Hightower v. Hartford Life & Accident Ins. Co., CASE No. 3:11-cv-1619(RNC)

RANDALL HIGHTOWER, Plaintiff, v. HARTFORD LIFE & ACCIDENT INSURANCE CO., Defendant.

CASE No. 3:11-cv-1619(RNC)

UNITED STATES DISTRICT COURT DISTRICT OF CONNECTICUT

So ordered: September 30, 2013

RULING AND ORDER

Plaintiff, Randall Hightower, brings this action under the Employee Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. § 1331 et seq, against the claims fiduciary of his employer's disability insurance plan, Hartford Life and Accident Insurance Company ("Hartford"). Plaintiff alleges that Hartford's termination of his long-term disability benefits and failure to provide him with certain documents relevant to his claim both violate ERISA. Hartford has filed a motion for summary judgment (ECF No. 34), arguing that its administrative determination was reasonable and supported by substantial evidence in the administrative record and that ERISA's disclosure requirement does not apply because it is not a "plan administrator" as defined by the statute. Plaintiff has filed a cross-motion for summary judgment (ECF No. 39). For the reasons that follow, Hartford's motion is granted and plaintiff's motion is denied.

I. Background

In opposing Hartford's motion for summary judgment, plaintiff has failed to file a Local Rule 56(a)2 Statement. Accordingly, the material facts set forth in the defendant's Local Rule 56(a)1 Statement (ECF No. 35), taken from the administrative record, are deemed admitted. See Sanchez v. Univ. of Conn. Health Care, 292 F. Supp. 2d 385, 390 (D. Conn. 2003).

A. The Plan

Plaintiff began working for the American International Group ("AIG") in 2006 as a Workman's Compensation Claims Reviewer. This occupation required plaintiff to sit for seven hours, stand for half an hour, and walk for one hour, with the opportunity to alternate sitting and standing as needed. Administrative Record ("AR") 422. AIG employees are covered by a Group Long Term Disability Plan ("the Plan") that provides long-term disability ("LTD") benefits under an insurance policy issued to AIG by Hartford. See AR 461-500. AIG is the sole "Plan Administrator" named in the Plan. AR 494. The Plan designates Hartford as its "claims fiduciary" and grants Hartford "full discretion and authority to determine eligibility for benefits and to construe and interpret [the Plan's] terms and provisions." Id.

The Plan states, in pertinent part: "Disability or Disabled means . . . you are prevented from performing one or more of the Essential Duties of Your Occupation, and as a result your CurrentMonthly Earnings are less than 80% of your Indexed Pre-disability earnings." AR 481. The Plan requires employees to provide documentation of their disability that is "satisfactory to [Hartford]" and authorizes Hartford to require employees to be examined by a medical professional of Hartford's choice to assist with Hartford's disability determination. AR 477. The Plan also provides that Hartford "will terminate benefit payments on the first to occur of: 1. the date [the employee is] no longer disabled as defined; . . . [or] 7. the date no further benefits are payable under any provision in [the Plan] that limits benefits duration." AR 469. Plan benefits payable for a mental illness are limited to "a total of 24 months for all such Disabilities during [the insured's] lifetime." Id.

B. Plaintiff's Initial Disability Claim

In May 2008, plaintiff stopped working for AIG when he was hospitalized for a mental illness. AR 443. Plaintiff's treating physician, Dr. Ellyssa Eror, diagnosed him with bipolar disorder and schizoaffective disorder. AR 436. Plaintiff applied for disability benefits in June 2008 and Hartford approved his claim in November of that year stating "[w]ith your benefits commencing on November 10, 2008, no benefits will be payable beyond November 9, 2010." AR 132.

On January 9, 2009, Dr. Eror wrote that plaintiff was "socially and cognitively impaired for any work activity," butthat no other medical condition impacted on his ability to function. AR 413. In January 2010, Hartford received an Attending Physician's Statement ("APS") from Dr. Eror noting that plaintiff was reporting back pain, AR 355, as well as a report dated August 2009 from a neurosurgeon, Dr. Kvam, stating that plaintiff had been referred by Dr. Eror with "significant localized low back pain." AR 359. The Kvam report also stated that plaintiff was a "fit, muscular . . . man" and that although "the patient was prescribed physical therapy, [he] evidently did not attend. He found the co-pay prohibitive." Id.

On May 19, 2010, Hartford again notified plaintiff that the twenty-four month limitation period for his mental illness disability benefits would be reached on November 9 and advised him to "immediately provide [Hartford] with any evidence of [a] disabling physical condition" that would entitle him to additional benefits. AR 100. Hartford also notified plaintiff of his right to administratively appeal the termination of his benefits. Id.

Plaintiff challenged Hartford's 24-month limitation on mental illness benefits in a letter dated May 27, 2010, arguing that "a new federal law and mandate has been passed to arrest such practices." AR 346-47. Plaintiff did not mention any physical disability or submit any new medical evidence. See id. Treating the letter as an administrative appeal of the impendingtermination of plaintiff's benefits, Hartford reviewed his claim and issued an appeal decision on June 22, 2010, reaffirming that the policy limitation "will have been met as of 11/09/10 and no further benefits will be payable after that date." AR 97. On September 20, 2010, plaintiff wrote to Hartford to contest its "capricious appeal decision" and characterized his disability claim as "due to [his] L5/S1 hernia" and "chronic ongoing back pain." AR 222. In this letter, plaintiff referred Hartford to another of his attending physicians, Dr. Fejos, "to request any medical information [necessary] . . . to continue [his] claim." Id.

In a letter dated September 29, 2010, Hartford informed plaintiff that "Section 502(a) of [ERISA] entitles [employees] to one appeal of termination of benefits" and declined to consider his back pain claim on the grounds that his appeal had already been processed. AR 95. In response, plaintiff provided Hartford with a magnetic resonance imaging ("MRI") report dated October 3, 2010, and a letter he had sent to Dr. Eror noting a referral to a surgeon, Dr. Spero, for a possible discectomy and claiming that Hartford had prematurely processed his appeal and overlooked his "medical diagnosis for the disc herniation[] and chronic pain preventing [him] from being able to sit, stand or walk for any significant amount of time over the past 2 years." AR 223. Hartford's claim management report from November 3, 2010 notesthat the "MRI submitted by [claimant] indicates positive findings" of "disc herniation" "but [does] not provide physical restrictions and or limitations preventing sed[entary]/light level work." AR 38. Hartford sent plaintiff another letter on November 4, 2010, reiterating its position that he had exhausted the opportunity to appeal the termination of his benefits. See AR 95.

Plaintiff persisted in challenging the termination of his benefits, informing a supervisor in Hartford's claim management department that he wanted his benefits reinstated and noting that he had contacted the Department of Labor and would contact his attorney. AR 38. On November 9, 2010, the day plaintiff's mental illness disability benefits expired, Hartford agreed to gather further evidence regarding plaintiff's back condition and review his disability claim. AR 37, 93. Hartford requested medical records from Dr. Fejos and Dr. Spero and agreed to continue plaintiff's benefits under a reservation of rights while it investigated his claim. AR 92.

C. Investigation Into Plaintiff's Physical Disability Claim

The administrative record indicates that plaintiff first went to Dr. Fejos on July 19, 2010 for an evaluation of low back pain he claimed originated from an injury in January 2009. AR 233. Dr. Fejos's intake notes show that plaintiff had an MRI on October 1, 2009, which revealed evidence of a small L5-S1 discherniation. Id. Dr. Fejos recommended a trial of epidural steroid injections. Id. Dr. Fejos's case notes from August 24, 2010, report no improvement following two steroid injections and recommend physical therapy for plaintiff, noting that "he has not had [physical therapy] in the past for his symptoms." AR 231. Dr. Fejos's notes state that plaintiff reported his low back pain to be "currently a 7 out of 10" on the pain scale, but that he was "in no acute distress" and that he would be referred to Dr. Spero for a surgical consultation. AR 232-33. An APS of functionality prepared by a physician's assistant ("PA") in Dr. Fejos's office, Tammy Gaines, concluded that in a general workplace environment plaintiff could sit, stand and walk for one hour at a time each, for a total of two hours a day each; lift/carry up to ten pounds frequently; occasionally bend at the waist; with no restrictions on handling, fingering or reaching above shoulder or waist level. AR 247.

Dr. Spero's intake notes from October 27, 2010 state that plaintiff claimed he injured his back in January 2009 while lifting weights. AR 216. Dr. Spero diagnosed plaintiff with a herniated disc as well as lumbar spondylosis and radiculitis and recommended that plaintiff undergo a "left L5-S1 discectomy." AR 218-219. Dr. Spero advised the plaintiff that a discectomy would significantly reduce his pain, but plaintiff never underwent surgery. See AR 172-73.

On January 4, 2011, Hartford asked plaintiff to sign a form authorizing it to obtain his medical information in connection with an independent medical examination ("IME"). AR 88. Plaintiff sent a letter in response stating that, "due to the Schizo-effective disorder and the paranoia associated with the disorder; I will not submit [to] an overreaching medical...