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Killian v. Hartford Life & Accident Insurance Co.

United States District Court, E.D. Pennsylvania

January 31, 2017

DONNA J. KILLIAN, Plaintiff,
v.
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY, Defendant.

          MEMORANDUM OPINION

          EDWARD G. SMITH, J.

         The Employee Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C. §§ 1001-1461, provides protections for employees participating in their employers’ benefits plans. Based upon her diagnosis of breast cancer, the plaintiff employee received short-term disability benefits under her employer’s short-term disability plan and, after the expiration of those benefits, long-term disability benefits under the employer’s “Staff Long Term Disability Plan.” Once the plaintiff's cancer had resolved and her doctor released her to return to work, the claims administrator terminated her benefits. After the claims administrator denied the plaintiff's appeal of the termination of benefits, the plaintiff filed the instant ERISA action against the administrator.

         Currently before the court are the parties’ cross-motions for summary judgment on the issue of whether the termination of long-term disability benefits was arbitrary and capricious. As explained below, the court finds that there are no genuine issues of material fact and that the claims administrator’s decision to terminate the plaintiff's long-term disability benefits was not without reason, unsupported by substantial evidence, or erroneous as a matter of law.

         Accordingly, the court will grant the claims administrator’s motion for summary judgment and deny the plaintiff employee’s motion for summary judgment.

         I. PROCEDURAL HISTORY

         The plaintiff, Donna J. Killian (“Killian”), commenced this ERISA action by filing a complaint in the Lancaster County Court of Common Pleas on February 25, 2016, against the defendant, Hartford Life and Accident Insurance Company (“Hartford”). Notice of Removal at Ex. A, Compl. (“Compl.”) In the complaint, Killian alleged that, pursuant to section 502(a)(1)(B) of ERISA, 29 U.S.C. § 1132(a)(1)(B), Hartford’s decision to terminate her long-term disability (“LTD”) benefits and its subsequent denial of her appeal were arbitrary and capricious. Compl. at 6. On March 25, 2016, Hartford properly removed the action to this court because Killian’s claim arose under ERISA, a federal law. Notice of Removal at 1-2. Hartford filed an answer to the complaint on April 1, 2016, Doc. No. 5, and the court held an initial pretrial conference on April 19, 2016. Doc. No. 6.

         After the parties unsuccessfully attempted to settle this matter, Killian filed a motion for summary judgment on August 3, 2016. Doc. No. 17. Hartford filed a response in opposition on August 19, 2016. Doc. No. 23. Hartford also filed a motion for summary judgment on August 5, 2017, and Killian filed a response in opposition thereto on August 19, 2016. Doc. Nos. 20, 21. Presently before the court are those cross-motions for summary judgment.

         II. APPLICABLE RECORD

         Killian worked as a healthcare consultant for PricewaterhouseCoopers LLP (“PwC”) from May 3, 1999, through January 15, 2015. Def. Hartford Life and Accident Ins. Co.’s Statement of Facts in Supp. of its Mot. for Summ. J. (“Def.’s Facts”) at ¶ 1, Doc. No. 20-4; Pl.’s Resp. to Def.’s Statement of Material Facts (“Pl.’s Resp.”) at ¶ 1, Doc. No. 22. As a healthcare consultant, Killian’s job required traveling between 80% and 100% of the workweek. Pl.’s Statement of Material Facts (“Pl.’s Facts”) at ¶ 23, Doc. No. 19; Def. Hartford Life and Accident Ins. Co.’s Resp. to Pl.’s Statement of Material Facts (“Def.’s Resp.”) at ¶ 23, Doc. No. 24; Administrative Record (“Admin. R.”) at HLAIC 00302, HLAIC 00351; see also Def.’s Facts at ¶ 9; Pl.’s Resp. at ¶ 9.

         A. The Applicable Plan Provisions

         As a former PwC employee, Killian was potentially eligible to receive LTD benefits through a group employee welfare benefit plan (the “Plan”) sponsored by PwC. Def.’s Facts at ¶ 2; Pl.’s Resp. at ¶ 2. Hartford issued an insurance policy (the “Policy”) that funds the benefits payable under the Plan. Def.’s Facts at ¶ 3; Pl.’s Resp. at ¶ 3; Admin. R. at POL0001-77. The Plan defines “disability” or “disabled” as follows:

         Disability or Disabled means that during the Elimination Period and for the next 60 months You are prevented by:

1. accidental bodily injury;
2. sickness;
3. Mental Illness;
4. Substance Abuse; or
5. pregnancy, from performing one or more of the Essential Duties of Your Occupation, and as a result Your Current Monthly Earnings are no more than 80% of Your Indexed Pre-disability Earnings.
After that, You must be so prevented from performing one or more of the Essential Duties of Any Occupation.
Your failure to pass a physical examination required to maintain a license to perform the duties of Your Occupation does not alone mean that You are Disabled.

Def.’s Facts at ¶ 4; Pl.’s Resp. at ¶ 4; Pl.’s Facts at ¶ 3; Def.’s Resp. at ¶ 3; Admin. R. at HLAIC 00187, POL0010.

         The Plan grants Hartford authority to determine eligibility for benefits in several places.

         For example, the “ERISA INFORMATION” section states as follows:

The benefits described in your booklet-certificate (Booklet) are provided under a group insurance policy (Policy) issued by the Hartford Life and Accident Insurance Company (Insurance Company) and are subject to the Policy’s terms and conditions. The Policy is incorporated into, and forms part of, the Plan. The Plan has designated and named the Insurance Company as the claims fiduciary for benefits provided under the Policy. The Plan has granted the Insurance Company full discretion and authority to determine eligibility for benefits and to construe and interpret all terms and provisions of the Policy.

Admin. R. at POL0053. The “Plan Administrator” section of the ERISA information states: The Plan Administrator is PricewaterhouseCoopers LLP. . . . The firm contracts with Hartford Life and Accident Company to insure the Long-Term Disability portion of the Plan. For purposes of claims administration, the Plan Administrator has assigned fiduciary responsibility for claim determinations to Hartford Life and Accident Company, the Claims Administrator for this program.

         Admin R. at POL0055. Under the “CLAIM PROCEDURES” section of the Plan, it states: “The Plan has designated and named the Insurance Company as the claims fiduciary for benefits provided under the Policy. The Plan has granted the Insurance Company full discretion and authority to determine eligibility for benefits and to construe and interpret all terms and provisions of the Policy.” Admin. R. at POL0062. Finally, the Plan states under the “GENERAL PROVISIONS/CLAIMS” section: “We have full discretion and authority to determine eligibility for benefits and to construe and interpret all terms and provisions of the Group Insurance Policy.” Admin. R. at POL0039. The Policy defines “We” as the Hartford Life and Accident Insurance Company. Admin. R. at POL0015.

         With respect to the LTD Plan, there are no wrap documents, and the only plan document is the Hartford Certificate of Insurance. Pl.’s Facts at ¶ 36; Def.’s Resp. at ¶ 36.

         B. Killian’s Diagnosis and Award of Short-Term and Long-Term Disability Benefits

         In December 2014, Killian was diagnosed with breast cancer. Def.’s Facts at ¶ 6; Pl.’s Resp. at ¶ 6; Admin. R. at HLAIC 00374. Killian ceased work at PwC on January 15, 2015, and she underwent partial mastectomy surgery the following day. Def.’s Facts at ¶ 7; Pl.’s Resp. at ¶ 7; Pl.’s Facts at ¶ 4; Def.’s Resp. at ¶ 5; Admin. R. at HLAIC 00291, HLAIC 00379-00382.[1]

         Beginning in February 2015, Killian underwent cycles of chemotherapy and radiation treatment and, as a result of that treatment, experienced nausea, fatigue, low blood counts (anemia), and some pain. Def.’s Facts at ¶ 8; Pl.’s Resp. at ¶ 8; Pl.’s Facts at ¶¶ 4, 9; Def.’s Resp. at ¶¶ 5, 10; Admin. R. at HLAIC 00360. The chemotherapy also increased Killian’s risk of infection, and, as a result, her treating oncologist, Christina I. Truica, M.D., restricted her from traveling, which her job required, due to the risk of infection. Def.’s Facts at ¶ 9; Pl.’s Resp. at ¶ 9; Pl.’s Facts at ¶ 5; Def.’s Resp. at ¶ 6; Admin. R. at HLAIC 00323, HLAIC 00357, HLAIC 00360.

         During Killian’s appointments with Dr. Truica in April and May of 2015, she complained of fatigue and shortness of breath. Def.’s Facts at ¶ 10; Pl.’s Resp. at ¶ 10; Admin. R. at HLAIC 00273-00274, HLAIC 00325. In May 2015, Dr. Truica determined that Killian’s symptoms of fatigue and shortness of breath were likely related to anemia. Def.’s Facts at ¶ 11; Pl.’s Resp. at ¶ 11; Admin. R. at HLAIC 00273. Dr. Truica also noted that because of Killian’s diagnosis of fatty liver disease, she was monitoring her liver function tests, which had been stable. Def.’s Facts at ¶ 12; Pl.’s Resp. at ¶ 12; Admin. R. at HLAIC 00274. Dr. Truica’s examination of Killian that day was otherwise normal. Def.’s Facts at ¶ 12; Pl.’s Resp. at ¶ 12; Admin. R. at HLAIC 00273-00274. Due to Killian’s ongoing treatment and presence of symptoms, Dr. Truica signed forms in March 2015 and May 2015, in which she opined that Killian was disabled from working at that time. Def.’s Facts at ¶ 13; Pl.’s Resp. at ¶ 13; Admin. R. at HLAIC 00322-00323, HLAIC 00360.

         In office visit notes from Killian’s visit on May 29, 2015, Dr. Truica indicated that Killian was hospitalized with sepsis on May 16, 2015, and was discharged on May 20, 2015. Pl.’s Facts at ¶ 6; Def.’s Resp. at ¶ 7; Admin. R. at HLAIC 00215. In office visit notes from Killian’s visit on June 26, 2015, Dr. Truica indicated that Killian was readmitted to the hospital on June 14, 2015 with pancolitis and C. difficile infection and was discharged on June 18, 2015. Pl.’s Facts at ¶ 7; Def.’s Resp. at ¶ 8; Admin. R. at HLAIC 00209. On June 26, 2015, Dr. Truica diagnosed Killian with grade III thrombocytopenia. Pl.’s Facts at ¶ 8; Def.’s Resp. at ¶ 8; Admin. R. at HLAIC 00209.

         Killian had received short-term disability benefits starting in January 16, 2015, but exhausted those benefits on July 16, 2015. Pl.’s Facts at ¶ 13; Def.’s Resp. at ¶ 14; Admin. R. at HLAIC 00340. Hartford approved Killian’s claim for LTD benefits effective July 17, 2015. Def.’s Facts at ¶ 14; Pl.’s Resp. at ¶ 14; Pl.’s Facts at ¶¶ 12, 14; Def.’s Resp. at ¶¶ 13, 14; Admin. R. at HLAIC 00020-00024, HLAIC 00340, HLAIC 00343.

         C. Killian’s Condition after the Award of Long Term Disability Benefits

         By September 2015, Killian had completed radiation and chemotherapy and the side effects from these treatments tapered off significantly. Def.’s Facts at ¶ 15; Pl.’s Resp. at ¶ 15; Admin. R. at HLAIC 00291-00292. Killian’s echocardiograms remained status quo and her anemia had resolved. Def.’s Facts at ¶ 15; Pl.’s Resp. at ¶ 15; Admin. R. at HLAIC 00291-00292. Nonetheless, Killian continued to complain of nausea and vomiting after the completion of her treatment. ...


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