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Fredericks v. Hartford Life Insurance Co.

January 23, 2009



Plaintiff Terri Fredericks commenced this action on October 25, 2005, against Defendant Hartford Life Insurance Company, pursuant to the Employee Retirement Income Security Act of 1974 as amended ("ERISA"), 28 U.S.C. § 1132. Compl. (Dkt. No. 1).*fn1 Plaintiff asserts two claims: that Defendant wrongfully terminated Plaintiff's long term disability benefits and that Defendant breached its fiduciary duty to Plaintiff. Both parties have moved for summary judgment on the administrative record, pursuant to Rule 56 of the Federal Rules of Civil Procedure. For the reasons discussed below, Defendant's Motion is granted and Plaintiff's motion is denied.


A. Plaintiff's Long Term Disability Policy with Defendant

In November 2001, Plaintiff was employed by Univera Healthcare-CNY, Inc., now known as Health Services Medical Corporation of Central New York. Inc., as a medical secretary. Compl. ¶ 7. Incidental to her employment, she was covered under the terms of the Group Insurance Policy ("Policy") issued by Defendant to Health Services Medical Group. See Policy at 3 (Dkt. No. 33, Attach. 2).

The Policy provides long term disability benefits for eligible employees of Health Services Medical Group during periods that such employees are disabled (as that term is defined in the policy), after the Elimination Period prescribed in the Policy, and as long as the claimant provides Defendant with satisfactory proof that the claimant remains disabled. See generally Policy.

The Policy defines "disability" or disabled" as meaning that [D]uring the Elimination Period and for the next 24 months you are prevented by:

(1) accidental bodily injury;

(2) sickness;

(3) Mental Illness;

(4) Substance Abuse; or

(5) pregnancy, from performing one or more of the Essential Duties of Your Occupation, and as a result your Current Monthly Earnings are no more than 80% of your Indexed Pre-Disability Earnings.

After that, you must be so prevented from performing one or more of the Essential Duties of Any Occupation. . . . .

Policy at 6. The Policy defines "Essential Duty" as a duty that "1. is substantial, not incidental; 2. is fundamental or inherent to the occupation; and 3. can not be reasonably omitted or changed." Id. The Policy defines "Your Occupation" as "your occupation as it is recognized in the general workforce . . . [and] does not mean the specific job you are performing for a specific employer or at a specific location." Id. at 12.

A claimant's entitlement to benefits is conditioned, inter alia, upon the claimant's providing satisfactory Proof of Loss to Defendant. Policy at 19. Under the Policy, Proof of Loss may include but is not limited to the following:

1. documentation of:

a) the date your Disability began;

b) the cause of your Disability;

c) the prognosis of your Disability;

d) your Earnings or income . . . ; and

e) evidence that you are under the Regular Care of a physician;

2. any and all medical information, including x-ray films and photocopies of medical records, including histories, physical, mental or diagnostic examinations and treatment notes;

All proof submitted must be satisfactory to us.

Policy at 25. Proof of loss must be sent within 30 days after the start of the period for which Defendant owes payment, and Defendant "may require, at reasonable intervals, additional written Proofs of Loss throughout [the claimant's] Disability." Id. If the claimant fails to provide timely proof of loss, such failure will not affect the claim if "it was not possible to give proof within the required time" and "Proof of Loss is given as soon as possible." Id.

Benefits terminate at the first of various occurrences, including "the date [the claimant is] no longer Disabled as defined [in the Policy]" or "the date [the claimant] fail[s] to furnish Proof of Loss, when requested by [Defendant]." Policy at 20. The Policy provides that Defendant has "full discretion and authority to determine eligibility for benefits and to construe and interpret all terms and provisions of the Group Insurance Policy." Id. at 28.

B. Plaintiff's Illness and Claim for Benefits

In August 2001, Plaintiff discovered a lump in her upper leg. Administrative Record ("AR") at 329. As a result, Plaintiff underwent inpatient chemotherapy treatments. Id. Plaintiff underwent surgery on February 19, 2002, and the surgeon removed a large soft tissue mass from Plaintiff's left buttock. Id. at 321. Plaintiff last worked on November 13, 2001. Id. at 329.

In February 2002, Plaintiff applied to Defendant for long term disability benefits under the Policy. AR at 326-34. Defendant approved Plaintiff's benefits claim in a letter dated April 12, 2002. Id. at 301-03. Defendant calculated Plaintiff's disability date as November 14, 2002, and Plaintiff's benefits became effective retroactive to January 13, 2002 (upon conclusion of the 60 day elimination period). Id. at 303.

Subsequent to the approval of Plaintiff's long term disability benefit claim, Defendant's claims examiner periodically reviewed Plaintiff's condition to assess whether she continued to qualify for benefits under the Policy. See generally AR. In March 2003, Defendant's claims examiner sent a letter to Plaintiff's treating physician, Dr. Timothy Damron, M.D., requesting that Dr. Damron provide Defendant with office notes for the previous six months, including any test reports, and that Dr. Damron complete a Physical Capacities Evaluation Form for Plaintiff. Id. at 269. Dr. Damron provided the requested information. Id. at 160-74. On July 17, 2003, Defendant's claims examiner sent a letter to Dr. Damron seeking office notes and test reports for Plaintiff since March, as well as an updated Physical Capacities Evaluation Form. Id. at 149. The claims examiner also sent a letter to Plaintiff on July 17, 2003, notifying her of the request sent to Dr. Damron, and asking ...

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