O'Brien v. Hartford Life & Accident Insurance

932 F. Supp. 2d 703, 2012 WL 7802756, 2012 U.S. Dist. LEXIS 187386
CourtDistrict Court, E.D. Louisiana
DecidedJune 7, 2012
DocketCivil Action No. 11-1838
StatusPublished

This text of 932 F. Supp. 2d 703 (O'Brien v. Hartford Life & Accident Insurance) is published on Counsel Stack Legal Research, covering District Court, E.D. Louisiana primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
O'Brien v. Hartford Life & Accident Insurance, 932 F. Supp. 2d 703, 2012 WL 7802756, 2012 U.S. Dist. LEXIS 187386 (E.D. La. 2012).

Opinion

ORDER AND REASONS

CARL J. BARBIER, District Court.

This matter is before the Court on the parties’ cross-motions for judgment on the administrative record (Rec. Docs. 18, 21). Each party opposes the other’s motion, and the motions are before the Court on supporting memoranda and without oral argument.

PROCEDURAL HISTORY AND BACKGROUND FACTS

This civil action is a claim for additional disability benefits under an employee benefit plan governed by the Employee Retirement Income Security Act (“ERISA”). Plaintiff Kathleen O’Brien worked as a traveling nurse for American Nursing Services, Inc., and is a participant in and a beneficiary of a Group Short-Term Disability, Long-Term Disability, Supplemental Dependant Life, and Supplemental Term Life Plan (“the Plan”) created and sponsored by her former employer.1 American Nursing Services provided dis[707]*707ability benefits to Plan participants through a group disability policy issued by Defendant Hartford Life & Accident Insurance Company (“Hartford”).

Under the terms of Hartford’s policy, short-term and long-term disability benefits are payable only if the insured becomes “Disabled from a covered injury, Sickness, or pregnancy.”2 The short-term disability benefit provided under the policy is a weekly benefit comprised of “[t]he lesser of: 1) 65% of Your Pre-disability Earnings; or 2) $2,000, reduced by Other Income Benefits.”3

The term “Pre-disability Earnings” is defined under the policy’s short-term disability benefits section as “[the insured’s] regular weekly rate of pay, not counting bonuses, commissions, tips and tokens, overtime pay or any other fringe benefits or extra compensation in effect on the date” the insured was actively at work before becoming disabled.4 The long-term disability benefit provided under the policy is also calculated with respect to the insured’s Pre-disability Earnings. The monthly long-term disability benefit is calculated by multiplying the insured’s Predisability Earnings by a set “Benefit Percentage,” which, in this case, is 65%, up to a maximum monthly benefit of $5,000.5 The long-term disability benefit section employs a substantially similar definition of the term “Pre-disability Earnings,” stating: “Pre-disability Earnings means Your regular monthly rate of pay, not counting bonuses, commissions and tips and tokens, overtime pay or any other fringe benefits or extra compensation in effect on the last day You were Actively at Work before You became Disabled.”6

Plaintiff filed a claim for disability benefits with Hartford after experiencing severe headaches that precluded her from continuing to work as a full-time registered nurse. After reviewing her claim, Hartford determined that Plaintiff was disabled under the terms of the policy and began paying her short-term disability benefits, based upon Plaintiffs $20/hour wage, for a total weekly rate of pay of $800.7 On March 12, 2009, Plaintiff notified Hartford that its information regarding her income was incorrect, in that her regular weekly income was $1,682, rather than $800.8 Hartford responded that it would need to verify this information with American Nursing Services before taking any action. On March 16, 2009, American Nursing Services notified Hartford that Plaintiffs weekly income was $1,682, rather than $800, and as a result, Hartford adjusted the short-term disability benefit to reflect the Pre-Disability Earnings Plaintiff reported, rather than the $800 initially determined.9 Later, on August 11, 2009, Hartford approved and began paying Plaintiff long-term disability benefits based upon the $1,682 weekly income figure that Plaintiff had reported.10

Subsequently, during a periodic review of benefits, Hartford requested and reviewed Plaintiffs 2009 tax returns, at which point it reportedly discovered that Plaintiffs weekly taxable rate of pay was $770.38, and not $l,682.11 Based upon this [708]*708information, on December 20, 2010, Hartford reduced Plaintiffs long-term disability benefits in accordance with a weekly rate of pay of $770.38 and notified Plaintiff of its decision and its intention to seek reimbursement for the overpayment of both long-term and short-term disability payments.12

Plaintiff promptly challenged Hartford’s decision through an administrative appeal, arguing that her “Pre-disability Earnings” included a weekly per diem payment of $882, which included $280 per week for meals and other incidentals and $602 per week for housing.13 In support of her appeal, Plaintiff also submitted additional documentation for Hartford’s consideration, including her American Nursing Services Travel Employment Agreement and Travel Assignment Pricing Spreadsheet.14 On June 23, 2011, Hartford denied the appeal based on its determination that the fixed weekly per diem Plaintiff received from her employer should not be included in the calculation of her “Predisability Earnings” because it amounted to a “fringe benefit” or “extra compensation,” rather than her “regular weekly rate of pay.”15 Plaintiff subsequently requested further review of Hartford’s determination, but the request was denied.16

Having exhausted her administrative appeals, Plaintiff initiated this action in federal court, seeking payment of benefits under the policy, along with prejudgment interest, attorney’s fees, and costs.17 Hartford then filed an Answer and Counterclaim, seeking to recover $40,313.36 in improperly paid benefits based on the allegedly inflated rate of pay Plaintiff reported.18 The administrative record has now been filed, and the parties have filed cross-motions for judgment on the administrative record.

PARTIES’ ARGUMENTS

In her motion, Plaintiff argues that her $882 per diem allowance was part of her regular monthly rate of pay, rather than a “fringe benefit” or form of “extra compensation,” contrary to Hartford’s determination. She reports that this payment was regularly made with each pay check she received from her employer, and not as an additional or irregular form of compensation. She also points out that this payment was made- regardless of whether she actually incurred any expenses for lodging, meals, or any other incidental costs, and in exchange she waived her right to seek reimbursement for any other business expenses incurred in connection with her employment with American Nursing Services. She further notes that Hartford was operating under a structural conflict of interest, because it both evaluates and pays claims. In sum, because the administrative record shows that her per diem was a component of her regular rate of pay, Plaintiff submits that Hartford’s determination that it was a “fringe benefit” or “extra compensation” was arbitrary and capricious.

[709]*709Plaintiff additionally contends that Hartford’s reliance on the Internal Revenue Service (“IRS”)’s “Taxable Fringe Benefits Guide” to determine whether her per diem constituted a “fringe benefit” within the meaning of the policy is further evidence that its determination was arbitrary and capricious.

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Bluebook (online)
932 F. Supp. 2d 703, 2012 WL 7802756, 2012 U.S. Dist. LEXIS 187386, Counsel Stack Legal Research, https://law.counselstack.com/opinion/obrien-v-hartford-life-accident-insurance-laed-2012.