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Gary S. Hines v. Hartford Life Insurance Company

March 29, 2012


The opinion of the court was delivered by: Herndon, Chief Judge:


I. Introduction and Background

Pending before the Court are the parties' cross motions for summary judgment, memorandums in support and responses in opposition (Docs. 33, 40, 54, 55). Both parties maintain that they are entitled to summary judgment on plaintiff's ERISA cause of action. Defendant Hartford Life Insurance Company ("Hartford") maintains that it is entitled to summary judgment as it reasonably determined that plaintiff Gary S. Hines ("Hines") was not disabled under the terms of his long-term disability benefits plan, while, Hines maintains that he is entitled to summary judgment as Hartford's continuing refusal to pay his long-term disability benefits in spite of clear medical evidence in the Administrative Record supporting payment to him is in violation of the plan and of ERISA and that Hartford's decisionmakers have an inherent conflict of interest and bias in favor of denying and terminating claims.

Based on the applicable law and the following, the Court grants plaintiff's motion for summary judgment and denies defendant's motion.

On April 9, 2010, Hines filed a one count complaint against Hartford under the Employee Retirement Income Social Security Act of 1974, as amended, 29 U.S.C. § 1001 et seq. ("ERSIA") to recover disability pension benefits due under a Disability Pension Plan (Doc. 2). The complaint alleges that Hines, while employed at MasterCard Worldwide, participated in a Long-Term Disability Plan from Hartford. Hines has been declared disabled and unable to work in any capacity and was declared eligible, by Hatford, for the initial classification of Long-Term Disability benefits under the Group Insurance plan. Thereafter, Hines alleges that defendant has improperly withheld disability benefits which are due to him pursuant to the terms of the Long-Term Disability Plan. Hines seeks the back disability benefits under the plan plus future disability benefits, attorney's fees, costs and expenses.

II. Facts*fn1

Gary Hines was employed by Mastercard Worldwide as a Senior Professional Software Engineer. As an employee of MasterCard, Hines was eligible for and participated in its ERISA regulated employee welfare benefit plan (the "Plan"). Defendant Hartford is the long term disability insurer for the Plan. As a Senior Professional Software Engineer, Hines primarily worked in a sedentary position using the computer and telephone. Hines worked in a sedentary position for approximately 7 hours per day with the ability to alternate sitting and standing as needed.

On January 17, 2008, Hines ceased work due to back and right leg pain and left foot drop secondary to spondylosisthesis and lumbar disc displacement.*fn2 At that time, Hines claimed to be totally disabled. On January 21, 2008, Hartford approved Hines' short term disability claim, finding Hines disabled pursuant to the terms of the Plan. On January 24, 2008, Hines underwent lumbar fusion surgery for an L5-S1 fusion, bone graft and screw fixation. Shortly thereafter, Hines submitted a claim for long term disability benefits under the Plan. After reviewing medical records from Hines' treating physicians, Dr. Yoon (Hines' neurosurgeon) and Dr. Guy Burrows (Hines' neurologist), Hartford determined that Hines' condition continued to limit his ability to perform his regular occupation and approved his claim for long-term disability benefits effective April 16, 2008.*fn3 Around the same time, Hines filed for and was declared disabled by the Social Security Administration.*fn4

After his initial lumbar fusion surgery, Hines participated in physical therapy and received an epidural steroid injection to relieve his back pain. Hines reported that the physical therapy and steroid injection worsened his pain. On July 1, 2008, Hines underwent a second lumbar fusion surgery. Subsequently, Hines was examined by Dr. Yoon on August 11, 2008; September 15, 2008; October 23, 2008; and November 17, 2008. After most visits, Dr. Yoon executed a form provided by Hartford titled "Attending Physicians Statement of Continued Disability" ("APS"). Dr. Yoon also wrote letters detailing Hines' treatment and prognosis. The following is a summary of relevant statements in Dr. Yoon's APS forms and letters:

* In the APS form following Hines' August 11, 2008 visit, Dr. Yoon reported that Hines tolerated the second fusion surgery but still had some post-operative pain, with the need to continue using a walker and left foot drop. Dr. Yoon recommended additional physical therapy for a 4-week period.

* In a letter dated September 15, 2008, Dr. Yoon Stated: "I believe [Hines'] disability is severe enough that he should consider applying for disability. I will refer him to Dr. Berry who has seen him before, but has not had any pain management procedures done by Dr. Berry up to this point."

* In a letter dated October 23, 2008, Dr. Yoon indicated that on November 17, 2008, Hines would be released to return to work full-time.

* In an APS form faxed to Hartford on October 24, 2008, Dr. Yoon referenced Hines' continued pain, persistent left foot drop, use of a walker, and referral to pain management. Hines' diagnosis was listed as spondylolisthesis.

* On November 21, 2008, Dr. Yoon signed a letter stating that Hines was no longer released to work on November 17, 2008. The accompanying APS form referenced Hines' continued pain. The form also listed Hines' diagnosis as spondylolisthesis and stated that his current treatment plan was pain management. Hines' next scheduled office visit was listed as March 16, 2009.

On December 1, 2008, Debra Gutierrez (a Hartford "decision maker"), noted that "per form signed on November 17, 2008, [Hines] has not been ready to return to work full time." On December 4, 2008, Rowena Buckley (a Hartford claim management employee) contacted Dr. Yoon's office to discuss Hines' ability to perform sedentary work. Buckley did not speak directly with Dr. Yoon because Dr. Yoon was not at his office that day. Instead, Buckley spoke with "Allison." Allison stated "there was nothing in his chart at this time that says he could do sedentary work so she will have to speak with [Dr. Yoon]." Later that day, Allison advised Buckley that Dr. Yoon had "responded on the note she sent him" and said that Hines could perform full time seated activities with the option of changing positions and using his hands for a keyboard starting immediately. Allison also faxed a handwritten note containing her question for Dr. Yoon and Dr. Yoon's purported response. On December 8, 2008, based on the information provided by Allison, Buckley recommended termination of Hines' long term disability benefits.

On December 9, 2008, Hines went to Pain Management Services for an epidural steroid injection. Hines' reported that his back pain was worse, throbbing, aching, sharp, and constant. The physician examining Hines observed that Hines was "well developed, well nourished and in no acute distress in the seated position."

On December 16, 2008, Hines' long term disability benefits were terminated by Hartford. According to Hartford's benefits termination letter, Hines' disability benefits were terminated because he no longer met the disability policy definitions in that Hartford determined he was physically able to perform sufficient duties of employment under the policy. Further, the letter stated that the decision to terminate benefits was based on Hartford's entire file. However, the only record referred to in the termination letter evidencing Hines' ability to perform his employment duties was the December 4, 2008 note faxed by Allison to Buckley. Subsequently, Gutierrez informed Hines that his "claim was terminated as info from Dr. Yoon stated he was capable of performing sedentary work for 8 hours/day." On December 19, 2008, Buckley again spoke to Allison. Allison told Buckley, "there seems to be some misunderstanding" and said, "[Dr. Yoon] probably did not intend for [Hines] to return to his own job right away." Allison also said that Hines is complaining of a lot of pain and is seeing pain management. Hartford responded that it "accept[s] the findings of treating physicians and if Dr. Yoon had objective findings that support a level of pain that would preclude full time seated activities, using his hands, they would defer to [Dr. Yoon]." Allison advised that Hines was last seen by Dr. Yoon on November 17, 2008, that the next office visit was scheduled for December 29, 2008. Allison further advised that Dr. Yoon's opinions were also based on the findings of pain management. Hartford advised that it would "wait to hear from [Dr. Yoon] following the next office visit."

On December 22, 2008, Hines informed Gutierrez that there was a misunderstanding. Hines "state[d] that he is still using [a] walker and is in a lot of pain and unable to return to work." Hartford informed Hines that it would "check on requirements for appeal if received info from Dr. [Yoon] retracting return to work [statement]."

In a letter dated December 30, 2008, addressed to Dr. Guy T. Burrows of the neurologic institute, Dr. Yoon stated that Mr. Hines "still has a significant amount of pain. Even though he does want to go back to work he apparently cannot perform even his daily routine at home. I have suggested to him that it maybe worthwhile to obtain a functional capacity evaluation. However, this is not covered by his insurance. I believe his pain is genuine and probably should be applying for disability."

On December 31, 2008, Dr. Burrows examined Hines. During the examination, Hines reported that the second surgery made his pain worse. Dr. Burrows' physical exam findings reflected neurological deficits in Hines' legs and the following: "[p]atient uses a walker for gait and support of his back as well as standing intermittently when sitting for any period of time to relieve back pain." Dr. Burrows concluded Hines had (1) Sensory axonal peripheral polyneuropathy. (2) Lumbar pain with left L5 and right S1 radicular findings and (3) Gait abnormality and prolonged sitting difficulty related to pain."

On January 28, 2009, Hines, through his attorney, appealed Hartford's termination of his claim for continued benefits. Hines' appeal included a letter from Dr. Stuart Mauch, an internist, stating:

My patient Gary Hines is diagnosed with severe low back pain radiating down the right leg and left foot drop, which limits walking and interferes with prolonged sitting. He is status post lumbar fusion 1/24/2008 and 7/1/2008 with persistent pain and left foot drop. He continues to use a walker for gait abnormality and support of his back. Because of these conditions, [Hines] is ...

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