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Quarles v. Hartford Life & Accident Insurance Co.

United States District Court, W.D. Kentucky, Louisville

March 20, 2019



          Charles R. Simpson III, United States District Court Senior Judge

         This matter is before the Court on cross-motions for judgment on the administrative record.[1] DN 48; DN 49. Plaintiff requests oral argument on the Parties' competing motions “[b]ased on the factually intensive nature of the issues presented, as well as the confusion that can occur when parties are filing competing motions.” DN 54, at 39. Plaintiff's request will be denied, as this Court finds oral argument unnecessary. The issues are clearly presented in the Parties' thorough briefs. These issues are ripe for review. For the reasons set forth below, the Court will GRANT Defendant's Motion for Judgment (DN 49) and DENY Plaintiff's Motion for Judgment (DN 48).


         Plaintiff, Emmanuel J. Quarles (“Quarles”), brought suit against Defendant, Hartford Life and Accident Insurance Company (“Hartford”) alleging wrongful termination of his long-term disability (“LTD”) benefits and waiver of premiums (“WOP”) of his basic life and accidental death and dismemberment (“AD&D”) coverages under the Employment Retirement Income Security Act of 1974 (“ERISA”). The Administrative Record (“AR”) of this matter has been filed. DN 21. The AR consists of 700 numbered pages which will be cited as “AR (page number).”

         A. Relevant Plan Provisions

         In 2012, Quarles began to work as a Selector for Gordon Food Service, Inc. (“Gordon”). AR 621. Hartford issued Group Insurance Policies GL-395259, GLT-395259, and ADD-507325 to Gordon to insure the life insurance, LTD, and AD&D components, respectively, of the employee welfare benefit plan established and maintained by Gordon (the “Plan”). AR 1-112. By virtue of his employment with Gordon, Quarles was insured under the Life Policy, LTD Policy, and the AD&D Policy (collectively, the “Policies”). Each policy provides a benefit in the event Quarles became “Disabled.” Id.

         1. The LTD Policy

         The LTD Policy pays disability benefits if participants:

1) become Disabled while insured under The Policy;
2) are Disabled throughout the Elimination Period;
3) remain Disabled beyond the Elimination Period; and
4) submit Proof of Loss to Us.

AR 22.[2] “Disability” for purposes of a participant's eligibility for disability benefits under the LTD Policy is defined 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; 2) Your Occupation, for the 24 month(s) following the Elimination Period, and as a result Your Current Monthly Earnings are less than 80% of Your Indexed Pre-disability Earnings; and 3) After that, Any Occupation.

AR 30.

         The LTD Policy provides that benefits terminate under the following relevant circumstances:

Termination of Payment: When will my benefit end?
Benefit payments will stop on the earliest of:
2) the date You fail to furnish Proof of Loss; [or]
8) the date Your Current Monthly Earnings exceed:
a) 80% of Your Indexed Pre-disability Earnings if You are receiving benefits for being Disabled from Your Occupation; or b) the product of Your Indexed Pre-disability Earnings and the Benefit percentage if You are receiving benefits for being Disabled from Any Occupation…

AR 23 (emphasis in original).

         Under the LTD Policy, Hartford “may request Proof of Loss throughout Your Disability. In such cases, [Hartford] must receive the proof within 30 day(s) of the request.” AR 27. Proof of Loss is used to assist Hartford in determining if a participant is disabled under the conditions entitling participant to benefits under the LTD Policy. AR 26. The LTD Policy sets out a nonexclusive list of what Proof of Loss may include:

1) documentation of:
a) the date Your Disability began;
b) the cause of Your Disability;
c) the prognosis of Your Disability;
d) Your Pre-disability Earnings, Current Monthly Earnings or any income, including but not limited to copies of Your filed and signed federal and state tax returns; and
e) evidence that You are under the Regular Care of a Physician;
2) any and all medical information, including x-ray films and photocopies of medical records, including histories, physical, mental or diagnostic examinations and treatment notes;
3) the names and addresses of all:
a) Physicians or other qualified medical professionals You have consulted;
b) hospitals or other medical facilities in which You have been treated; and
c) pharmacies which you have filled Your prescriptions within the past three years;
4) Your signed authorization for Us to obtain and release:
a) medical, employment and financial information; and
b) any other information We may reasonably require;
5) Your signed statement identifying all Other Income Benefits; and
6) proof that You and Your dependents have applied for all Other Income Benefits which are available.

AR 26. The definition further explains that all “proof submitted must be satisfactory” to Hartford. Id.

         The LTD Policy provides that in the event a claim for benefits is denied, Hartford will provide “You” with written notification of the decision. AR 27. This written notification will:

1) give the specific reason(s) for the denial:
2) make specific reference to The Policy provisions on which the denial is based;
3) provide a description of any additional information necessary to perfect a claim and an explanation of why it is necessary; and
4) provide an explanation of the review procedure.

Id. In order to appeal this decision, the participant:

1) must request a review upon written application within:
a) 180 days of receipt of claim denial if the claim requires Us to make a determination of disability; or
b) 60 days of receipt of claim denial if the claim does not require Us to make a ...

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