Hembree Ex Rel. Hembree v. Provident Life & Accident Insurance

127 F. Supp. 2d 1265, 2000 U.S. Dist. LEXIS 19507
CourtDistrict Court, N.D. Georgia
DecidedNovember 27, 2000
DocketCiv.A. 1:99CV19760-DE
StatusPublished
Cited by10 cases

This text of 127 F. Supp. 2d 1265 (Hembree Ex Rel. Hembree v. Provident Life & Accident Insurance) is published on Counsel Stack Legal Research, covering District Court, N.D. Georgia primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Hembree Ex Rel. Hembree v. Provident Life & Accident Insurance, 127 F. Supp. 2d 1265, 2000 U.S. Dist. LEXIS 19507 (N.D. Ga. 2000).

Opinion

ORDER

ORINDA D. EVANS, District Judge.

This civil action to recover disability benefits brought pursuant to the Employee Retirement Income Security Act (“ERISA”), as amended, 29 U.S.C. §§ 1001-1461, is currently before the court on the opposed motion for summary judgment of Defendant Provident Life and Accident Insurance Company. For the reasons set forth below, the motion for summary judgment is granted.

Helen Hembree (“Plaintiff’) brings the instant action to recover disability benefits on behalf of her husband, Hoke Hembree (“Hembree”), whom she alleges is mentally incompetent. Hembree was formerly employed by Georgia Power Company where he received disability insurance coverage under a group policy issued by Provident Life And Accident Insurance Company (“Provident”). Both parties agree that the group policy at issue is part of an employee welfare benefit plan as defined by ERISA.

Provident terminated Hembree’s disability benefits in January, 1989, stating that Hembree failed to establish proof of disability as required by the policy. This suit was filed in 1999.

Few records exist regarding Hembree’s claim and the termination of benefits because Hembree’s file was destroyed pursuant to Provident’s seven-year records retention policy. However Plaintiff asserts that she has been able to “fairly reconstruct [Hembree’s] medical history which would have been available to Defendant at all times while it was processing [Hem-bree’s] disability claim and paying him benefits throughout most of the 1980’s.” [PL Response to Def.Mot. Summary Judgment at 8]. This has been done through discovery from the Georgia Power Company, Social Security, and Hembree’s medical providers.

Hembree received long term disability benefits from Provident beginning in 1982 through and until January 31, 1989. The monthly benefit amounted to $365.31. There is no dispute that Hembree was disabled as defined by the policy during the years that he received the benefits. 1 *1267 Hembree’s disability mainly involves severe and often debilitating back and neck pain. He has had several back surgeries, including an anterior cervical discectomy and fusions of his vertabrae at C5-6 and C6-7. Additionally, Hembree is afflicted with other medical problems including stomach ulcers, hypertension, and an atrial abnormality.

Provident requires that proof of continued disability be submitted by the attending physician setting forth fully the condition and its expected duration as a condition precedent to receiving disability payments every six months. [Policy, Claim Provisions, Def.Ex. 3], Provident submits that Hembree failed to submit this proof of disability, and accordingly his benefits were terminated.

Through discovery from the Georgia Power Company, Provident obtained a letter that it had sent to Hembree, certified and return receipt requested, dated January 16, 1989, which chronicles the events that led up to the termination of Hem-bree’s benefits. The letter reads:

Your group plan provides that you must furnish Provident with a periodic report in writing from your attending physician or surgeon fully stating your condition and the probable duration of your disability. On September 7, October 19, and December 6, we wrote you requesting this proof of your continued disability.
As of this date, we have not received the requested proof; therefore, we can only assume that you are no longer totally disabled as provided in your group plan, and your LTD claim has been closed accordingly. Your final LTD benefit check will represent benefits through January 31,1989.
There is an Employee Retirement Income Security Act of 1974 (ERISA) qualified plan, under which you have certain rights, including the right of appeal. If you disagree with our determination, you may submit a written request for reconsideration within 90 days from the date of this letter, accompanied by detailed documents or records from your physician in support of your appeal.
If you have any questions regarding the above, please let us know.

[Def.Ex. 7]. A subsequent letter obtained from the Georgia Power Company dated January 26, 1989, sent to Hembree from Provident, certified and return receipt requested, shows that Provident did receive an attending physician statement for Hem-bree from Dr. Richardson. [Def.Ex. 8]. In the January 26, 1989, letter Provident informed Hembree that Dr. Richardson’s letter indicated that he was “not totally disabled from any occupation and that [he] was to stay active and continue working.” [Id.] Based on that language, Provident affirmed its earlier decision to discontinue Hembree’s disability benefits in the January 26th letter. [Id]

Prior to Provident’s termination of disability benefits, Hembree had been approved for and awarded. Social Security disability benefits. He continues to receive these benefits. Provident had knowledge of the Social Security disability benefits, and thus Social Security’s determination that Hembree was indeed disabled, when it terminated Hembree’s benefits. Plaintiff contends that Provident knew this information because Provident was entitled to a credit for Social Security benefits received.

Following the termination of Provident’s disability benefits in January, 1989, Provident asserts it received no further claim or communication from Hembree until April, 1999, when Hembree’s attorney sought to reopen the claim and demanded that the benefits be paid from January 31, 1989 through January 20, 1998, the end of the maximum’ benefit period. Plaintiff brought this suit on behalf of her husband, Hoke F. Hembree, whom she alleges is mentally incompetent and unable to handle *1268 his affairs at times relevant to these proceedings. Plaintiff asserts that she handled all of Mr. Hembree’s business and legal matters during the marriage but that the couple separated shortly before Hem-bree’s benefits were terminated. 2 Plaintiff submits that she learned the disability benefits had been terminated upon reuniting with Hembree in 1998. 3 She inquired with the Georgia Power Company and Provident but was unsuccessful in learning why the benefits had been terminated.

On June 28, 1999, Plaintiff filed the instant action in the State Court of Fulton County. The action was removed to the United States District Court of the Northern District of Georgia on July 30, 1999 pursuant to the provisions of 28 U.S.C. §§ 1441 and 1446. This court has federal question jurisdiction under 28 U.S.C. § 1331 as this action was filed under ERISA. Plaintiff has filed two claims against Provident: (1) a claim for benefits under the group policy pursuant to 29 U.S.C.

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Cite This Page — Counsel Stack

Bluebook (online)
127 F. Supp. 2d 1265, 2000 U.S. Dist. LEXIS 19507, Counsel Stack Legal Research, https://law.counselstack.com/opinion/hembree-ex-rel-hembree-v-provident-life-accident-insurance-gand-2000.