United States District Court, D. New Hampshire
B. MCCAFFERTY UNITED STATES DISTRICT JUDGE
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. 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).The parties
cross-move for judgment on the administrative record. The
court held oral argument on July 2, 2018.
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.
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.
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.
6, 2009, Fortier stopped working due to a medical
condition. 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.
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.
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.
Hartford Terminates then Reinstates Fortier's LTD
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."
letter dated March 5, 2012, Fortier's counsel requested
that Hartford extend the deadline to appeal the adverse
benefit determination by 60 days. 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."
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.
Hartford Again Terminates Forties s LTD Benefits
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
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."
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.
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.The March 26 letter informed
Fortier's counsel that Hartford would not consider her
appeal because it was untimely.
Hartford Terminates Fortier's Waiver of Premium
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.
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.
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
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.
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
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 ...