Faulkner v. Hartford Life & Accident Insurance

860 F. Supp. 2d 1127, 2012 WL 913632, 2012 U.S. Dist. LEXIS 36116
CourtDistrict Court, E.D. California
DecidedMarch 16, 2012
DocketNo. CIV. S-11-0408 LKK/CKD
StatusPublished
Cited by1 cases

This text of 860 F. Supp. 2d 1127 (Faulkner v. Hartford Life & Accident 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
Faulkner v. Hartford Life & Accident Insurance, 860 F. Supp. 2d 1127, 2012 WL 913632, 2012 U.S. Dist. LEXIS 36116 (E.D. Cal. 2012).

Opinion

ORDER

LAWRENCE K. KARLTON, Senior District Judge.

This is a case brought under the Employee Retirement Income Act of 1974 (“ERISA”), 29 U.S.C. § 1001, et seq. Mary Beth Faulkner challenges the termination of her disability benefits by defendant Hartford Life & Accident Ins. Co. (“Hartford”). For the reasons set forth below, plaintiffs motion for summary judgment is GRANTED, and defendant’s cross-motion for summary judgment is DENIED.

SUMMARY

Plaintiff Mary Beth Faulkner was bitten by a tick while camping with her family in Maryland. Soon after, she began complaining of debilitating fatigue and other symptoms. She was examined and treated by several physicians and diagnosed with Lyme Disease (among other diagnoses). These physicians did not agree on the etiology of her complaints,1 but they all agreed that Faulkner was suffering fatigue and other debilitating symptoms, that the symptoms were real, and that they prevented her from working on a full-time basis. On December 20, 2003, the Social Security Administration determined that Faulkner was disabled (effective October 20, 2001), and awarded her benefits.2 It reached the same conclusion again on October 19, 2005.3 Hartford itself concluded that plaintiff, who was covered by Hartford’s disability policy, was disabled by these symptoms, and awarded her short-term disability benefits and then long-term disability benefits. It conducted periodic reviews of plaintiffs medical records, and concluded each time that she was indeed disabled and unable to work.

However, in 2008, Hartford thought that it had detected a discrepancy in her treating physician’s statements, and initiated a fraud investigation of plaintiffs claim. After conducting a surreptitious surveillance of plaintiff, and finding no fraud, Hartford hired a series of reviewers who concluded that Faulkner was not disabled (one of them concluded, contrary to Hartford’s own conclusions, that she had never been sick), and that she could work. Based on the views of these hired reviewers, Hartford terminated Faulkner’s disability bene[1129]*1129fits. Faulkner sues here seeking reinstatement of the benefits.

I. BACKGROUND

Starting March 15, 1999, plaintiff worked as a tax consultant for PricewaterhouseCoopers LLP (“PwC”).4 In July 1999, plaintiff became covered by defendant PricewaterhouseCoopers LLP Health & Welfare Benefits Plan (the “Plan”).5 The Plan is an employee benefit plan sponsored by plaintiffs employer PwC.6 The Plan was administered and insured by defendant Hartford Life & Accident Ins. Co.7 The Plan confers on Hartford “full discretion and authority to determine eligibility for benefits.”8 Accordingly, in its fiduciary capacity as administrator (“claims review fiduciary”), Hartford determines whether a claim should be paid under the policy,9 and” then either pays the claim or not, in accordance with its determination.10

A. Tick Bite and Initial Treatment; Plaintiff Is Treated by Dr. Mo.11

On May 19, 2001, while hiking with her family in Maryland, plaintiff was bitten by a tick.12 She soon developed a bull’s-eye expanding rash and came down with flu-like symptoms, including fatigue, fever, headaches, myalgia, weakness, facial pain and palsy, and dizziness.13 On June 14, 2001, plaintiff visited Steven Mo, M.D., who was apparently her primary care doctor at that time.14 Dr. Mo diagnosed plaintiff with “Lyme disease.”15 Plaintiff continued to be treated by Dr. Mo (June 2001 to December 2001), who reported on plaintiffs fatigue, lethargy, neurologic deficits, tremulous hands, inability to stand, walk or sit, and incapacitating symptoms.16 Some of these findings were listed as examination findings and others were listed as subjective complaints. Dr. Mo never expressed any doubts about plaintiffs subjective complaints, and set the tone for the remainder of plaintiffs experiences when he noted that she was “unable to perform meaningful tasks for long.”17

[1130]*1130On July 5, 2001, plaintiff was admitted to the hospital, where she was treated by Daniel P. Ikeda, M.D.,18 and received IV antibiotic treatment.19 In July 2001, plaintiff applied for short-term disability benefits under the Hartford policy.20 Plaintiffs last day of work at PwC was July 15, 2001.21 On August 20, 2001, Hartford approved the payment of short-term disability benefits to plaintiff, and subsequently extended payments through January 2, 2002, the maximum period for short-term disability benefits.22

B. Plaintiff Is Treated by Dr. Ikeda.23

On January 11, 2002, Hartford approved the payment of long-term disability benefits to plaintiff, after finding that she was unable to work in her own occupation.24 Soon afterward, it appears that plaintiff began to be treated principally by Daniel P. Ikeda, M.D. (July 2001 to September 2004). Dr. Ikeda was clearly dubious about plaintiffs Lyme disease diagnosis.25 Over the course of many examinations, he too noted her fatigue, although he indicated that it might be caused by fibromyalgia or chronic fatigue syndrome.26 Indeed, he never expressed any doubts about plaintiffs subjective complaints. He was so doubtful of the Lyme disease diagnosis, however, that he scheduled plaintiff for a lab test, predicting confidently that it would be negative. The test came back positive, leading Dr. Ikeda to a new conclusion: “it suggests that Mary Beth continues to have persistent Lyme disease.”27

C. Plaintiff Is Examined by Dr.

[1131]*1131Liegner.28

On September 10, 2002, plaintiff was evaluated by Kenneth B. Liegner, M.D., of New York.29 Dr. Liegner reported that despite the absence of laboratory substantiation, he had no doubt that plaintiff had Lyme disease.30

D. Plaintiff is Treated by Dr. Green.31

Plaintiff was then examined and treated by Christine Green, M.D. (April 2002 to the present).32 On April 27, 2002, Dr. Green wrote a letter to Hartford setting forth her view that plaintiff was disabled from Lyme disease, and proposing to treat her for neuroborreliosis.33 Like the doctors before her, Dr. Green consistently reports on plaintiffs fatigue and “cognitive trouble memory issues.”34 She diagnosed plaintiff with Lyme disease and encephalopathy, and concluded that plaintiff was “physically unable to stand, sit or walk consistently,” and that she “has had real cognitive difficulty.”35 Dr.

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Related

Topalian v. Hartford Life Insurance
945 F. Supp. 2d 294 (E.D. New York, 2013)

Cite This Page — Counsel Stack

Bluebook (online)
860 F. Supp. 2d 1127, 2012 WL 913632, 2012 U.S. Dist. LEXIS 36116, Counsel Stack Legal Research, https://law.counselstack.com/opinion/faulkner-v-hartford-life-accident-insurance-caed-2012.