Bertelsen v. Hartford Life Insurance

1 F. Supp. 3d 1060, 2014 U.S. Dist. LEXIS 19225, 2014 WL 585417
CourtDistrict Court, E.D. California
DecidedFebruary 14, 2014
DocketNo. 2:12-cv-01440-TLN-GCH
StatusPublished
Cited by6 cases

This text of 1 F. Supp. 3d 1060 (Bertelsen v. Hartford Life Insurance) is published on Counsel Stack Legal Research, covering District Court, E.D. California primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Bertelsen v. Hartford Life Insurance, 1 F. Supp. 3d 1060, 2014 U.S. Dist. LEXIS 19225, 2014 WL 585417 (E.D. Cal. 2014).

Opinion

FINDINGS OF FACT AND CONCLUSIONS OF LAW

TROY L. NUNLEY, District Judge.

This action arises out of Defendant Hartford Life and Accident Insurance Company’s (“Defendant”) termination of Plaintiff Karen Bertelsen’s (“Plaintiff’) long-term disability benefits. This motion is before the Court on Plaintiffs motion for judgment pursuant to Rule 521 (ECF [1063]*1063No. 17) and Defendant Hartford Life and Accident Insurance Company’s motion for judgment pursuant to Rule 52 or alternatively for summary judgment pursuant to Rule 56 (ECF No. 20). Each party opposes the other’s motion. (ECF Nos. 24, 25.) The Court has carefully considered the parties’ arguments, and hereby grants Plaintiffs motion for judgment pursuant to Rule 52.

I.FINDINGS OF FACT2

A. Plaintiff Files a Claim for Long-Term Disability Benefits

1. Plaintiff Karen Bertelsen was born on July 4,1964.

2. Plaintiff was employed by Soma Networks, Inc. (“Soma”) as an engineering document control manager. She worked for Soma from 2006 to 2008.

3. Her job duties as a document control manager were sedentary. Her job duties generally required her to communicate engineering plan changes to appropriate parties, create policies and procedures, and troubleshoot. To carry out her duties, she would frequently type and sit, and occasionally walk, stand, balance, stoop, and reach overhead to work.

4. During Plaintiffs employment with Soma, the company offered long-term disability benefits funded through an insurance policy issued by Defendant.

5. Defendant both administered and funded the long-term disability benefits at issue in this action. (Def.’s Opp’n Pl.’s Mot. J., ECF No. 25 at 1:12-13.)

6. The applicable long-term disability benefits plan has two definitions of disabled. In order to qualify as “disabled” under the first definition, the employee must be unable to work in the employee’s own occupation for the first two years. Specifically, the policy provides “Disability or Disabled means that during the Elimination Period and or the next 24 months you are prevented by: accidental bodily injury, sickness; mental illness; substance abuse; or 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.” (Soma Networks, Inc., Long Term Disability, Life and Acc. Death & Dismemberment, ECF No. 2-1 at CF 000003-52.)

7. After the first two years, the definition of disability becomes more restrictive and requires that the employee is unable to work in any occupation. Specifically, the policy provides: “After that, you must be prevented so from performing one or more of your Essential Duties of Any Occupation.” The policy defines “any occupation” as “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 Benefit Percentage and the Maximum Monthly Benefit shown in the Schedule of Insurance.” The policy also defines “essential duty” as a duty that is “substantial, not incidental; is fundamental or inherent to the occupation; and cannot be reasonably omitted or changed.” (ECF No. 2-1 at CF 000003-52.)

8. The policy provides that “When do benefits become payable? You will be paid a monthly benefit if: 1. You become Disabled while insured under this plan; 2. You are Disabled throughout the Elimination Period; 3. You remain Disabled beyond the Elimination Period; 4. You are, and have been during the Elimination Period, under the Regular Care of a Physi-[1064]*1064dan; and 5. You submit Proof of Loss satisfactory to us. Benefits accrue as of the first day after the Elimination Period and are paid monthly.” (Admin. Record, ECF No. 2-1 at CF 000003-52.)

9. The policy provides: “When will benefit payments terminate? 1. The date you are no longer Disabled as defined;.. ..” (ECF No. 2-1 at CF 000003-52.)

10. The policy contains a discretionary clause, providing: “Who interprets policy terms and conditions? We have full discretion and authority to determine eligibility for benefits and to construe and interpret all terms and provisions of the Group Insurance Policy.” (ECF No. 2-1 at CF 000003-52.)

11. The policy provides the participant with appeal rights which included, without limitation, the participant’s right to submit new or different information in addition to what had been submitted during the consideration of the claim. The policy requires an independent review of the appeal, by an individual who did not make the initial decision, and who was not the subordinate of the person who made the decision.

12. In July 2008, Plaintiff submitted a claim for long-term disability benefits, based on her complaints of back pain.

B. Defendant and the Social Security Administration Determine Plaintiff is Disabled Under Their Respective Deñnitions

13. After reviewing Plaintiffs medical records, Defendant approved Plaintiffs claim by letter dated September 12, 2008, retroactive to July 3, 2008. Defendant’s finding was pursuant to the policy’s “own occupation” definition of disability.

14. Plaintiff was a member of Kaiser Permanente, and primarily treated by nurse practitioner Roberta Heck between September 12, 2008, and 2010 for degenerative changes of her lower lumbar spine.

15. Plaintiff was also treated by chiropractor Dr. Kyle Yoder once or twice per week from September 23, 2009, through November 2010. (ECF No. 20 n. 3.)

16. In 2009, Plaintiff also consulted Dr. Tracy Ann Jones, a physical medicine and rehabilitation doctor with Kaiser. Dr. Jones provided Plaintiff with an epidural steroid injection for pain on March 6, 2009. (ECF No. 20 at 5:19-6:1.) Dr. Jones provided Plaintiff with a second epidural steroid injection on October 8, 2009. (ECF No. 20 at n. 5.)

17. Ms. Heck examined Plaintiff on February 1, 2010, and ordered a new MRI to compare with an MRI taken in 2006.

18. On April 27, 2010, Ms. Heck advised Plaintiff in writing that her MRI showed “mild worsening at most disc levels.” (ECF No. 4-4 at CF 000767.) Plaintiff did not see Ms. Heck after February 1, 2010.

19. Plaintiff also consulted with osteopath Dr. Robert Gabby in connection with her claim for Social Security Disability Benefits.

20. Defendant conducted an Employee Analysis Assessment dated June 22, 2010. Based on the information then available, Defendant determined that Plaintiff was not capable at that point of returning to qualifying employment. Defendant determined that there were no occupations that appeared to be reasonable for the purpose of the analysis, either because Plaintiff was not qualified to perform the job, the occupations were not available 30 hours per week, or they did not meet the required potential earnings.

21. By letter dated June 23, 2010, Defendant determined that Plaintiff qualified for long-term disability benefits under the expanded definition of disability which in-[1065]

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Bluebook (online)
1 F. Supp. 3d 1060, 2014 U.S. Dist. LEXIS 19225, 2014 WL 585417, Counsel Stack Legal Research, https://law.counselstack.com/opinion/bertelsen-v-hartford-life-insurance-caed-2014.