Papadopoulos v. Hartford Life Ins. Co.

379 F.Supp.2d 117

Pericles PAPADOPOULOS, Plaintiff, v. The HARTFORD LIFE INSURANCE COMPANY, Defendant.

No. CIV.A. 03-12010NMG.

United States District Court, D. Massachusetts.

July 19, 2005.

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Donald J. Correa, Quinn & Correa, Plymouth, MA, for Pericles Papadopoulos, Plaintiff.

David B. Crevier, Crevier & Ryan LLP, Springfield, MA, for Hartford Life Insurance Companies, Defendant.

Theodore F. Glockner, Crevier & Ryan, LLP, Springfield, MA, for Hartford Life Insurance Companies, Defendant.

MEMORANDUM & ORDER

GORTON, District Judge.

In the instant ERISA dispute, Pericles Papadopoulos ("Papadopoulos") alleges that his long term disability benefits were wrongfully terminated by the Hartford Life Insurance Company ("Hartford"). Papadopoulos now moves for leave to amend the complaint and both parties move for summary judgment.

I. Factual Background

A. The Plan

Fidelity Investments ("Fidelity") maintains a long term disability benefits plan ("the Plan") for its employees which is insured by Hartford. The Plan documentation states that Hartford is the administrator and that it:

has full discretion and authority to determine eligibility for benefits and to construe and interpret all terms and provisions of the Groups Insurance Policy.

Under the Plan, a participant is entitled to benefits if he or she is "Totally Disabled", which is defined as follows:

(a) during the Elimination Period; and

(b) for the next 24 months, you are prevented by Disability from doing all the material and substantial duties of your own occupation on a full-time basis. After that, and for as long as you remain Totally Disabled, you are prevented by Disability from doing any occupation or work for which you are or could become qualified by training, education, or experience.

The "Elimination Period" is defined as "[t]he first 90 days of any one period of Total Disability". "Disability" is defined as "any accidental bodily injury, sickness or pregnancy".

Thus, the Plan establishes a two-period system. During the first period (90-day Elimination Period plus 24 months thereafter), to be eligible for coverage the claimant must be unable to perform his own occupation. After that, the claimant must be prevented, by Disability, "from doing any occupation or work for which [he is] or could become qualified by training, education, or experience" ("the Any Occupation Period"). Benefits cease on the earlier of the date that the relevant condition is no longer satisfied or "the date [the claimant] refuse[s] to be examined, if The Hartford requires an examination".

B. Plaintiff's Claim for Benefits

Papadopoulos is a former employee of Fidelity where he worked as a software engineer and was a Plan participant. He stopped working on December 23, 1997, allegedly due to "cervical radiculopathy". On May 20, 1998, Papadopoulos submitted an application for long term benefits, claiming to be totally disabled by virtue of symptoms of "neck pains, migraines, dizziness, loss of balance, blurry vision, weak arms & legs, high blood pressure, other bodily pains".

The application prompted Hartford to gather the medical records of Papadopoulos's treating physicians, of which there were several. In 1995, Papadopoulos had come under the care of Dr. Albert Ackil ("Dr. Ackil"), a neurologist. Dr. Ackil diagnosed Papadopoulos with cervical radiculopathy and opined that he "should not do any heavy lifting, greater than 20 pounds, no prolonged sitting, standing, bending, climbing, [or] hyperextension of the neck." Dr. Ackil also restricted Papadopoulos from working at a computer and concluded that he was totally disabled.

Papadopoulos was also treated by Dr. Nicholas Tsanotelis ("Dr. Tsanotelis"), his primary care physician. On May 30, 2000, Hartford wrote to Dr. Tsanontelis and asked him whether he believed that Papadopoulos could perform sedentary work. The doctor did not respond.

Gregory Perron ("Perron"), a chiropractor, treated Papadopoulos from August, 1997 to February, 1998. At the end of that treatment, Perron concluded that Papadopoulos had reached his "maximum medical improvement" and that Papadopoulos was capable of working an eight hour day and that he could "frequently carry up to 25 lbs".

On September 15, 1998, Hartford informed Papadopoulos that his claim had been approved. It concluded that Papadopoulos had become eligible for benefits on November 25, 1997 and that, as a result, the Any Occupation Period would begin on November 25, 1999.

C. Hartford Terminates Benefits

In early 1999, Hartford initiated an investigation into whether Papadopoulos would be eligible for benefits during the upcoming Any Occupation Period. To that end, in August, 1999, Hartford hired Aragon Investigations, Inc. ("Aragon") to conduct surveillance of Papadopoulos to determine his physical limitations. The surveillance took place over several months. Ultimately, Aragon made a video of Papadopoulos which accompanies the instant motions. The video shows a man walking normally, carrying garbage to a dumpster, carrying a child, getting into a car and driving to various places.

Hartford also retained Dr. William Fishbaugh ("Dr. Fishbaugh") to conduct an independent medical evaluation and a Functional Capacities Evaluation of Papadopoulos. The Functional Capacities Evaluation never took place because Dr. Ackil refused to permit it, stating that Papadopoulos would be physically unable to participate. On March 7, 2000, Dr. Fishbaugh examined Papadopoulos. He also reviewed the medical records of Papadopoulos's treating physicians. He concluded that Papadopoulos was totally disabled, "mainly because of his migraine headaches".

In late April, 2000, Hartford contacted plaintiff and his attorney to request an interview. In addition to making several telephone calls, Hartford sent Papadopoulos a letter explaining that, if he refused to be "examined", i.e. interviewed, his benefits could be terminated. On May 1, 2000, a Hartford representative visited Papadopoulos at his house but he refused to be interviewed.

On May 5, 2000, Hartford sent a copy of the surveillance video to Dr. Fishbaugh. After reviewing the tape, Dr. Fishbaugh changed his conclusion, stating that Papadopoulos is not totally disabled and "is capable of returning to work at 40 hours per week".

On July 21, 2000, Hartford terminated Papadopoulos's benefits. It sent him a letter stating that "sufficient medical documentation proving you are Totally Disabled from any occupation has not been received, and you have refused an examination". On August 30, 2000, Papadopoulos appealed the termination and wrote a letter to Hartford explaining that the Social Security Administration had conducted a three-year review and had approved him for benefits. He also speculated that the surveillance video might depict his twin brother.

In response, Hartford made several more attempts to arrange an interview with Papadopoulos but was unsuccessful. On December 20, 2000, Hartford sent plaintiff's file to Dr. George Kazda ("Dr. Kazda") for another review. Hartford requested that Dr. Kazda determine Papadopoulos's restrictions on activity and comment as to whether those restrictions were consistent with the surveillance video. Dr. Kazda concluded that Papadopoulos could perform sedentary work as long as he could "change position frequently" and did not need to lift more than 50 lbs. He also concluded that the activities shown on the surveillance video were inconsistent with the restrictions put in place by Papadopoulos's treating physicians.

On January 29, 2001, Hartford denied Papadopoulos's appeal. It stated that its decision to deny coverage had been based upon 1) Dr. Fishbaugh's opinion, 2) Papadopoulos's refusals to be interviewed, 3) Dr. Kazda's opinion and 4) the surveillance tape.

D. Overpayment of Benefits

While the Hartford's investigation was taking place, another controversy was brewing. The Plan provides for an offset to the monthly benefit payable to a claimant if the claimant receives "other income benefits". Under the Plan provisions, social security disability benefits are included as "other income benefits".

On May 13, 1999, Papadopoulos's former counsel wrote to Hartford to disclose that Papadopoulos had received a social security benefit of $12,298. On June 15, 1999, Hartford responded that it believed Papadopoulos had been overpaid by Hartford in the amount of $20,500. It is unclear from the record how that figure was calculated.

The parties negotiated and, on September 8, 1999, they entered into a "Reimbursement Agreement". In that Agreement, Papadopoulos stated as follows:

I, Pericles Papadopoulos am in agreement with The Hartford Life Insurance Company that I owe a total of $13,101.45 to the Hartford Life Insurance Company. The Hartford Life Insurance Company has agreed to withhold $585.77 from my monthly LTD benefits of $2,638.75 in lieu of requiring immediate reimbursement. Should my disability benefits end, for any reason, including, but not limited to: recovery from disability, obtaining employment, or death, I, Pericles Papadopoulos, or my beneficiary, or Estate agree to pay the remaining balance of the overpayment in full at that time.

On March 22, 2000, Hartford received notification that Papadopoulos had received an increase in his monthly social security benefit of Eight Dollars ($8). Accordingly, Hartford informed Papadopoulos that he owed an additional $140 in connection with the overpayment.

Between the date of execution of the Agreement and the termination of benefits, the overpayment was reduced to $6,798. That amount has not been repaid but Papadopoulos contends that he need not pay it because the Reimbursement Agreement was "nullified".

E. Procedural History

Papadopoulos filed the instant action on October 16, 2003, stating a claim for wrongful termination of benefits under ERISA. On March 30, 2004, the complaint was amended to...