Potts v. Hartford Life & Accident Ins. Co.

272 F.Supp.3d 690

Jennifer POTTS, Plaintiff,

v.HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY, Defendant.

CIVIL ACTION NO. 3:16–35

United States District Court, W.D. Pennsylvania.

Signed September 28, 2017

Andrew M. Grabhorn, Michael Grabhorn, Grabhorn Law Office, PLLC, Louisville, KY, Tybe A. Brett, Feinstein Doyle Payne & Kravec, LLC, Pittsburgh, PA, for Plaintiff.

William B. Wahlheim, Jr., Grace R. Murphy, Maynard, Cooper & Gale, P.C., Birmingham, AL, Brian P. Downey, Pepper, Hamilton & Scheetz, Harrisburg, PA, for Defendant.

MEMORANDUM OPINION

KIM R. GIBSON, UNITED STATES DISTRICT JUDGE

I. Introduction

Before the Court are motions for summary judgment by Jennifer Potts, Plaintiff (ECF No. 56) and Hartford Life and Accident Insurance Company ("HLAIC" or "Hartford Life"), Defendant. (ECF No. 59.) The issues have been fully briefed (see ECF Nos. 57, 58, 60, 61, 62, 63, 64, 65, 66, 67) and both motions are ripe for disposition. For the reasons that follow, Plaintiff's motion will be DENIED and Defendant's motion will be GRANTED .

II. Jurisdiction

This Court has subject matter jurisdiction under 28 U.S.C. § 1331, as Plaintiff's claim arises under federal law. Venue is proper under 29 U.S.C. § 1332(e)(2).

III. Background

A. Procedural History

Plaintiff initiated this lawsuit by filing a complaint in the Western District of Kentucky on September 21, 2015. (ECF No. 1.) Plaintiff's complaint alleged "Breach of Contract" and "Breach of Fiduciary Duty." (Id. ) On October 15, 2015, Defendant filed a motion to dismiss Plaintiff's "Breach of Fiduciary Duty" claim (ECF No. 6) as well as an answer. (ECF No. 5.) On January 11, 2016, Defendant filed a motion to transfer this case to this Court (ECF No. 25.), which Plaintiff did not oppose. (See ECF No. 20.)

An Initial Rule 16 Scheduling Conference was held before this Court on March 8, 2016. (ECF No. 33.) After mediation proved unfruitful (see ECF No. 40), the Court entered a Scheduling Order granting the parties leave to brief the motion to dismiss under the law of the Third Circuit. (ECF No. 41.) This Court then granted Defendant's motion to dismiss Plaintiff's "Breach of Fiduciary Duty" claim on August 9, 2016. (ECF No. 47.) Thus, the only claim left at this juncture is Plaintiff's "Breach of Contract" claim.

B. Factual History

This case involves Defendant's denial of Plaintiff's benefits for long-term disability under the Employee Retirement Income Security Act of 1974, 29 U.S.C. §§ 1101, et seq. ("ERISA"). The following facts are undisputed.

Plaintiff was employed with Denny's, where she worked as a General Manager from January 7, 2010 through April 25, 2012. (ECF No. 63 at 1.) Through her employment with Denny's, Plaintiff participated in an employee welfare benefit plan ("Plan"). (Id. at 1.) The Plan provides for both short-term disability ("STD") and long-term disability ("LTD") (Id. at 1–2; ECF No. 58 at 1–2.); these benefits are funded by an insurance policy ("Policy") issued by Defendant. (ECF No. 61 at 1.) Under the Policy, "Disability or Disabled means You are prevented from performing one or more of the essential duties of: 1) Your Occupation during the Elimination Period; 2) Your Occupation, for the 24 month(s) following the Elimination Period, and as a result Your Current Monthly Earnings are less than 80% of Your Indexed Pre–Disability Earnings; and 3) after that, Any Occupation." (AR. 0028.)

Plaintiff ceased work on April 26, 2012, after being diagnosed with Fibromyalgia and Thoracic Disc Disease. (ECF 58 at 2.) Plaintiff applied for STD benefits immediately after ceasing work. (Id. ) On April 30, 2012, Defendant determined that Plaintiff could not perform her job duties and approved Plaintiff's claim for STD benefits, effective April 26, 2012. (Id. ) Defendant paid Plaintiff STD benefits for the maximum time period allowed under the policy. (Id. ) On January 18, 2013, after reviewing medical reports from several medical specialists who had treated Plaintiff in the preceding months, Defendant determined that Plaintiff was disabled from her own occupation and approved Plaintiff's claim for LTD benefits. (ECF No. 63 at 3–4.)

Plaintiff continued to receive LTD benefits for the next twenty-four (24) months—the entirety of the "Own Occupation" period. (ECF No. 58 at 2; AR. 0224.) When the Own Occupation period ended, Defendant terminated Plaintiff's LTD benefits, effective January 1, 2015. (ECF No. 63 at 12.) Plaintiff appealed Defendant's decision, and Defendant denied Plaintiff's appeal. (Id. at 17.) This lawsuit followed.

Because Plaintiff alleges that Defendant improperly denied her LTD benefits based on her medical conditions, it is necessary to review Plaintiff's treatment history and Defendant's reviews of Plaintiff's claims for benefits. While the record before this Court is quite voluminous, this Court will set forth a concise summary of the uncontested facts most relevant to the pending motions.

1. Plaintiff Ceases Work and is Awarded Short and Long–Term Disability Benefits

In April, 2012, Dr. Kern diagnosed Plaintiff with Fibromyalgia and noted that Plaintiff had subjective symptoms of "leg pain/weakness/fatigue." (AR. 1005.) Dr. Kern indicated that Plaintiff could not return to work at that time. (Id. ) On April 26, 2012, Plaintiff ceased work and was shortly thereafter awarded STD benefits. After receiving STD benefits, Plaintiff continued to be treated by Dr. Kern for a variety of issues, including, but not limited to, fibromyalgia, chronic pain in various parts of her body, depression, adjustment reaction, and other emotional disturbances. (See AR. 1000–1003, 0997, 0979–80, 0976, 0992–93, 0972–73.) On at least two occasions, Dr. Kern indicated in her notes that Plaintiff might need to see a psychiatrist. (AR. 1003, 0977.)

Plaintiff also was seen by a pain management specialist, Alice Jones, DNP. On October 1, 2012, Ms. Jones filled out Defendant's "Attending Physician's Statement of Functionality" ("APSF") and reported that Plaintiff's "primary diagnosis is chronic pain/syndrome, hip pain." (AR. 0942–43.) Ms. Jones further noted that she was "unable to determine" Plaintiff's functional capacity, and stated that Plaintiff "needs to be referred for functional capacity tests." (AR. 0943.) On November 11, 2012, Ms. Jones filled out a form letter sent by Defendant, in which she stated that Plaintiff "needs functional capacity testing." (AR. 0905.)

Defendant approved Plaintiff's claim for LTD benefits on January 18, 2013, effective November 1, 2012, after determining that Plaintiff was disabled from her own occupation. (AR. 0290–0293; ECF No. 63 at 4.) The letter was signed by "Tanya A. Walsh, Ability Analyst[,] Hartford Life and Accident Insurance Co." (AR. 0292.)

Plaintiff continued to be seen by various medical professionals, and Defendant regularly requested information from these providers about Plaintiff's medical conditions. On July 26, 2013, Ms. Jones checked the boxes on a form stating that Plaintiff could perform "light" and "sedentary work" on a "full-time basis." (AR. 0730; AR. 0733.) Defendant then contacted Dr. Kern and asked whether she concurred with Ms. Jones' opinion. Dr. Kern noted that she had not seen Plaintiff since April and would "defer to pain mgmt." (AR. 0692–93.)

Plaintiff met with Dr. Kern on September 13, 2013. Following the appointment, Dr. Kern wrote a letter in which she stated that "I understand by both your correspondence and from the patient that Pain management stated she was able to perform light duty." (AR. 0685.) However, Dr. Kern stated that Plaintiff "proves to be a hard case," and that "it is my opinion that she remain out of work." (Id. ) Dr. Kern further noted that Plaintiff had an appointment on October 10, 2013, with a chiropractor, Dr. Rizzo, who "is going to do a Functional Capacity test on her to see her ability to do work." (Id. ) Ultimately, Plaintiff did not complete the functional capacity test because Dr. Rizzo was not certified to administer it and other providers were prohibitively expensive. (AR. 0119.) Defendant did not offer to pay for Plaintiff to undergo a functional capacity test.

In a letter dated June 2, 2013, Dr. Rita Kammiel, Plaintiff's psychiatrist, noted that Plaintiff was unable to work because of "depression, lack of motivation, poor concentration, and trouble coping with physical pain." (AR. 0786.) On October 5, 2013, Dr. Kammiel filled out Defendant's "Attending Physician's Statement of Disability" ("APSD") form, indicating that Plaintiff suffers from chronic pain syndrome, depression, and bipolar disorder. (AR. 0676–687.) Dr. Kammiel also reported that Plaintiff had "No Ability" or "Minimal Ability" in eleven (11) out of twelve (12) work-related activities. (Id. at 0677.)

In a letter to Defendant dated November 20, 2013, Dr. Kern wrote "Please note, I am not treating any condition—but pt. has diagnosis of fibromyalgia & thoracic disc disease. She is unable to stand for long periods of time or sit." (AR. 0674.) Dr. Kern further stated "I think it is unreasonable to think she can work full time." (Id. )

Plaintiff returned to Dr. Kern on January 8, 2014. Dr. Kern noted Plaintiff's various diagnoses, stated that Plaintiff reported tenderness when pressure was applied to her upper back, and opined that while "[a]lone either of her diagnoses may not qualify her" for Social Security benefits, "her significant depression along with Thoracic radiculopathy /Fibromyalgia make for a poor work candidate." (AR. 0596.) Plaintiff saw Dr. Kern again on May 8, 2014. Dr. Kern again noted Plaintiff's various diagnoses, stated that Plaintiff "recoils from light touch to the chest wall, upper extremity, and upper back," and reiterated that, while she might not qualify for Social Security, she is a "poor work candidate." (AR. 0593.)

Plaintiff returned to Ms. Jones, the pain specialist, on February 12, 2014 (AR. 0430–431), March 14, 2014 (AR. 0428–429), and April 11, 2014. (AR. 0426–427.) During each of these visits, Ms. Jones...