Smith v. Hartford Life & Accident

• Decision Date: 30 January 2013
• Docket Number: No. C 11-03495 LB,C 11-03495 LB
• Court: U.S. District Court — Northern District of California
• Parties: LORI SMITH, Plaintiff, v. HARTFORD LIFE & ACCIDENT, Defendant.

LORI SMITH, Plaintiff,

v.HARTFORD LIFE & ACCIDENT, Defendant.

No. C 11-03495 LB

UNITED STATES DISTRICT COURT Northern District of California San Francisco Division

Dated: January 30, 2013

FINDINGS OF FACT AND

CONCLUSIONS OF LAW

INTRODUCTION

Plaintiff Lori Smith brings this action under the Employee Retirement Income Security Act ("ERISA"), 29 U.S.C. §§ 1001-1461, against defendant Hartford Life and Accident Insurance Company ("Hartford") seeking reinstatement of her life insurance waiver of premium benefits. Complaint, ECF No. 1 at 14.¹ On January 28, 2012, the court held a one-day "bench trial on the record."² See Kearney v. Standard Ins. Co., 175 F.3d 1084, 1095 (9th Cir. 1999). Having considered the administrative record, the parties' trial briefs, and the arguments that the parties made during the bench trial, the court rules that Ms. Smith is entitled to an award of benefits as set forth below.

FINDINGS OF FACT

I. THE POLICY

Ms. Smith was an employee of Chevron Federal Credit Union ("Chevron") from 1989 (AR 409) to 2007. Administrative Record ("AR") 409, 851, 974. As a Chevron employee, Ms. Smith received short-term disability ("STD"), long-term disability ("LTD"), and life insurance coverage as part of the Group Insurance Policy (Number GL-689059) (the "Policy") that Hartford issued to Chevron. AR 990-1065.

Whether an employee is "disabled" and qualifies for LTD and/or waiver of life insurance premium benefits depends on the definition of "disability" used. The Policy defines "disability" for LTD coverage purposes, in relevant part, as the inability (due to, among other things, accidental bodily injury, sickness, or mental illness) to perform the "Essential Duties" of "Your Occupation." AR 1017-18.³ This is commonly referred to as an "own occupation" standard. In the Policy, "Your Occupation" is defined as "your occupation as it is recognized in the general workplace." AR 1020.It "does not mean the specific job you are performing for a specific employer or at a specific location." AR 1020. "Essential Duty" is defined as "a duty that: 1. is substantial, not incidental; 2. is fundamental or inherent to the occupation; and 3. can not be reasonably omitted or changed." AR 1018. Further, "[t]o be at work for the number of hours in your regularly scheduled workweek is also an Essential Duty." AR 1018.

In comparison, with respect to the waiver of life insurance premium benefit, "disabled" "means that You have a condition that prevents You from doing any work for which You are or could become qualified by education, training or experience and it is expected that this condition will last for at least nine consecutive months from Your last day of work as an Active Full-time Employee; or You have been diagnosed with a life expectancy of 12 months or less." AR 1035.⁴ This is commonly referred to as an "any occupation" definition. To qualify for waiver of life insurance premium benefits, "1. You must be less than age 60, insured and Disabled; and 2. acceptable proof of Your condition must be furnished to Us within one year of Your last day of work as an Active Full-time Employee." AR 1035.

II. MS. SMITH'S INJURIES AND INITIAL TREATMENT

Sometime in or around 2005-2006, Ms. Smith developed carpel tunnel syndrome and arthritis in her hands. AR 2254-55 (describing Ms. Smith's injury history). She underwent carpel tunnel syndrome-related surgery (performed by Dr. Brian Cable) on her right hand and/or wrist on April 16, 2006, and she had surgery on her left thumb on May 23, 2007. AR 18, 1270-71, 2255. Later, on March 25, 2009, Ms. Smith had surgery on her right thumb. AR 2255. She received physical therapy on occasion after her May 23, 2007 surgery, through April 2008. AR 866-71.

Ms. Smith stopped working full-time after her May 23, 2007 surgery, and then returned to part-time work on August 14, 2007. AR 16-18, 82-83, 851. Her position at the time—Assistant Vice President, Regional Manager in Northern California—required her to "occasionally" stand and walk, to "occasionally" push, pull, lift, and carry items weighing up to 20 pounds, and to"frequently" sit and type on a keyboard. AR 974-75. It was estimated that 80% of the position's responsibilities involved typing on a keyboard, 15% involved "paperwork," and 5% involved "miscellaneous" tasks. AR 975. Ms. Smith stopped working completely on December 7, 2007. AR 851, 974.⁵ She claimed that she was experiencing job stress due to Chevron's hostility toward her after she filed a claim for workers compensation benefits. AR 828. Ms. Smith also made a claim for workers compensation based on job stress, but that claim was denied. AR 380.

She began seeing Dr. Cheri Forrester, a family practitioner, at least by December 2007 (and she continued to see her through at least December 2009). AR 294-303, 401-06, 828-37. Dr. Forrester proscribed Ms. Smith several medications for pain relief, headaches, and insomnia. AR 294-303, 401-06, 828-37.

To help lower the amount of stress and anxiety related to the uncertainty surrounding her job and the perceived mistreatment of her by Chevron, Ms. Smith began seeing Dr. Gary Rosenblatt, a licensed psychologist, in February 2008 for psychotherapy treatment. AR 841. She also began seeing Dr. Jeffrey Stevenson, an occupational medical consultant, in March 2008 for treatment related to her wrists and hands. AR 306-27, 364-90.

III. HARTFORD'S INITIAL APPROVAL OF MS. SMITH'S CLAIMS FOR STD, LTD, AND WAIVER OF PREMIUM BENEFITS

On June 19, 2008, Ms. Smith submitted a claim to Hartford for STD benefits, claiming that she was disabled due to her carpal tunnel syndrome and hand arthritis. AR 974-77. She did not apply for STD benefits sooner because she "was under the impression" that was not eligible for STD benefits at the same time that she was receiving worker compensation benefits. AR 970. In support of her claim, she submitted an Attending Physician's Statement ("APS") from Dr. Stevenson, datedJuly 7, 2008. AR 370.

After receiving Ms. Smith's STD claim, Hartford obtained the documents related to her medical treatment and physical therapy. AR 828-72. Ms. Smith's hand surgeon, Dr. Cable, supported May 23, 2007 as the onset date of her disability. AR 1233. Her physical therapy treatment records show that by December 2007, she had significantly increased strength of pinch and grip but still lacked full range of movement and strength in her thumb and hand joints. AR 868. She also reported stiffness in some joints in her fingers after prolonged activity. AR 868. By April 2008, while she reported improved tolerance to typing on a keyboard and writing by hand, she continued to have pain in her thumbs after using a computer for 30 minutes. AR 857. Dr. Stevenson's records indicated that as of June 2008, Ms. Smith continued to have aching pain and discomfort when she typed on a keyboard or grasped items. AR 371-72. He cleared her to return to work so long as she was restricted her from doing repetitive or forceful pushing, pulling or reaching and from frequent or forceful typing and grasping. AR 371-72 (June 2, 2008 assessment); see also AR 376-90 (prior assessments). Subsequent assessments in July and August 2008 were similar and featured the same limitations. See AR 367-70.

By letter dated September 10, 2008, Hartford approved Ms. Smith's claim for STD benefits for the period December 6, 2007 through June 18, 2008 (the maximum duration). AR 151. Hartford also noted that her "file has been referred to LTD," so that a claim for LTD benefits could be assessed. AR 151; see AR 248 (letter from Hartford dated September 16, 2008 confirming the referral and requesting information to process Ms. Smith's LTD claim).

In addition to reviewing Ms. Smith's medical records, Hartford interviewed Ms. Smith by telephone on September 17, 2008. AR 82-83. She said that she would like to return to work but she did not think that she could return to a job that required use of her hands, and her psychological condition would make it hard, too. AR 82-83.

By letter dated October 20, 2008, Hartford approved Ms. Smith's claim for LTD benefits. AR 237-42. Her benefit payments would continue as long as she remained "disabled" under the applicable definition, but in no event beyond January 30, 2024. AR 237-38. The next day, Hartford informed Ms. Smith that she might also be eligible for waiver of life insurance premium benefits.AR 980. Hartford stated that, to make this determination, it would review the "medical documentation" that she submitted for purposes of her LTD claim. AR 980. Hartford also stated that waiver of life insurance premium benefits "will be approved if you satisfy this Policy's eligibility requirements and if [it] receive[s] medical documentation that you have remained totally Disabled as defined in this Policy." AR 980.

Hartford interviewed Ms. Smith by telephone again on December 3, 2008. AR 73-74. Ms. Smith stated that she still had a lot of stiffness but was in less pain than she was before the surgery. AR 73. She was able to take care of herself but she needed help buttoning things and lifting items. AR 74. She tried to stay off of the computer. AR 74. She was kept busy with her two dogs, and she volunteered as a docent for dogs for the blind and gave tours to schoolchildren. AR 74. She also stated that she was seeing a new psychologist, Dr. Donald Nadler, AR 73, as she had stopped seeing Dr. Rosenblatt ten months earlier, AR 733.

On December 24, 2008, Ms. Smith submitted another APS from Dr. Stevenson, dated November 26, 2008, in which he noted that Ms. Smith could never lift or carry anything that weighed more than 10 pounds and could only rarely lift or carry anything that weighed less than that. AR 824-26. He also noted that she could only rarely engage in "fingering/handling." AR 826. While Dr. Stevenson did state that Ms. Smith could participate in "vocational rehabilitation services," he expected her limitations to be permanent. AR 826. He further noted that ...