Lamb v. Hartford Life & Accident Insurance

862 F. Supp. 2d 1342, 2012 U.S. Dist. LEXIS 39207, 2012 WL 1016116
CourtDistrict Court, M.D. Georgia
DecidedMarch 22, 2012
DocketCivil Action No. 5:10-CV-253
StatusPublished
Cited by3 cases

This text of 862 F. Supp. 2d 1342 (Lamb v. Hartford Life & Accident Insurance) is published on Counsel Stack Legal Research, covering District Court, M.D. Georgia primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Lamb v. Hartford Life & Accident Insurance, 862 F. Supp. 2d 1342, 2012 U.S. Dist. LEXIS 39207, 2012 WL 1016116 (M.D. Ga. 2012).

Opinion

ORDER

HUGH LAWSON, Senior District Judge.

This case arises from Defendant Hartford Life and Accident Insurance Company’s (“Hartford”) denial of Plaintiff Ruben Lamb’s (“Plaintiff’) long-term disability (“LTD”) benefits. Plaintiff claims that Hartford wrongfully determined that he [1344]*1344did not qualify for LTD benefits in violation of the Employee Retirement Income Security Act of 1974, 29 U.S.C. § 1001 et seq. (“ERISA”). In response, Hartford contends that the termination of coverage was appropriate, but even if it was de novo wrong, the decision was reasonable under the arbitrary and capricious standard.

Before the Court are Defendant’s Motion for Judgment on the Administrative Record (Doc. 28) and Plaintiffs Motion for Summary Judgment (Doc. 25). For the reasons stated below, Defendant’s Motion is granted and Plaintiffs Motion is denied. The Court makes the following Findings of Fact and Conclusions of Law.

I. FINDINGS OF FACT1

a. The Policy

The starting point for any judicial review is the policy itself. Effective January 1, 2006, Hartford issued Group Policy No. GLT-675456 (“Policy”) to Plaintiffs employer, Wal-Mart Stores, Inc. (“WalMart”). This Policy was intended to fund LTD benefits for Wal-Mart employees, and it was sponsored and maintained by Wal-Mart within the meaning of Section 8(1) of ERISA. See 29 U.S.C. § 1002(1).

The definitions within a policy are of the utmost importance in any ERISA case, and the present case is no exception. The Policy at issue defines disability for the first twelve months as the inability to perform the claimant’s “own occupation.” After the first twelve months of benefits, disability is defined as the inability to perform “any occupation.” (Administrative Record (“AR”) 000282.2) “Any occupation” is defined as “any occupation for which You are qualified by education, training or experience that has an earnings potential greater than the lesser of: 1) 50% of Your Pre-disability Earnings; or 2) the Maximum Monthly Benefit.” (AR 279.) The Policy also contains the following provisions regarding termination of coverage:

Termination: When will my coverage stop?
Your coverage will end on the earliest of the following:
[T]he date Your Employer terminates Your employment. Your employment terminates on the date You cease to be a Full-time Active Associate in an eligible class for any reason, unless coverage is extended under the Continuation Provisions.3
Coverage while Disabled: Does my insurance continue while I am Disabled and no longer an Active Associate?
If You are Disabled and You cease to be an Active Associate, Your Insurance will [1345]*1345be continued: during the Elimination Period4 while You remain Disabled by the same Disability; and after the Elimination Period for as long as You are entitled to benefits under the Policy.

(AR 285.)

The Policy expressly provides Hartford with “full discretion and authority to determine eligibility for benefits and to construe and interpret all terms and provisions of The Policy.” (AR293.)

b. Plaintiffs Employment

Plaintiff worked as a truck driver with Wal-Mart for twelve years. The job description of a truck driver included the following responsibilities:

Properly operate an over the road tractor/trailer unit safely and efficiently while complying with all Company, local, state, and federal laws/guidelines. Sitting for extended periods of time, firm grasping of steering wheel while shifting gears. Repetitive foot motion to operate brake, clutch, and fuel pedals. Climbing sufficient to gain entry/exit from tractor cab, deck plate, or trailer as required. Upper and lower body mobility and strength to climb into a cabover tractor. Walking to/from equipment locations, such as distribution center, stores, clubs, vendors. Occasionally moving/feathering freight inside trailer.

(AR 22.) Plaintiff worked until March 20, 2008, when he ceased driving for WalMart and applied for disability benefits. (AR 252-53.)

c. Plaintiffs Claim for Long-Term Disability Benefits

On June 16, 2008, Wal-Mart advised Hartford that Plaintiff was claiming a disability due to a staph infection in his right elbow. (AR 272.) On his application for disability benefits, Plaintiff cited symptoms of “joints aching” and complained that he was unable to walk or ride for long periods of time. (AR 252-55.) Included in his application was an attending physician statement (“APS”) completed by Jonathan Velasquez, M.D., Plaintiffs internist and primary care physician. (AR 257-58.) In the APS, Dr. Velasquez confirmed that Plaintiffs primary diagnosis was septic olecranon bursitis in the right elbow and his secondary diagnosis was degenerative disc disease of the lumbar spine. (AR 31-32, 257.) Dr. Velasquez reported that Plaintiff had undergone an open excision of a septic olecranon bursa on his right elbow on June 5, 2008. (AR 257.) Dr. Velasquez noted that Plaintiff had been referred to William B. Wiley, M.D., an orthopedist, and had also been referred to a corneal surgeon because of impaired vision in his left eye. (AR 258.)

Dr. Wiley completed a physical examination of Plaintiff on June 23, 2008, eighteen days after the excision by Dr. Velasquez. (AR 130.) Dr. Wiley noted that Plaintiffs “pain and swelling is decreasing. He is feeling better.” Id. Plaintiff was told to work on his range of motion and to come back to see Dr. Wiley in three weeks. Id. Three weeks later, on July 14, 2008, Plaintiff returned to Dr. Wiley, who noted that Plaintiffs chief complaint was “resolving right elbow pain.” (AR 131.) Plaintiff was ordered to take antibiotics and return in three weeks.

In the meantime, on July 15, 2008, Hartford sent a letter to Plaintiff informing him that he was approved for LTD benefits under the Policy. (AR 244-46.) Hartford notified Plaintiff that he was considered disabled from his “own occupation,” which [1346]*1346qualified Plaintiff for twelve-months of coverage. Hartford informed Plaintiff that to be eligible for LTD benefits beyond June 20, 2009, Plaintiff would have to show that he was “totally disabled” within the meaning of the Policy, which would mean showing that he was precluded from working “any occupation.” (AR 50.) Absent a showing of “total disability,” Plaintiffs coverage period for his disability from his “own occupation” was scheduled to run from June 20, 2008 until June 19, 2009.5

In September 2008, it was determined that Plaintiff had degenerative joint disease (“DJD”) in his right knee. (AR 133.) In October 2008, Dr. Wiley saw Plaintiff again, and noted that Plaintiff said he was “doing pretty good ... [h]e has some intermittent pain along the knee and elbow, but doing a lot better.” (AR 137.) Around the same time, Plaintiff told Hartford that while he wanted to return to work, he was worried about his eye, which had been giving him problems.

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Cite This Page — Counsel Stack

Bluebook (online)
862 F. Supp. 2d 1342, 2012 U.S. Dist. LEXIS 39207, 2012 WL 1016116, Counsel Stack Legal Research, https://law.counselstack.com/opinion/lamb-v-hartford-life-accident-insurance-gamd-2012.