or Partially Disabled." The Policy defines "Totally Disabled" as:
(1) during the Elimination Period; and
(2) for the next 24 months, you are prevented by disability from doing all the material and substantial duties of your own occupation.
After that, and for as long as you stay Totally Disabled, you are prevented by Disability from doing any occupation or work for which you are or could become qualified by:
The Policy defines the term "Disability" as any "(1) accidental bodily injury; (2) sickness; or (3) pregnancy." Thus, individuals with a disability that prevents them from performing the duties of their own occupation will be entitled to benefits for twenty-four months. After that, the claimant must be unable to perform the duties of any occupation or work which they are qualified, or could become qualified, to perform.
The Policy also provides:
You will be paid benefits if you:
(1) become Totally Disabled while under the Limiting Age;
(2) remain Totally Disabled throughout the Elimination Period;
(3) remain Disabled beyond the Elimination Period; and
(4) submit proof of loss satisfactory to The Hartford. . . .
The Hartford will pay benefits until the first to occur of:
(1) the date you are no longer Disabled;
(2) the date you fail to furnish proof that you are continuously Disabled . . .
On or about June 12, 1988, Plaintiff began her employment by The Grand Union Company as a deli clerk. Incidental to that employment, Plaintiff was covered under the terms of The Grand Union Company's long term disability employee welfare benefit plan, which was fully insured by the Policy issued by Hartford. On March 25, 1994, Plaintiff injured her shoulder and back while lifting a large box of chicken. Plaintiff was awarded Worker's Compensation benefits for this injury.
On January 25, 1995, Hartford received a claim for group long term disability benefits relative to Plaintiff's injury, which included an employer statement, attending physician statement, and other supporting documentation. In the Attending Physician's Statement of Disability (dated January 4, 1995), Dr. Barton Sachs stated that Plaintiff had been diagnosed with "cervical spondylosis [with] cervical discogenic pain syndrome." Dr. Sachs also reported that Plaintiff's subjective symptoms included "cervical pain, facial pain, periorbital pain, left shoulder pain with numbness into left arm," and that the Plaintiff's x-rays and MRI scan were consistent with the diagnosis rendered. While Plaintiff was being treated with a soft cervical collar and physical therapy, Dr. Sachs noted that Plaintiff was scheduled for a cervical discectomy C5-6.
Hartford was aware at this time that Plaintiff was confined to the house, but nonetheless ambulatory. Additionally, Edna Golych, in evaluating the claim, noted that Plaintiff's daily activities were "very limited; son, daughter and her mother do work, can only sit for about 20 minutes."
After receiving these claim documents from Plaintiff, Hartford began processing Plaintiff's claim for long term disability under the Policy, making numerous requests for information from Plaintiff's medical providers. After receiving medical records from Plaintiff's physicians and conducting an interview of Plaintiff, the claim examiner recommended approving Plaintiff's claim for benefits under the Policy. On February 21, 1995, Plaintiff's claim for long term disability benefits was approved by Hartford, retroactive to September 26, 1994 (at the conclusion of the six (6) month elimination period). Hartford's in-house nurse noted, "It is apparent that she is not going to be able to [return to work] at any [time] in the near future and is most probably permanently disabled." Thereafter, Plaintiff continued to receive benefits under the Policy, and would continue to receive benefits so long as she continued to provide Hartford with evidence that she continued to be disabled.
In 1996, Ms. Tucker was awarded social security benefits based upon a finding that she did "not have the residual functional capacity for even sedentary work . . . ." On June 9, 1997, Hartford notified Plaintiff that, effective September 26, 1996, Plaintiff qualified for long term disability benefits under the "any occupation" standard.
In late 2004 or early 2005, Anne Marie Kirner, the specialist assigned to Plaintiff's claim, began a re-examination of Plaintiff's claim for long term disability benefits. Ms. Kirner's reevaluation included a review of an Attending Physician Statement dated October 2004, in which Dr. Ramaswami listed "chronic back pain" as Plaintiff's primary diagnosis and "fibromyalgia" as Plaintiff's secondary diagnosis. Dr. Ramaswami did not specifically list any test results or physical examination findings, although Plaintiff asserts that Dr. Ramaswami relied upon all the medical records in the file. Dr. Ramaswami noted that Plaintiff was most recently treated on October 28, 2004, is treated "as needed." Although Dr. Ramaswami stated that Plaintiff had not been referred to any other physician, surgery had not been performed, and Plaintiff was not hospitalized for this condition, Plaintiff notes that the record indicates that an anterior C5-6 discectomy with decompression and bone grafting from the right iliac crest with instrumentation was performed on January 24, 1996. Dr. Ramaswami also stated "unable for prolonged" next to standing, walking, sitting, lifting/carrying, reaching/working overhead, pushing, pulling, driving, and keyboard use/repetitive hand motion.
Ms. Kirner also reviewed a claimant questionnaire completed by Plaintiff on November 5, 2004, in which Plaintiff asserted that she had the following conditions: cervical disc disease, fibromyalgia pain left shoulder, neck and back, numbness in her neck, shoulder, and arm, and headaches. Plaintiff also stated that her condition had become "progressively" worse "to other parts of the body" and that she was still unable to engage in the types of activities that she engaged in prior to her injury. Plaintiff did not indicate that she was unable to perform her activities of daily living, and confirmed that she had consulted with or been treated by only one physician in the preceding eighteen months--Dr. Ramaswami.
Additionally, Ms. Kirner conducted a telephone interview with Plaintiff on January 13, 2005, during which Plaintiff confirmed that she underwent neck surgery many years prior, and that her condition has become "worse" since that time. Plaintiff stated that she had bilateral hand numbness (though worse in her left hand), and that her back pain made her unable to sit still for long periods of time. Plaintiff confirmed that she was only being treated by Dr. Ramaswami, and was taking Xanax, Ibuprofen, and Tylenol. Plaintiff explained that she was able to drive, but only to the drug store, and that while she was able to ambulate without a cane, she limited herself from moving around too much. Plaintiff also reported that she did not engage in many activities of daily living, such as cooking, laundry, food shopping or yard work, which is all performed by family members.
On January 10, 2005, Ms. Kirner sent a letter to Dr. Ramaswami requesting all medical records regarding Plaintiff from January 1, 2004. She also requested the following:
Also, please provide a brief narrative description of Ms. Tucker's current capabilities and limitations. What is her diagnosis and how you are currently treating her? How does she function on a day to day basis? Does she require assistances ...