United States District Court, E.D. Virginia, Alexandria Division
JAMES C. CACHERIS, District Judge.
This matter is before the Court on Defendants Hartford Life and Accident Insurance Company ("Hartford") and Booz Allen Hamilton Long Term Disability Plan's (the "Plan") (collectively "Defendants") Motion for Summary Judgment or, in the Alternative, For Remand, [Dkt. 59], and Plaintiff Linda Bruce's ("Plaintiff" or "Bruce") Motion for Summary Judgment, [Dkt. 58]. For the following reasons, the Court will grant Defendants' Motion and will deny Plaintiff's Motion.
Plaintiff has filed this action seeking long-term disability benefits under § 502(a)(1)(B) of the Employee Retirement Income Security Act of 1974, 29 U.S.C. § 1132(a)(1)(B) ("ERISA").
A. Factual Background
1. The Parties and the Plan
Bruce was a professional administrator for Booz Allen Hamilton, Inc. ("Booz Allen") and participated in an employee welfare benefit plan ("the Plan") sponsored by Booz Allen. (H1637.) The Plan is at least partially funded by a long term disability ("LTD") insurance policy ("the Policy") issued by Hartford. (H2788.) The named Plan Administrator is Booz Allen Hamilton, Inc. (H2816.) Hartford is the "claims fiduciary for benefits provided under the Policy." (H2816.) Hartford has "full discretion and authority to determine eligibility for benefits and to construe and interpret all terms and provisions of the Policy." (H2816.) The Policy defines "Disability or Disabled" as follows:
Disability or Disabled means 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.
2. Bruce's LTD Claim
Plaintiff became unable to work full time following a car accident on or about October 19, 2010. Plaintiff suffers from a "lower lumbar condition, related pain, obesity and medication side effects resulting in severe functional limitations." (Pl. Mem. ¶ 1.) Plaintiff was approved for short term disability benefits, which were paid for six months. ( Id. at ¶ 2.) On May 4, 2011, Hartford notified Plaintiff that her claim for LTD benefits had been approved effective April 19, 2011. (H11.) Hartford also required Plaintiff to apply for Social Security Disability Benefits. (H21.) Under the Policy, Plaintiff was "required to provide continuing proof that she was disabled from working in her sedentary occupation." (Def. Mem. at 4.)
In July 2012, Plaintiff's internist, Dr. Michon Bechamps ("Dr. Bechamps"), submitted to Hartford an Attending Physician's Statement of Functionality. (H306.) The report states that plaintiff reported "back pain and pressure, " "peripheral neuropathy" and physical examination findings revealed limited lumbar spine range of motion. (H306.) Dr. Bechamps reported that Plaintiff's progress was unchanged and the expected current duration of these restrictions or limitations was for her "lifetime." (H307.) Dr. Bechamps's office notes from June 2012, however, suggest some improvement in Plaintiff's condition. (Def. Mem. at 4.) These notes state "back pain is somewhat better" and that "neuropathy is somewhat better." (H308-10.) Additionally, Defendants state that Dr. John Choi, a neurologist, submitted a nerve conduction study ("NCS") and an electromyography examination ("EMG") showing normal results. (Def. Mem. at 5.) Plaintiff disagrees with these assertions, noting that Dr. Bechamps's reports show numbness, vertigo, peripheral neuropathy, obstructive sleep apnea, and back pain, and Dr. Choi noted "numbness and vertigo." (Pl. Mem. at 4-5.)
On November 28, 2012, Hartford referred Plaintiff's claim to MES Solutions ("MES") a third party vendor. MES assigned Plaintiff's case to Dr. Albert C. Fuchs. In December 2012, Dr. Fuchs provided a paper review based on the medical records from Drs. Choi and Bechamps, and discussion with Dr. Bechamps. (H2363-66.) Plaintiff asserts that Dr. Fuchs's report presents "little more than a selective summary of the medical evidence followed by naked conclusions" because Dr. Fuchs's report was issued without the benefit of examination or testing. (Pl. Mem. at 6.) Defendants point to portions of Dr. Fuchs's report where he discussed Plaintiff's case with Dr. Bechamps. (Def. Mem. at 5.) Defendants note that the report indicates that Dr. Bechamps and Dr. Fuchs agreed that "Plaintiff was functionally impaired and there was evidence supporting her claimed muscular back pain" but also that Plaintiff's symptoms did not correlate with objective findings. (Def. Mem. at 5; H2365.)
3. Appeal Process
On February 4, 2013, Plaintiff sent a letter to Hartford appealing the denial of her LTD benefits. (H2344-46.) On February 7, 2013, Plaintiff requested that Hartford disregard her initial appeal letter and stated that she had retained counsel in this matter. (H239.) On February 14, 2013, Plaintiff's counsel wrote to Hartford requesting a copy of the claims file, among other information, and noting that the request for information did not constitute an appeal of benefits. (H222-23.) On February 15, 2013, Hartford wrote to Plaintiff acknowledging receipt of the February 14, 2013 letter and stating "we will consider the appeal incomplete to allow you time to submit any additional information." (H51.) The letter further states, "if we do not receive additional information by August 5, 2013 we will consider your appeal complete at that time and we will evaluate your appeal using the information currently in your claim file." (H52.) Additionally, Hartford stated, "[o]nce you submit your complete appeal, we will make an appeal decision as soon as possible and should make the decision within 45 days of the receipt of the request. If there are special circumstances that prevent us from making the decision in that time, the evaluation period can be extended by an additional 45 days." (H52.)
On August 2, 2013, Plaintiff sent Hartford her additional documentation in support of her appeal. (H2054.) The letter contained a list of files scanned to a CD-R. (H2054.) Hartford did not receive this CD-R on August 2, 2013, although the parties disagree on where in the process the CD-R went missing. On August 15, 2013, Hartford wrote to Plaintiff, informing her that it did not receive the CD-R. (H1672.) On August 23, 2013, Plaintiff submitted further documentation to be made part of her appeal. (H1837.)
On September 11, 2013, Hartford wrote to Plaintiff, acknowledging receipt of the August 15, 2013 letter, the CD-R, and the documents submitted on August 23, 2013. (H1667.) In this letter, Hartford informed Plaintiff's counsel that "clarification of Ms. Bruce's capabilities is necessary" and that Hartford had contacted Dr. Bechamps to request her permission to have Plaintiff participate in an FCE. ( Id. ) Plaintiff's counsel responded that day that "should you wish to examine Ms. Bruce, you will need to restore her benefits including all back benefits owed." (H1806.) On October 4, 2013, Hartford informed Plaintiff that it was unable to make a decision on her appeal during the initial 45-day period, and that it would make the appeal determination within 45 days of the date she completed the FCE. (H1666.) On October 7, 2013, a third party vendor engaged by Hartford, D & D Associates, wrote to Plaintiff stating that an FCE had been scheduled for October 30, 2013. (H1813.) On October 17, 2013, Plaintiff's counsel wrote to D & D associates stating that the company had impermissibly contacted Plaintiff in excess of the 90 day review period and that an evaluation would occur only if Plaintiff's claim was paid in full to that date. (H1805.) On October 30, 2013, ...