Goldman v. Hartford Life and Accident Insurance Company

• Decision Date: 23 February 2006
• Docket Number: No. Civ.A. 03-0759.,Civ.A. 03-0759.
• Parties: Gilbert M. GOLDMAN, Jr. v. HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY.
• Court: U.S. District Court — Eastern District of Louisiana

417 F.Supp.2d 788

Gilbert M. GOLDMAN, Jr. v. HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY.

No. Civ.A. 03-0759.

United States District Court, E.D. Louisiana.

February 23, 2006.

COPYRIGHT MATERIAL OMITTED

Joseph L. Waitz, Waitz & Downer, Houma, LA, for Gilbert M. Goldman, Jr.

Jennifer M. Lawrence, Virginia N. Roddy, Preaus, Roddy & Associates, LLP, New Orleans, LA, for Hartford Life And Accident Insurance Company.

ORDER AND REASONS

VANCE, District Judge.

This is an action for review of the denial of long-term disability benefits under an employee disability benefit plan governed by the Employee Retirement Income Security Act of 1974, 29 U.S.C. §§ 1001, et seq. Plaintiff Gilbert Goldman now moves for summary judgment and defendant Hartford Life and Accident Company moves to strike Goldman's pleadings and to impose sanctions. For the reasons stated below, the Court DENIES Goldman's motion for summary judgment and DNIES Hartford's motion to strike and for sanctions.

I. BACKGROUND

Gilbert Goldman is a former employee of Baroid, a division of the Halliburton Company. On March 23, 2001, Goldman injured his head, arm and neck while he worked as a mud engineer on an offshore drilling rig. This action stems from Goldman's attempts to collect long-term disability benefits as a result of this accident.

A. The Plan

Goldman's claims in this case arise under the Halliburton long-term disability insurance plan. (See Admin. Rec. at H-1792-H-1832). Defendant Hartford Life and Accident Insurance Company insures the plan and also makes benefit determinations under the plan. (See Admin. Rec. at H-1821 ("The Hartford reserves the right to determine if your proof of loss is satisfactory.")). An employee" is eligible for benefits under the plan if he has a "disability," as that term is defined by the plan. The plan provides two definitions of disability. During the 180-day "Elimination Period"¹ and the next two years, a "disability" is an injury or illness that prevents the employee from performing an essential duty of his occupation and causes him to suffer a decline in earnings. See Admin. Rec. at H-1801). At the end of that time period, the definition of disability changes to mean an injury or illness that prevents the employee from performing an essential duty of any occupation for which he is qualified that provides the potential to make more than 60% of his predisability earnings. (See Admin. Rec. at H-1801). Benefits under the plan are equal to 60% of lost income for the first three years of disability and are reduced to 30% of lost income thereafter. (See Admin. Rec. at H-1797-H-1798).

To make a claim for benefits under the plan, an employee must provide Hartford with written notice of disability and proof of loss establishing the disability. (See Admin. Rec. at H-1820-H-1821). If Hartford denies the claim, the plan requires Hartford to provide the claimant with written notice of the decision, including the specific reasons for the denial, the specific policy provisions on which the denial is based, a description of any additional information necessary for processing the claim, and an explanation of the claims appeal procedure. (See Admin. Rec. at H-1821).

Once Hartford denies a claim, the claimant may appeal the decision for a full and fair review of the claim. (See Admin. Rec. at H-1822). The plan provides that appeals will be decided within 60 days under most circumstances and within 120 days in all cases. (See Admin. Rec. at 1822).

B. Procedural History

On February 3, 2003, Goldman sued Hartford in Louisiana state court for long-term disability benefits under the plan. Hartford removed the action to this Court in March 2003 on the ground that this Court had jurisdiction over Goldman's claims under the Employee Retirement Income Security Act, 29 U.S.C. §§ 1001, et seq. Around the time that Hartford removed Goldman's action to this Court, Goldman applied with Hartford for long-term disability benefits under the plan. The Court stayed this action in order to allow the parties to complete the administrative review process on Goldman's claims. Hartford ultimately denied Goldman's claim on the ground that he was not a covered employee eligible for benefits under the plan.

On October 27, 2004, this Court found that Hartford had abused its discretion in determining that Goldman was not covered by the plan. The Court determined that Goldman was, in fact, a covered employee and remanded the matter to Hartford for a determination of whether Goldman was entitled to benefits under the terms of the plan. (See Rec. Doc. 129).

On November 30, 2004, Hartford informed Goldman that it needed additional information in order to evaluate his reopened claim for benefits. (See Admin. Rec. at H-1131-H-1134). On December 21, 2004 and January 28, 2005, Hartford again requested additional information from Goldman. (See Admin. Rec. at 1119-H-1120, H-1114-H-1115). On March 10, 2005, Hartford denied Goldman's claim for benefits on the ground that Goldman had failed to provide it with sufficient proof of loss in a timely manner. (See Admin. Rec. at H-1107-H-1113). In its March 10, 2005 letter, Hartford provided Goldman with a detailed list of the information that it still needed from him in order to determine his eligibility for benefits under the plan. (See Admin. Rec. at H-1110-H-1112). Hartford also informed Goldman that he had the right to administratively appeal Hartford's decision. (See Admin. Rec. at H-1112).

After Hartford denied his claim, Goldman did not appeal administratively, but instead moved in this Court for a judgment determining that Hartford owed him benefits. (See Rec. Does. 131-36). The Court denied Goldman's motion because his first case was closed and the matter was still before Hartford. (See Rec. Doc. 139). Goldman moved for reconsideration of the Court's April 5, 2005 order, and the Court denied his motion. (See Rec. Doc. 145). The Court again explained that its October 27, 2004 decision that Goldman was covered under the plan did not establish that he was entitled to benefits under the plan. The Court stated that this action was closed and that Goldman could file a new civil action in this Court if, after exhausting his administrative remedies with Hartford, he remained dissatisfied with Hartford's disposition of his claim. Goldman filed a second motion for reconsideration, which the Court denied. (See Rec. Doc. 154). The Court reiterated that the action was closed and warned Goldman's counsel that additional filings of this nature could subject him to sanctions.

Goldman appealed Hartford's decision to deny his claim for benefits by letter dated May 2, 2005. (See Admin. Rec. at 1639). On June 14, 2005, Hartford informed Goldman that it needed additional time to render a decision on his May 2, 2005 appeal and that a decision would be made no later than July 31, 2005. (See Admin. Rec. at H-1787-H-1789). On July 20, 2005, Hartford rendered a decision on Goldman's appeal. (See Admin. Rec. at H-1639-H-1643;² Rec. Doc. 158 Ex. 2). Hartford determined that Goldman was eligible for long-term disability benefits for the period September 20, 2001 (the end of the Elimination Period under the plan) through September 19, 2003. See Admin. Rec. at H-1639). Hartford denied Goldman's claim for benefits after September 19, 2003 because it found that there was insufficient evidence in the record to establish that Goldman qualified as disabled under the plan after September 19, 2003. Hartford pointed to medical evidence indicating that Goldman was capable of performing essentially light duty work, which would mean that he would not qualify as disabled under the definition of disability that applied after September 19, 2003. (See Admin. Rec. at H-1642-1643; Rec. Doc. 158 Ex. 2). Hartford's July 20, 2005 letter again advised Goldman of his right to administratively appeal its benefits decision. (See Admin. Rec. at H-1643 ("[ERISA] gives you the right to appeal our decision and receive a full and fair review. You may appeal our decision even if you do not have new information to send us.")).

On July 26, 2005, Goldman appealed Hartford's determination that he was not entitled to benefits after September 19, 2003. (See Admin. Rec. at H-1579). Hartford acknowledged receipt of Goldman's appeal on July 28, 2005 and informed Goldman that it had 45 days in which to decide his appeal, and up to 90 days under special circumstances. (See Admin. Rec. at H-1576). The parties exchanged a number of letters from late July 2005 through September 2005, but that correspondence related primarily to the amount of benefits to which Goldman was entitled for the period September 20, 2001 through September 19, 2003, not to his July 26, 2005 appeal. (See Admin. Rec. at H-1574-H-1575, H-1587, H-1591, H-1594, H-1596, H-1598-H-1600, H-1619, H-1628-H-1629). The Court's review of the administrative record indicates that Hartford never informed Goldman that it would need additional time to process his July 26, 2005 appeal and never informed Goldman that it had made a decision on that appeal.

Goldman commenced this action on September 22, 2005 by filing a new complaint under this docket number. (See Rec. Doc. 157). Goldman's new complaint alleges both that Hartford did not provide him with the full amount of benefits to which he is entitled for the period September 20, 2001 through September 19, 2003 and that Hartford never made a decision on his July 26, 2005 appeal concerning the denial of benefits after September 19, 2003. Goldman moved for summary judgment on these claims, seeking benefits owed from September 20, 2001 through the present, as well as penalties and attorney's fees. Hartford moved to strike Goldman's pleadings and to impose sanctions for violation of the Court's order that Goldman cease filing pleadings in this case. Goldman thereafter moved to voluntarily dismiss his claim for benefits for the period September 20, 2001 through September...