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Fortier v. Hartford Life and Accident Insurance Co.

United States District Court, D. New Hampshire

July 23, 2018

Theresa Fortier
v.
Hartford Life and Accident Insurance Company et al.

          ORDER

          LANDYA B. MCCAFFERTY UNITED STATES DISTRICT JUDGE

         Plaintiff Theresa Fortier, a former doctor at the Dartmouth-Hitchcock Clinic ("DH Clinic"), brings suit alleging that defendants Hartford Life and Accident Insurance Company ("Hartford") and the Dartmouth-Hitchcock Clinic Long Term Disability Plan ("Plan") unlawfully stopped paying long-term disability benefits to which she is entitled. She also alleges that Hartford wrongfully terminated her waiver of premium benefits under her life insurance policy.[1] The causes of action remaining in this case are two claims pursuant to the Employee Retirement Income Security Act ("ERISA") to recover benefits under the LTD policy (Count I) and Fortier's life insurance policy (Count II); and a third claim seeking an award of. attorney's fees and costs (Count IV).[2]The parties cross-move for judgment on the administrative record. The court held oral argument on July 2, 2018.

         STANDARD OF REVIEW

         The standard of review in an ERISA case differs from that in an ordinary civil case, where summary judgment is designed to screen out cases that raise no trial-worthy issues. See Orndorf v. Paul Revere Life Ins. Co., 404 F.3d 510, 517 (1st Cir. 2005). "In the ERISA context, summary judgment is merely a vehicle for deciding the case" in lieu of a trial. Bard v. Bos. Shipping Ass'n, 471 F.3d 229, 235 (1st Cir. 2006) . Rather than consider affidavits and other evidence submitted by the parties, the court reviews the denial of ERISA benefits based "solely on the administrative record," and neither party is entitled to factual inferences in its favor. Id. Thus, "in a very real sense, the district court sits more as an appellate tribunal than as a trial court" in deciding whether to uphold the administrative decision. Leahy v. Raytheon Co., 315 F.3d 11, 18 (1st Cir. 2002) .

         BACKGROUND

         The facts recited in this section are drawn from the parties' joint statement of material facts, which they submitted pursuant to Local Rule 9.4(b), see doc. no. 29, as well as documents contained in the administrative record.

         At all times relevant to this case, Fortier was employed as a physician at the DH Clinic. Through her employment, Fortier was a beneficiary and participant in DH Clinic's Plan, offered through Hartford. The Plan provided both the LTD policy and a life insurance policy. Fortier maintained coverage under both policies throughout her employment.

         On May 6, 2009, Fortier stopped working due to a medical condition.[3] In November 2009, she filed an LTD claim with Hartford, stating that she was unable to work because of a disability as of May 6, 2009. By letter dated December 18, 2009, Hartford notified Fortier that it had approved her LTD claim and would begin paying benefits effective November 2, 2009.

         On February 5, 2010, Hartford informed Fortier by letter that her LTD policy required her to apply for Social Security Disability benefits if she anticipated being out of work for 12 months or more. Fortier applied for Social Security benefits and, on April 10, 2011, was awarded benefits effective May 6, 2009.

         By letter dated June 1, 2010, Hartford notified Fortier that because of her disability, she qualified for a waiver of premium for her life insurance coverage under the Plan. The letter stated that Fortier's life insurance benefits "will remain in effect without premium payment until date of termination 01/07/2026, provided you remain Disabled as defined by the Policy." Doc. no. 29 at ¶ 11. The letter further stated: "Periodically, we will be requesting updated medical information from you to verify your continued disability, and consequently your continued eligibility for the Waiver of Premium benefit." Admin. Rec. at 159.

         I. Hartford Terminates then Reinstates Fortier's LTD Benefits

         In a letter dated September 13, 2011, Hartford notified Fortier that her LTD benefits would terminate on November 1, 2011 because her disability was subject to the LTD policy's "Mental Illness" limitation, which limits LTD benefits to 24 months for disabilities "because of . . . Mental Illness that results from any cause; . . . [or] any condition that may result from Mental Illness." Doc. no. 29 at ¶ 15. The letter stated that Fortier's medical records supported a diagnosis of "Cognitive Disorder NOS," which fell under the Mental Illness policy provision. Id. The letter also provided: "If you do not agree with our denial, in whole or in part, and you wish to appeal our decision, you or your authorized representative must write to us within one hundred eighty (180) days from your receipt of this letter." Id.

         By letter dated March 5, 2012, Fortier's counsel requested that Hartford extend the deadline to appeal the adverse benefit determination by 60 days.[4] Hartford granted the request and extended Fortier's time to appeal to May 11, 2012. Fortier's counsel appealed Hartford's determination on that date, and submitted medical records to Hartford to contest the diagnosis of Cognitive Disorder NOS. The court will refer to Fortier's May 11, 2012 appeal as the "2012 appeal."

         By letter dated May 22, 2012, Hartford notified Fortier's counsel that "[b]ased on a complete and thorough review of this file, we have determined that Dr. Fortier is entitled to continued LTD benefits beyond November 1, 2011, subject to all policy provisions and guidelines." Id. at ¶ 19. Although not stated in the letter, Hartford's records show that Fortier's benefits were reinstated because, per Hartford's policy, the 24-month limitation for Mental Illness benefits begins to run from the date Hartford informs the beneficiary of the limitation. In other words, Hartford reset the 24-month period to begin on September 13, 2011, the date it informed Fortier of the limitation. On June 4, 2012, Hartford notified Fortier by letter of the reason for the reinstatement, and informed her that "no benefits will be payable beyond 09/12/2013 for mental illness." Id. at ¶ 20.

         II. Hartford Again Terminates Forties s LTD Benefits

         By letter dated July 17, 2013, Hartford notified Fortier's counsel that Hartford would stop paying Fortier LTD benefits on September 13, 2013. The letter read, in relevant part:

We based our decision to terminate Dr. Fortier's claim on policy language. All the documents contained in her file were reviewed as a whole ....
As we indicated in our letter dated 06/04/2012, Dr. Fortier[] was notified on 09/13/2011 that her claim for benefits was subject to the limitation for Mental Illness benefits.
The information in Dr. Fortier's file shows that she received LTD benefits beginning 11/02/2009 for Disability due to Cognitive Disorder NOS. When she stopped working 05/06/2009, she presented with reported impaired concentration and forgetfulness and it was suggested this was possibly due to encephalopathy secondary to viral infections. However, subsequent objective testing did not provide support of a physically disabling condition.
Since her Disability was the result of a Mental Illness, the LTD benefits were subject to the Mental Illness and Substance Abuse Benefits provision. Dr. Fortier's benefits commenced on 11/02/2009. You were notified of the limitation for Mental Illness on 09/13/2011. Therefore, the 24 month duration of benefits for your Mental Illness will expire on 09/13/2013 and her claim will be closed. However, if she is hospitalized prior to that date, the benefits may be extended.
Please notify our office immediately if Dr. Fortier is hospitalized at any time, or if she becomes Disabled due to a physical impairment. If she were hospitalized at any time prior to the date her benefits are currently set to expire, we will need to obtain copies of the medical records from the hospital during the exact dates that she was hospitalized.

Id. at ¶ 21. Importantly, the letter also stated: "If you do not agree with our denial, in whole or in part, and you wish to appeal our decision, you or your authorized representative must write to us within one hundred eighty (180) days from the receipt of this letter." Id.

         On August 10, 2013, Fortier's counsel requested a copy of the claim file from Hartford. On August 19, 2013, Hartford provided the claim file to Fortier's counsel.

         By letter dated March 7, 2014, Fortier, through her counsel, appealed Hartford's adverse LTD benefit determination (the "2014 appeal"). Hartford notified Fortier's counsel in a letter dated March 26, 2014, that Fortier's appeal was untimely because it was not submitted within 180 days of her receipt of the July 17, 2013 adverse benefit determination letter.[5]The March 26 letter informed Fortier's counsel that Hartford would not consider her appeal because it was untimely.

         III. Hartford Terminates Fortier's Waiver of Premium Benefits

         By letter dated September 23, 2013, Hartford notified Fortier's counsel:give rise to an ERISA claim:

[I]n order for your client's Group Life Insurance to continue through [the LWOP] benefit, she must remain totally Disabled as defined in this Policy. Please complete the enclosed Authorization to Obtain and Release Information form and the Personal Profile Evaluation form and return to us in the self-addressed envelope. In accordance with the terms of this Policy, we ask that you also submit evidence of continuing disability. Enclosed is an Attending Physician's Statement, Psychiatric Attending Physician's Statement, and Behavioral Functional Evaluation form that her physician must complete and return to us . . . by 10/7/13. We need this information to determine if you continue to meet the definition of Disability and remain under the care of a Physician.

Id. at ¶ 24.

         Hartford sent Fortier's counsel follow-up letters on October 10 and November 8, 2013, reminding him that Hartford needed additional information to determine whether Fortier remained under a disability. The letters informed Fortier's counsel that absent further information, her waiver of premium benefits would be terminated.

         On December 4, 2013, Hartford notified Fortier's counsel by letter that it had not received any response to its September 23, October 10, or November 8, 2013 letters. Hartford stated in its letter that it was terminating Fortier's waiver of premium benefits as of that date. The December 4 letter also stated: "If you do not agree with the reason why your claim was denied, in whole or part, and you wish to appeal our decision, you must write to us within one hundred eighty (180) days of the date of this letter." Id. at ¶ 27.

         By letter dated June 1, 2014, Fortier's counsel timely appealed Hartford's adverse determination regarding the waiver of premium benefits. In the letter, Fortier's counsel stated that he was including the March 7, 2014 letter appealing Hartford's termination of her LTD benefits, as well as "clinical notes of Dr. Belliveau." Admin. Rec. at 172. The letter also stated "[a]dditional documents will be sent to Hartford soon." Id.

         By letter dated June 10, 2014, Hartford acknowledged receipt of the appeal, gave Fortier's counsel the address to send any additional documents, extended the deadline for Fortier's appeal to July 7, 2014 so that he could forward any additional documents, and stated that if Hartford did not receive additional documentation by that date, it would evaluate the appeal based on the information it currently had.

         Fortier's counsel did not submit any further documents in connection with Fortier's appeal. By letter dated July 21, 2014, Hartford denied the appeal, noting that it had not received any additional documentation, and that the psychiatric office visit notes ...


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