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Green v. Hartford Life and Accident Insurance Co.

September 30, 2010

MARY-LOU A. GREEN, PLAINTIFF,
v.
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY, DEFENDANT.



The opinion of the court was delivered by: Scullin, Senior Judge

MEMORANDUM-DECISION AND ORDER

I. INTRODUCTION

Plaintiff was employed as a special education teacher for Enable until she went on medical leave on June 14, 1991. When she went on leave, Plaintiff was covered by a long-term disability policy ("Policy") that Defendant now administers and on which Defendant pays benefits.*fn1 Plaintiff ceased working on June 14, 1991, due to complaints of fibromyalgia, fatigue, and irritable bowel syndrome and began receiving long-term disability benefits on December 12, 1991, under the Policy's "own occupation" disability provision. On December 13, 1993, Plaintiff continued receiving benefits under the Policy's "any occupation" disability provision.

Plaintiff received payment under the Policy until March 28, 2007, at which time Defendant sent her a termination letter. On April 23, 2007, Plaintiff notified Defendant that she was appealing the termination decision. On July 25, 2007, Plaintiff submitted her appeal. Defendant issued a final decision on October 16, 2007, upholding its initial decision; and Plaintiff commenced this litigation on November 30, 2007.

In her amended complaint, Plaintiff asserts the following two claims against Defendant under the Employee Retirement Income Security Act ("ERISA"): (1) failure to provide a full and fair review of her long-term disability claim pursuant to 29 U.S.C. § 1133 and (2) wrongful termination of her long-term disability benefits pursuant to 29 U.S.C. § 1132(a)(1)(b).

II. DISCUSSION

A. Standard Of Review And The Record Before The Court

"Summary judgment is appropriate if there is no genuine issue as to any material fact and the moving party is entitled to judgment as a matter of law." Holcomb v. Iona Coll., 521 F.3d 130, 137 (2d Cir. 2008) (citing Fed. R. Civ P. 56(c)). Where a benefit plan does not give the administrator or fiduciary discretionary authority to determine eligibility for benefits or to construe the terms of the plan, a district court reviewing a denial of benefits applies a de novo standard of review. See Lijoi v. Cont'l Cas. Co., 414 F. Supp. 2d 228, 237 (E.D.N.Y. 2006) (citing Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115, 109 S.Ct. 948, 103 L.Ed. 2d 80 (1989)); see also DeFelice v. Am. Int'l Life Assurance Co. of N.Y., 112 F.3d 61, 66-67 (2d Cir. 1997).

In this case, the parties agree that the Plan does not grant any discretionary authority to Defendant and that, therefore, the de novo standard of review applies. When applying this standard of review, the court reviews all aspects of the denial including factual issues to determine whether the claimant should receive the requested relief. See Lijoi, 414 F. Supp. 2d at 238 (citations omitted). Plaintiff has the burden to prove, by a preponderance of the evidence, that she is totally disabled. See Paese v. Hartford Life & Accident Ins. Co., 449 F.3d 435, 441 (2d Cir. 2006). The record on de novo review is limited to the record before the claims administrator unless the court finds good cause to consider additional evidence. See DeFelice, 112 F.3d at 66-67. Since neither party has argued that good cause exists to consider additional evidence nor have they submitted any additional evidence, the Court will limit its review to the record that was before the claims administrator.

B. Plaintiff's § 1133 Claim

ERISA requires that, when a benefit plan denies a claim for benefits, it must "provide adequate notice in writing . . . setting forth the specific reasons for such denial, written in a manner calculated to be understood by the participant[.]" 29 U.S.C. § 1133(1). Such notice applies to "any adverse benefit determination" and must include "(i) The specific reason or reasons for the adverse determination; . . . [and] (iii) A description of any additional material or information necessary for the claimant to perfect the claim and an explanation of why such material is necessary . . . ." 29 C.F.R. § 2560.503-1(g)(1).

The Second Circuit requires substantial compliance to meet § 1133's full and fair review requirement. See Cook v. N.Y. Times Co. Long-Term Disability Plan, No. 02 Civ. 9154, 2004 WL 203111, *6 (S.D.N.Y. Jan. 30, 2004) (citing Burke v. Kodak Retirement Income Plan, 336 F.3d 103, 107-09 (2d Cir. 2003)). To assess whether notice was adequate, precise compliance is not required "as long as the plan administrator has substantially complied with such regulations and has provided the beneficiary with sufficient information to appeal the denial." Camarda v. Pan Am. World Airways, Inc., 956 F. Supp. 299, 311 (E.D.N.Y. 1997). "Substantial compliance means that the beneficiary was 'supplied with a statement of reasons that, under the circumstances of the case, permitted a sufficiently clear understanding of the administrator's position to permit effective review.'" Cook, 2004 WL 20311, at *6 (quotation omitted).

In the termination letter that Defendant sent to Plaintiff, there were several references to the lack of objective evidence to support Plaintiff's long-term disability claim. When discussing Dr. Forbes' and Dr. Hyla's office notes, Defendant noted that physical findings were normal or not mentioned, respectively. See Affidavit of Nancy Deskins dated October 9, 2008 ("Deskins Aff."), Exhibit "B" ("Claim File") at 155. When discussing Dr. Marion's review, the letter noted that Dr. Forbes agreed that there was "'no specific objective impairment;'" that "[n]either Dr. Hart [n]or Dr. Forbes were able to provide any quantitative findings supporting . . . impairment;" and that Dr. Marion opined that "there remains no objective impairment to support any specific objective occupational restrictions/limitations." See id. at 156.

Although the termination letter never directly stated that the lack of objective evidence was the key issue with respect to Plaintiff's claim, the Court finds that the letter, in language that Plaintiff was capable of understanding, made it clear that the lack of objective evidence was the key reason for Defendant's determination with respect to Plaintiff's limitations. Therefore, the Court concludes that Defendant's termination letter substantially complies with the requirement that the notice provide the claimant with the reasons for the termination of her benefits.

Alternatively, Plaintiff argues that the termination letter did not include a description of any additional information or material she needed to submit to perfect her claim and did not include an explanation as to why such material or information was necessary. Although Defendant's letter contains a general instruction that Plaintiff could submit additional information, it is clear that Defendant did not deny Plaintiff's claim because any specific information was missing. See, e.g., Camarda, 956 F. Supp. at 311 (discussing denial because claimant failed to provide plan-required information about Social Security benefits). Based on the record, the Court concludes that Defendant did not deny Plaintiff's claim because any specific information was missing that would trigger the ...


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