Lamuth v. Hartford Life & Accident Insurance

30 F. Supp. 3d 1036, 2014 WL 3360322, 2014 U.S. Dist. LEXIS 93387
CourtDistrict Court, W.D. Washington
DecidedJuly 9, 2014
DocketCase No. C13-1832-JCC
StatusPublished
Cited by2 cases

This text of 30 F. Supp. 3d 1036 (Lamuth v. Hartford Life & Accident Insurance) is published on Counsel Stack Legal Research, covering District Court, W.D. Washington primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Lamuth v. Hartford Life & Accident Insurance, 30 F. Supp. 3d 1036, 2014 WL 3360322, 2014 U.S. Dist. LEXIS 93387 (W.D. Wash. 2014).

Opinion

ORDER

JOHN C. COUGHENOUR, District Judge.

This matter comes before the Court on the motion to dismiss filed by Defendant Hartford Life and Accident Insurance Company (Dkt. No. 21) and Plaintiff Dela-cy Lamuth’s motion for partial summary judgment (Dkt. No. 28). Having thoroughly considered the parties’ briefing and the relevant record, the Court finds oral argument unnecessary and hereby GRANTS IN PART and DENIES IN PART Defendant’s motion to dismiss and GRANTS Plaintiffs motion for summary judgment.

I. BACKGROUND

Plaintiff Delacy Lamuth, M.D., brought this ERISA lawsuit to recover benefits due under a long-term disability plan established and maintained by her former employer, Inland Imaging Associates, PS (“Inland”), and to seek clarification of her rights to future benefits under the same. The employee welfare benefit plan is underwritten and insured by Defendant Hartford Life and Accident Insurance Company (“Hartford”), which has authority to grant or deny claims under the Plan. As explained herein, Hartford denied, then granted, then reversed itself and again denied Dr. Lamuth’s claim for benefits. After Dr. 'Lamuth brought this lawsuit, Hartford again changed course, re-reviewed the claim, and awarded her benefits. While Dr. Lamuth'is currently receiving long-term disability benefits under the Plan, the parties dispute whether she may continue this lawsuit and obtain a declaratory ruling as to when she first became disabled under the Policy. Dr. Lamuth seeks such a ruling in order to preclude Hartford from continuing to reverse its position on this issue. The Court reviews the Policy provisions and the parties’ relationship to date.

A. The Hartford Policy

Under the terms of the Policy, the terms “Disabled” and “Disability” are defined in relevant part as follows:

You are prevented from performing one or more of the Essential Duties of:

1) Your Occupation during the Elimination Period; and
2) Your Occupation following the Elimination Period, and as a result Your Current Monthly Earnings are less than 80% of Your Indexed Pre-disability Earnings.
If at the end of the Elimination Period, You are prevented from performing one or more of the Essential Duties of Your Occupation, but Your Current Monthly Earnings are 80% or more of Your Pre-disability Earnings, Your Elimination Period will be extended....
Your Disability must result from: 1) accidental bodily injury; 2) sickness; 3) Mental Illness; 4) Substance Abuse; or 5) pregnancy.

(Dkt. No. 23, Ex. 1 at 25-26.) An “Essential Duty” is defined as a duty that “1) is substantial, not incidental; 2) is fundamental or inherent to the occupation; and 3) cannot be reasonably omitted or changed. Your ability to work the number of hours in Your regularly scheduled work week is an Essential Duty.” (Id. at 26.) The Plan contains a Pre-existing Conditions Limitation, however, which precludes the payment of benefits for an individual with a qualifying Disability under certain circumstances. That provision states that Hartford “will not pay any benefit ... under The Policy for any Disability that ... is caused or contributed to by, a Pre-existing [1039]*1039Condition, unless, at the time You became Disabled ... 1) You have‘been continuously insured under The Policy for 12 consecutive month(s).” (Id. at 20.)

If an individual is deemed “Disabled” under the Plan and not subject to the Pre-Existing Conditions Limitation, among others, Hartford will pay benefits. The Policy contains numerous additional requirements with which a claimant must comply for benefits payment to continue on a regular basis. The Policy requires ongoing Proof of Loss to qualify for benefits, which includes, in part: documentation of the prognosis of disability; earnings and income; evidence that the claimant is under the Regular Care of a Physician; any and all medical information; the identification of all physicians, hospitals, pharmacies; and documentation regarding Other Income Benefits. (Id. at 20.) The Policy also permits Hartford to require the claimant to meet and interview with its representative and to have the claimant examined by a Physician, vocational expert, functional expert, or other professional. (Id. at 21.) The Policy specifically provides that Hartford “may request Proof of Loss throughout Your Disability!),]” and “must receive the proof within 30 day(s) of the request.” (Id.)

Finally, the Policy contains a Termination of Payments provision, pursuant to which benefit payments will stop on the earliest of:

1) the date You are no longer Disabled; 2) the date You fail to furnish Proof of Loss; ' 3) the date You are no longer under the Regular Care of a Physician; 4) the date You refuse Our request that You submit to an examination by a Physician or other qualified professional; 5) the date of Your death; 6) the last day benefits are payable according to the Maximum Duration of Benefits Table; 7) the date Your Current monthly Earnings exceed 80% of Your Indexed Pre-disability Earnings if You are receiving benefits for being Disabled from Your Occupation; or 8) the date no further benefits are payable under any provision in The Policy that limits benefit duration.

(Id. at 15-16.) Notably, the Pre-existing Conditions Limitation is not subject to the ongoing Proof of Loss provision or the Termination of Payments provision; instead, it exists as a separate exclusion under the Policy’s terms.

B. Dr. Lamuth’s Claim Under the Hartford Policy

Dr. Lamuth is a radiologist. She first became a beneficiary under the Hartford Plan on July 1, 2011, when she began working for Inland Imaging Associates, PS at Samaritan Hospital in Moses Lake, Washington. (Dkt. No. 25-2, Ex. 1 at 48.) Before joining Inland Imaging, Dr. La-muth was diagnosed with multiple sclerosis. Her diagnosis notwithstanding, Dr. Lamuth worked as the sole radiologist at Samaritan Hospital until February 14, 2013, when she ended her employment due to the effects of her MS. (Id. at 36, 48, 68.)

Dr. Lamuth applied for long-term disability (“LTD”) benefits under the Hartford Plan on March 1, 2013. (Dkt. No. 25-1, Ex. 1. at 32.) Upon receipt of her claim, Hartford noted in its files that Dr. La-muth’s “Recovery Outlook” was “Low,” her “Occupational Complexity” was “High,” and her disability was likely “permanent” due to the fact that MS is a “progressive disease.” (Id. at 30.) Shortly thereafter, Hartford noted that Dr. La-muth’s “Date of Disability” (“DOD”) was February 15, 2013, the day after she ended her employment. (Id. at 29.) However, Hartford expressed reservations as to Dr. Lamuth’s Date of Disability,'noting that it [1040]*1040may be able to apply an earlier DOD based on a report that Dr. Lamuth began working a “reduced schedule” on June 1, 2012. (Id. at 30.) If Hartford could use an earlier date, the claim notes repeatedly state, the Pre-existing Conditions Limitation would bar coverage. (See id. at 30 (“Will need to review for earlier DOD and pre-ex (if earlier supported)”); id. at 29 (noting need to “review for earlier [DOD] date”); id. at 27 (noting that Dr.

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30 F. Supp. 3d 1036, 2014 WL 3360322, 2014 U.S. Dist. LEXIS 93387, Counsel Stack Legal Research, https://law.counselstack.com/opinion/lamuth-v-hartford-life-accident-insurance-wawd-2014.