Lewis v. Itt Hartford Life and Acc. Ins. Co.

395 F.Supp.2d 1053

Judith A. LEWIS, Plaintiff, v. ITT HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY, Defendant.

No. 04-1116-JTM.

United States District Court, D. Kansas.

October 11, 2005.

Jack R. Shelton, Martin E. Updegraff, Wichita, KS, for Plaintiff.

Charles R. Hay, Goodell, Stratton, Edmonds & Palmer, Topeka, KS, for Defendant.

MEMORANDUM AND ORDER

MARTEN, District Judge.

This matter comes before the court on the parties' cross-motions for summary judgment (Dkt.Nos.30, 32). Plaintiff argues that she did not receive a full and fair review and that substantial evidence does not support defendant Hartford's termination decision. Defendant objects to these assertions and argue that Hartford properly terminated plaintiff's benefits under the terms of her plan. Further, defendant argues that its review procedures complied with Department of Labor Regulations and ERISA. For the reasons set forth herein, the court grants in part and denies in part the cross-motions for summary judgment.

I. FINDINGS OF FACT

Ms. Lewis is a beneficiary under the Long-Term Disability Plan (hereafter "Plan"). The Plan is a long-term disability group insurance policy issued to Columbia/HCA Healthcare Corporation, which provided coverage to plaintiff when she was an employee of Wesley Medical Center. Hartford is the insurance carrier for the Plan, Policy Number ITT Hartford Policy GLT 034174 and made all decisions relating to Ms. Lewis' claim for long-term disability benefits under the Plan.

In pertinent part, the policy defined disability with reference to the first 24 months after the elimination period and any period after the first 24 months as follows:

Total Disability or Totally Disabled means that:

(1) during the Elimination Period; and

(2) for the next 24 months, you are prevented by;

(a) accidental bodily injury

(b) sickness;

(c) mental illness;

(d) substance abuse; or

(e) pregnancy,

from performing the essential duties of your occupation, and as a result you are earning less than 20% of your Pre-disability Earnings, unless engaged in a program of Rehabilitative Employment approved by us.

After that, you must be so prevented from performing the essential duties of any occupation for which you are qualified by education, training, or experience.

Your failure to pass a physical examination required to maintain license to perform the duties of your occupation does not alone mean that you are Totally Disabled.

Adm. R. 20. The Plan provided for termination of benefits on the date that an employee participant was no longer disabled or failed to furnish proof, when requested by Hartford, of continued disability. The Plan also defined the authority of Hartford to interpret the Plan and the factual circumstances of a particular claim: "The Hartford has full discretion and authority to determine eligibility for benefits and to construe and interpret all terms and provisions of the Group Insurance Policy." Adm. R. 34.

On May 16, 1995, while employed by Wesley Medical Center, the plaintiff suffered what was termed a cardiovascular accident and ceased work. On that date, Ms. Lewis became disabled and eligible for long-term disability benefits under the Plan, subject to an elimination period. She began receiving disability benefits effective November 1995.

By letter dated February 25, 2003, Hartford notified the plaintiff that it wished to update its records as to her continuing eligibility for disability payments. Adm. R. 236. By letter dated April 10, 2003 to Dr. James Logan, the plaintiff's attending physician, Hartford requested copies of medical records and specifically inquired "How does the patient's condition impair their [sic] ability to work?" Adm. R. 221. Dr. Logan's handwritten response to this was "Mild hemiparesis and anxiety." Adm. R. 218. Dr. Logan completed a Physician's Statement of Continued Disability which he signed March 19, 2003. No comment was made with reference to a question as to psychiatric impairment. He described her condition as follows:

Primary diagnosis CVA secondary diagnosis L hemiparesis subjective symptoms L side weakness Physical examination findings: weak on L side

Impairment: standing ok, walking ok, slightly off balance sitting ok Lifting/carrying: reaching/working overhead: Pushing: Pulling: a little weak on L side; driving: ok Keyboard use/repetitive hand motion: unknown If physical or psychiatric limitations exist, how long do you feel limitations will last? She has mild anxiety.

Adm. R. 231-233.

In addition, Hartford received on March 25, 2003, a questionnaire completed by the plaintiff. In response to a question requesting that the plaintiff "describe [her] current medical condition or conditions (including the specific limitations or restrictions they place on your ability to work)," the plaintiff stated only "weakness left arm & leg — headaches — fatigue." Adm. R. 225. She also described her ability to do "the types of activities that you do during the course of a typical day" (Adm. R. 225, ¶ 2) and hobbies. She responded in the negative to an inquiry as to whether she had cognitive impairment that rendered her unable to perform common tasks such as using the phone, money management or medication management. Adm. R. 225-27.

By letter dated May 13, 2003, Hartford requested that the plaintiff complete a form entitled work and educational history. Adm. R. 199. Plaintiff's response to questions about her education indicated she is a high school graduate and attended Friends University in Wichita but did not graduate. Her work experience was described as follows: from 1970 through 1977 she was an office manager, production coordinator and secretary; from 1977 through 1979 she was a sales clerk of industrial tools; from 1979 through 1980 she was a buyer of materials needed in manufacturing construction machinery; from 1981 through 1982 she was an office manager, which included secretarial, bookkeeping, buying materials, payroll and monthly reports. Her most recent employment from February 1984 to the date of her CVA was a buyer at Wesley Medical Center and her duties included purchasing medical and non-medical items. Adm. R. 134-135.

As a part of its review, Hartford referred the medical record to Medical Advisory Group, LLC for an independent medical review. Adm. R. 181. By letter dated June 3, 2003, the Medical Advisory Group advised Hartford that the file had been assigned to Internal Medicine Specialist Coleman Levin, M.D., for such review. Adm. R. 180. Dr. Levin contacted Dr. Logan to clarify the plaintiff's physical and functional capabilities for employment. By letter dated June 13, 2003 to Dr. Logan, Dr. Levin summarized the conversation to the effect that Dr. Logan believed that the plaintiff "had the physical capacity to perform a sedentary occupation" and "recommended a job without undue stress." The letter requested that Dr. Logan approve it and return a copy to Dr. Levin, but Dr. Logan failed to do so. Adm. R. 173. Dr. Levin then prepared and submitted to Hartford a detailed medical report dated June 13, 2003 summarizing Dr. Logan's medical records and other related records concluding as follows:

Ms. Lewis is a 59-year-old woman who had a right temporal lobe CVA in 1995 with residual mild left hemiparesis.

. . . . .

In 2001, she had three episodes of transient left facial weakness and episodes of slurred speech. The medical record reveals no recurrence of these events over the past 18 months. Work-up in December of 2001, revealed a negative carotid sonogram and a normal CT scan of the brain. In December 2002, the claimant had a 15-minute period of unresponsiveness while eating a meal with friend. There is no reporting of any neurological findings and no report of recurrent episodes of unresponsiveness.

It is my opinion that although the above described neurological episodes are worrisome and may presage a future nervous system event, the history of their having occurred does not preclude the claimant's ability to perform full-time employment. Likewise, the mild left-sided weakness from the CVA in 1995 would not, in my opinion, prevent Ms. Lewis from performing a sedentary occupation.

I agree with Dr. Logan that Ms. Lewis currently has the physical capacity to perform a sedentary occupation.

CONCLUSION: Based on my review of the medical record and my conversation with the claimant's primary care physician, Dr. James E. Logan, it is my opinion that Ms. Lewis has the physical capacity to meet the demands of a sedentary occupation as defined in the Dictionary of Occupational Titles of the U.S. Department of Labor. I believe her restriction to a sedentary occupation with minimal ambulation is permanent. Due to Ms. Lewis' reported anxious state, I believe she would have the best opportunity for employment success if she worked in a job without undue stress.

Adm. R. 174-176 (emphasis added).

Hartford then referred the file to its Vocational Department for an employability analysis. Adm. R. 133. This resulted in an employability analysis dated June 27, 2003 outlining the plaintiff's education, training and work history and determining that her transferable skills would allow her to perform a number of sedentary jobs. The report drew heavily upon the Dictionary of Occupational Titles published by the U.S. Department of Labor. The report concluded as follows:

Analysis Results:

As a Buyer, Ms. Lewis was responsible for purchasing, scheduling communication of medical and non-medical items. She also worked as a procurer of all materials needed in manufacturing of construction machinery. As an Office Manager, she was responsible for secretarial duties, bookkeeping, processing payroll, preparing monthly reports and purchasing materials. The transferable skills, math skills, bookkeeping skills, following instructions and the ability to perform multi-tasking, reading and verbal communications skills. The vocational implication is semi-skilled to unskilled jobs.

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