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Ramstine v. Hartford Life and Accident Insurance Co.

September 14, 2010

TRUDY L. RAMSTINE, PLAINTIFF,
v.
THE HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY, DEFENDANT.



The opinion of the court was delivered by: Hon. Norman A. Mordue, Chief U.S. District Judge

MEMORANDUM-DECISION AND ORDER

INTRODUCTION

This action under the Employee Retirement Income Security Act ("ERISA"), 29 U.S.C. § 1001, et seq., concerns a Group Insurance Policy, No. GLT-674180 ("Policy"), issued by defendant to plaintiff's former employer, BAE Systems North America ("BAE"). Plaintiff claims defendant wrongfully terminated her waiver of premium benefits under the group life insurance portion of the Policy based on defendant's determination that plaintiff failed to prove she was disabled within the meaning of the applicable Policy provision. The first cause of action of the complaint alleges wrongful denial of benefits, and the second alleges defendant breached its fiduciary duty to plaintiff. Defendant moves (Dkt. No. 24) for summary judgment dismissing the action. Plaintiff cross-moves (Dkt. No. 25) for summary judgment. As set forth below, upon review of the entire administrative record, the Court grants defendant's motion, denies plaintiff's motion, and dismisses the action.

FACTS

Background

On May 20, 2005, plaintiff ceased working as an Operations Associate for BAE due to a herniated cervical disc and neck pain. In July 2005, plaintiff's neurosurgeon, Daniel D. Galyon, M.D., performed on plaintiff an "anterior cervical diskectomy with fusion and plating and interbody fixation from C5 to C6 with the use of Tisseel for incidental durotomy." Defendant approved plaintiff's long term disability ("LTD") benefit claim on January 20, 2006, retroactive to November 19, 2005 (the

The undisputed facts set forth below are drawn from the administrative record.*fn1 end of the 180-day elimination period), and notified her that she may also be eligible for waiver of premium benefits under the group life insurance portion of the Policy. On July 20, 2007, plaintiff underwent surgical repair of a left rotator cuff tear by Mark V. Wilson, M.D., an orthopedic surgeon. Defendant notified plaintiff on October 22, 2007 that her waiver of premium benefits had been approved, effective February 20, 2006.

Subsequently, defendant terminated plaintiff's waiver of premium benefits effective March 7, 2008. In the termination letter, defendant summarized recent medical reports it had received from Drs. Wilson and Galyon, as well as from plaintiff's family doctor, Kazimieras A. Snieska, M.D. Based on these reports, defendant concluded that plaintiff "should be able to return to work part time on light duty to any occupation" with specified restrictions, and that therefore "the evidence obtained in support of [plaintiff's] claim does not establish that [she] continue[s] to meet the definition of Disabled" in the waiver of premium benefits portion of the Policy.

On March 18, 2008, plaintiff appealed defendant's termination of her waiver of premium benefits. On May 27, 2008, defendant denied the appeal and upheld the termination of waiver of premium benefits. This action followed.

The Policy

The Policy issued by defendant to BAE, plaintiff's former employer, provides benefits for eligible employees including LTD benefits and life insurance. The Policy specifically provides that defendant has "full discretion and authority to determine eligibility for benefits and to construe and interpret all terms and provisions of the Policy."

For purposes of LTD benefits, the Policy defines "disability" as follows:

Disability or Disabled means that during the Elimination Period and for the next 24 months you are prevented by:

1. accidental bodily injury;

2. sickness; *** 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. (Emphasis added.) It defines "Any Occupation" as follows:

Any Occupation means an occupation for which you are qualified by education, training or experience, and that has an earnings potential greater than an amount equal to the lesser of the product of your Indexed pre-disability Earnings and the Benefit Percentage for which you enrolled and the Maximum Monthly Benefit shown in the Schedule of Insurance. (Emphasis added.) Defendant found plaintiff eligible for LTD benefits under the "Your Occupation" provision as of November 19, 2005 (after the 180-day elimination period). After the 24-month period elapsed on November 19, 2007, defendant found plaintiff eligible for LTD benefits under the "Any Occupation" provision.

The Policy also provides for the waiver of life insurance premiums so long as the insured meets the definition of "disabled" for purposes of waiver of premium benefits. The waiver of premium provision in the group life insurance portion of the Policy provides:

When will We waive premium?

We will waive premium after proof that You are Disabled is provided by an attending physician licensed to practice in the United States and We approve the proof. ***

The Policy definition of "disabled" as it relates to waiver of premium benefits reads:

Disabled means that You have a condition that prevents You from doing any work for which You are or could become qualified by education, training or experience and it is expected that this condition will last for at least nine consecutive months from Your last day of work or You have been diagnosed with a life expectancy of 6 months or less.

(Emphasis added.) If a claimant is no longer disabled, the Policy provides as follows:

If, for any reason, You are no longer Disabled, Your premium will no longer be waived. On that date, You may or may not return to work.

Defendant notified plaintiff on October 22, 2007 that her waiver of premium benefits had been approved, effective February 20, 2006 (that is, 90 days after the effective date for LTD benefits as provided in the Policy).

Termination of Waiver of Premium Benefits

The record evidence in connection with defendant's termination of waiver of premium benefits as of March 7, 2008 includes the following. Defendant obtained an Attending Physician's Statement of Functionality from Dr. Galyon, dated December 20, 2007, noting that plaintiff's primary diagnosis remained "residual neck pain following cervical fusion on 7/20/05"; that her "gait remains stable w/ use of cane, remains limited in forward flexion & extension"; that she took Vicodin for her condition; that in the "general workplace environment" she was able to sit for two hours at a time, to stand for two hours at a time, and to walk for two hours at a time; and that she is able occasionally to lift or carry up to -- but no more than -- ten pounds with both hands, finger/handle with both hands, bend at the waist, kneel or stoop, drive, and reach at all levels with both hands.

On February 7, 2008, defendant requested updated information from plaintiff's physicians.

In his response, marked "received" by defendant on February 18, 2008 ("February 18, 2008 Report"), Dr. Galyon commented that he had last examined plaintiff on February 4, 2008; that she had decreased range of motion in her cervical spine and muscle spasms; that he scheduled a three-month follow-up examination of plaintiff; that no treatments were planned; that her prognosis was "fair"; that her activities were limited by her need to change between sitting and standing every 30 minutes (as needed); and that she should not lift, push or pull more than 20 pounds. In response to the question whether plaintiff was "capable of performing part time work (any occupation) on a reasonable and consistent basis beginning 3/1/2008" he did not check "yes" or "no" but wrote: "She does have other medical problems including shoulder surgery." He added: "I would recommend a FCE for her functional status and if she would be employable."

In response to defendant's request for updated information, Dr. Wilson submitted a report, received by defendant on February 14, 2008 ("February 14, 2008 Report"), stating that he had last examined plaintiff on September 28, 2007 with regard to her left shoulder and on January 29, 2008 with regard to her right knee. Dr. Wilson stated, with respect to her left shoulder, that plaintiff's range of motion had improved, though she still had some pain; that she was receiving physical therapy for the shoulder; and that her prognosis was "good." With respect to her right knee, Dr. Wilson stated that she had increased pain, patella femoral pain and crepitation; that she was receiving a synthetic lubricant injection for her knee; and that her prognosis was "guarded." Dr. Wilson stated that plaintiff should not engage in any lifting, pushing or pulling of more than 10 pounds, should not work overhead, should not stand or walk for more than 45 minutes at a time (without a sitting 10-15 minute rest), and should not climb. In response to the question whether plaintiff "capable of performing part time work (any occupation) on a reasonable and consistent basis beginning 3/1/2008" he checked "Yes" and wrote "light duty." He added that plaintiff "[s]hould be able to return to light duty and increase hours in a controlled fashion."

Kazimieras A. Snieska, M.D., plaintiff's family doctor, wrote to defendant on February 22, 2008, stating that he had last examined plaintiff on March 2007, at which time she complained that her legs were very weak and "giving out on her"; that she had "suffered a contusion to her knee in November; and that she had been "complaining of weakness in the right knee and also pain in the shoulder since that time." He stated that she was recently diagnosed as having a rotator cuff tear in the right shoulder and that her treatment was provided by Drs. Wilson and Galyon. He added: "I truly feel that this patient has been damaged permanently through all of her injuries. I do not think that she is capable of returning to work in any capacity at this time."

On March 7, 2008, defendant issued a letter referring to the physician's reports and terminating plaintiff's waiver of premium benefits, stating:

Based on the information provided by your doctors above, you should be able to return to work part time on light duty to any occupation with the following restrictions: refrain from lifting with your left shoulder, no pushing or pulling greater than 10 [pounds], no working overhead, no prolonged standing or walking greater than 45 minutes without sitting ...


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