Topalian v. Hartford Life Ins. Co.

Decision Date16 May 2013
Docket NumberNo. 10–CV–1965.,10–CV–1965.
Citation945 F.Supp.2d 294
PartiesStephen J. TOPALIAN, Plaintiff, v. HARTFORD LIFE INSURANCE COMPANY, Defendant.
CourtU.S. District Court — Eastern District of New York

OPINION TEXT STARTS HERE

Michael E. Quiat, Uscher, Quiat, Uscher & Russo, Hackensack, NJ, for Plaintiff.

Michael H. Bernstein, Sedgwick LLP, Elizabeth Richer Chesler, John Thomas Seybert, Sedgwick, Deter, Moran & Arnold, New York, NY, for Defendant.

MEMORANDUM & ORDER

MATSUMOTO, District Judge.

On April 30, 2010, plaintiff Stephen J. Topalian (plaintiff or “Topalian”), a former employee of Allstate Insurance Company(“Allstate”), commenced this action against Hartford Life Insurance Company (defendant or “Hartford”), pursuant to § 502 of the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. § 1132(a)(1)(B), challenging Hartford's termination of his long term disability (“LTD”) benefits under the Group Long Term Disability Income Plan for Allstate Employees (the “Plan”). ( See ECF No. 1, Complaint dated 4/27/10 (“Compl.”).) Plaintiff seeks reversal of Hartford's decision to terminate his LTD benefits, unpaid LTD benefits retroactive to July 30, 2008, interest on those unpaid benefits, attorneys' fees, costs, a declaration that he is totally disabled within the meaning of the Plan, and future payment of LTD benefits under the Plan. ( See Compl. at 6.)

Presently before the court are the parties' fully-briefed cross-motions for summary judgment pursuant to Federal Rule of Civil Procedure 56. (ECF No. 55, Hartford's Motion for Summary Judgment dated 4/20/12 (“Hart. Mot.”); ECF No. 56, Hartford's Memorandum in Support of Summary Judgment Motion (“Hart. Mem.”); ECF No. 66, Plaintiff's Memorandum in Opposition to Hart. Mot. (“Pl. Opp.”); ECF No., 63, Hartford's Reply Memorandum (“Hart. Reply”); ECF No. 60, Hartford's Rule 56.1 Statement (“Hart. 56.1 Stmt.); ECF No. 66, Exh. 1, Plaintiff's 56.1 Counter–Statement (“Pl. 56.1 Resp.); ECF No. 64,1 Exh. 1, Plaintiff's Redacted Motion for Summary Judgment dated 2/29/12 (“Pl. Mot.”); ECF No. 64, Exh. 2, Plaintiff's Memorandum in Support of Summary Judgment Motion (“Pl. Mem.”); ECF No. 61, Hartford's Memorandum in Opposition to Pl. Mot. (“Hart. Opp.”); ECF No. 65, Plaintiff's Reply Memorandum (“Pl. Reply”); ECF No. 64, Exh. 17, Plaintiff's Rule 56.1 Statement (“Pl. 56.1 Stmt.); ECF No. 62, Hartford's 56.1 Counter–Statement (“Hart. 56.1 Resp.).)

For the reasons set forth below, Hartford's motion for summary judgment is granted, and plaintiff's cross-motion for summary judgment is denied.

BACKGROUND

The following facts, taken from the parties' Rule 56.1 statements 2 and relevant portions of the expansive Administrative Record,3 are undisputed unless otherwise noted. The court has considered whether the parties have proffered admissible evidencein support of their positions and, in evaluating each party's respective summary judgment motion, has viewed the facts in the light most favorable to the non-moving party. See Spiegel v. Schulmann, 604 F.3d 72, 77, 81 (2d Cir.2010).

Plaintiff, a morbidly obese man in his fifties during the period relevant to this action, is a former Allstate employee who began receiving LTD benefits through the Plan in 2004. In 2008, Hartford terminated those LTD benefits, upon a finding that plaintiff was no longer disabled under the meaning of the Plan. After filing an unsuccessful administrative appeal of Hartford's termination decision, plaintiff now argues that Hartford's termination of his LTD benefits was improper, unfair, and unsupported by substantial evidence.

Set forth below is a detailed summary of the Plan documents, plaintiff's personal background and employment history, and the extensive medical evidence and proceedings relevant to Hartford's termination of plaintiff's LTD benefits.

I. The Plan Documents

Beginning in January 1, 2000, Hartford, a claims administrator, insured and administered the Plan through an insurance policy designated “GLT–673454.” 4 (Hart. 56.1 Stmt. ¶ 3; Pl. 56.1 Resp. ¶ 3; AR 1, 15–16.) The parties do not dispute that plaintiff enrolled and participated in the Plan and received disability benefits under that Plan. (Hart 56.1 Stmt. ¶ 3; Pl. 56.1 Resp. ¶ 3.) The parties disagree, however, regarding whether the documents included in the Administrative Record constitute “the Plan” that lies at the heart of this action. ( Compare Pl. 56.1 Stmt. ¶¶ 117–20, Pl. 56.1 Resp. ¶¶ 3–6, and Pl. Mem. at 28, with Hart. 56.1 Stmt. ¶¶ 3–8, Hart. Resp. ¶¶ 117–20, and Hart. Opp. at 8–9.) These documents include: (A) the “Group Benefit Plan: Allstate Insurance Company (the “Group Benefit Plan Document”), (AR 12–39), and (B) the Amendment to Group Policy 673454 on July 30, 2004 (the 2004 Policy Amendment or the Amendment), (AR 1–11).

A. The Group Benefit Plan Document/Booklet–Certificate

The Group Benefit Plan Document contains a Certificate of Insurance, which explains that

[t]he terms of the Group Insurance Policy which affect an employee's insurance are contained in the following pages [of the Group Benefit Plan]. This Certificate of Insurance and the following pages will become your Booklet-certificate. The Booklet-certificate is part of the Group Insurance Policy.

This Booklet-certificate replaces any other which Hartford Life may have issued to the Policyholder to give you under the Group Insurance Policy specified herein.

(AR 15.) Additionally, the Group Benefit Plan Document includes a “Schedule of Insurance” document, which provides a “Plan Effective Date” of January 1, 2000, identifies the Group Insurance Policy as “GLT–673454,” and clarifies that the benefits described within the Group Benefit Plan are “those in effect as of January 1, 2003.” (AR 16.) The Schedule of Insurance also specifies that [t]his plan of Disability Insurance provides you with loss of income protection if you become disabled from a covered accidental bodily injury, sickness or pregnancy.” ( Id.)

Moreover, in response to the question “Who interprets policy terms and conditions?”, the Group Benefit Plan Document clarifies that Hartford retains “full discretion and authority to determine eligibility for benefits and to construe and interpret all terms and provisions of the Group Insurance Policy.” (AR 27.)

The Group Benefit Plan Document then provides the following definitions of relevant terms:

Any Occupation means an occupation for which you are qualified by education, training or experience, and that has an earnings potential greater than an amount equal to the lesser of the product of your Indexed Pre-disability Earnings and the Benefits Percentage and the Maximum Monthly Benefit shown in the Schedule of Insurance.

...

Disability or Disabled means that during the Elimination Period and for the next 24 months you are prevented by: 1. accidental bodily injury; 2. sickness; 3. Mental Illness; 4. Substance Abuse; or 5. pregnancy, from performing one or more of the Essential Duties of Your Occupation, and as a result your Current Monthly Earnings are no more than 80% of your Indexed Pre-disability Earnings. After that, you must be so prevented from performing one or more of the Essential Duties of Any Occupation.

...

Monthly Benefit means a monthly sum payable to you while you are Disabled, subject to the terms of the Group Insurance Policy.

Physician means a person who is: 1. a doctor of medicine, osteopathy, psychology or other healing art recognized by us; 2. licensed to practice in the state or jurisdiction where care is being given; and 3. practicing within the scope of that license.

Regular Care of a Physician means you are attended by a Physician, who is not related to you: 1. with medical training and clinical experience suitable to treat your disabling condition; and 2. whose treatment is: a) consistent with the diagnosis of the disabling condition; b) according to guidelines established by medical, research and rehabilitative organizations; and c) administrated as often as needed, to achieve the maximum medical improvement.

(AR 28–31.)

The Group Benefit Plan Document further provides that Hartford may terminate a claimant's LTD benefits on any the following dates, among others:

1. the date you are no longer Disabled as defined;

2. the date you fail to furnish Proof of Loss, when requested by [Hartford];

3. the date you are no longer under the Regular Care of a Physician, or refuse [Hartford's] request that you submit to an examination by a Physician;

...

7. the date no further benefits are payable under any provision in this plan that limits benefit duration.

(AR 20.)

Further, the Group Benefit Plan Document contains an ERISA Information” section, which states as follows:

This employee welfare benefit (Plan) is subject to certain requirements of the Employee Retirement Income Security Act of 1974 (ERISA), as amended. ERISA requires that you receive a Statement of ERISA Rights, a description of Claim Procedures, and other specificinformation about the Plan. This document ... provides important information about the Plan.

The benefits described in your booklet-certificate (Booklet) are provided under a group insurance policy (Policy) issued by ... Hartford ... and are subject to the Policy's terms and conditions. The Policy is incorporated into, and forms a part of, the Plan. The Plan has designated and named the Insurance Company as the claims fiduciary for benefits provided under the Policy. The Plan has granted the Insurance Company full discretion and authority to determine eligibility for benefits and to construe and interpret all terms and provisions of the Policy.

A copy of the Plan is available for your review during normal working hours in the office of the Plan Administrator.

(AR 33.) The Group Benefit Plan Document thereafter describes the procedures for filing claims for benefits and appealing denials of such claims. (AR 36–38.)

B. The 2004 Policy Amendment

Like the Group Benefit Plan Document, the 2004 Policy Amendment sets forth an effective date...

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