United States District Court, D. Connecticut
MEMORANDUM OF DECISION
Dominic J. Squatrito United States District Judge
The plaintiff, Jeanne Soares ("Soares"), brings this action against the defendants, United of Omaha Life Insurance Company, Mutual of Omaha (the "United of Omaha defendants"), Qualidigm Group Policy #GLUG-371J, and Qualidigm Plan Administrator (the "Qualidigm defendants"), alleging violations of the Employee Retirement Income Security Act of 1974, as amended, 29 U.S.C. §§ 1101 et seq. ("ERISA"). Now pending before the Court are motions for summary judgment filed by the Qualidigm defendants (doc. # 36) and the United of Omaha defendants (doc. # 38). For the following reasons, both of the motions for summary judgment are granted.
Connecticut Peer Review Organization, Inc., d/b/a Qualidigm, provides healthcare consulting and research services to clients in the public and private sectors. From May 2000 until April 8, 2011, Soares was employed by Qualidigm as a Nurse Reviewer. As a Qualidigm employee who worked more than twenty hours per week, Soares was entitled to group term life and accidental death and dismemberment insurance benefits that were paid for by Qualidigm. In September 2007, Qualidigm moved its employees' group term life and accidental death and dismemberment insurance to a new carrier, United of Omaha Life Insurance Company ("United of Omaha"). As of September 1, 2007, eligible Qualidigm employees became participants in United of Omaha Life Insurance Company Group Policy No. GLUG-371J (the "Plan"). Qualidigm delegated to United of Omaha the discretion to determine eligibility for benefits under the Plan.
The Plan provided in part that, "You may be able to continue Life insurance under this provision without payment of premium if You become Totally Disabled while insured under the Policy prior to age 60." (Doc. # 37-4, at 17). For purposes of the Plan, "Total Disability, Totally Disabled or Disabled means that because of an Injury or Sickness You are completely and continuously unable to perform any work or engage in any occupation." (Id. at 37). The Plan also provided that, "You must notify Us in writing of Total Disability within three months from the date You became Totally Disabled. Satisfactory proof of Total Disability must be submitted to Us before the end of the Waiver of Premium Benefit Elimination Period." (Id. at 18). "The Waiver of Premium Benefit Elimination Period is a period of 9 consecutive months of Total Disability beginning on the date You became Totally Disabled while insured under the Policy." (Id.). The Plan also specified that, "No legal action can be brought more than three years after the date written proof of loss is required." (Id. at 33).
Soares was out of work on a medical leave of absence beginning on March 22, 2010. She applied for short-term disability benefits under a disability policy issued by United of Omaha. Soares' application was initially denied. In response to her appeal of that denial, however, her application was later approved. In a letter dated February 7, 2011, United of Omaha notified Soares that she had been approved for long-term disability benefits, effective September 28, 2010, because she was "prevented from performing at least one of the Material Duties of [her] Regular Occupation on a part-time or full-time basis, " was "unable to generate Current Earnings which exceed 80% of [her] Basic Monthly Earnings, " and was beyond the "Elimination Period" of 180 calendar days. (Doc. # 37-7, at 1, 2).
In a letter dated April 8, 2011, the Qualidigm Human Resources Director notified Soares that "in light of your medical leave of absence exceeding the one-year mark (since March 22, 2010), and your continued inability to return within one year of your initial absence, in accordance with our existing policies, we will terminate your employment effective today, April 8, 2011." (Doc. # 37-3, at 1). That letter also advised Soares that Qualidigm was cancelling her group life, accidental death and dismemberment insurance, i.e., the Plan, "on 4/5/11, " but that she had "the option of continuing this coverage on your own, at your expense." (Id.). Soares thereafter converted her coverage into an individual life insurance policy that was issued to her by United of Omaha on May 8, 2011. That policy has a face value in the amount of $144, 000.00 and requires payment of an annual premium in the amount of $4, 788.00 for a period of forty-seven years. Soares was 53 years old at the time her individual life insurance policy was issued.
At the time Soares was approved for long-term disability benefits, United of Omaha's Long Term Disability Department notified its Group Life Claims Department ("Life Claims Department") that she had been disabled and unable to work since March 2010. The Life Claims Department subsequently obtained copies of the medical records in Soares' long-term disability file and referred the matter to Dr. Stuart Schlanger for an assessment of her eligibility for waiver-of-premium benefits under the Plan. Dr. Schlanger's report indicates that he reviewed records of Dr. Karnasiewitz concerning Soares that covered the period between February 22, 2010, and December 14, 2010. Dr. Schlanger's report reached the following conclusion: "Recommendation: enclosed records do not support Restrictions and Limitations from sedentary level work or activities. Note: policy definition is 'any work.'" (Doc. # 37-11, at 2).
By way of a letter dated March 16, 2011, the Life Claims Department notified Soares that, based on a review of her medical records, United of Omaha concluded that she did not meet the definition of Total Disability in accordance with the provisions of the Plan, and, consequently, United of Omaha was "unable to approve the Continuation of your Group Life Insurance [without payment of premium] during Total Disability." (Doc. # 37-10, at 1). The letter stated that the Plan "defines totally disabled as completely and continuously unable to perform any work or engage in any occupation." (Id.). The letter informed Soares that she had "the right to convert $144, 000.00 of this terminating insurance by completing the application in the attached conversion brochure . . . ." (Id.).
The March 16, 2011, letter further advised Soares that "[i]n the event you wish to appeal this denial, you have the right to request a review by the Life Claims Department. This request for an appeal must be submitted within 60 days from receipt of this notice." (Id.). The letter specified certain information required to be submitted with a request for an appeal, and then stated, "In addition to the above information, please submit any written comments, documents, records, and other information you may have related to the claim. Upon receipt, we will review and take into account all information submitted related to the claim without regard to whether such information was submitted or considered in the initial claim decision." (Id. at 1-2). Soares was advised that, "You have the right to bring a civil action under ERISA section 502(a) following the appeal process." (Id. at 2).
Soares appealed the denial of the continuation of her group life insurance coverage without payment of premium in a letter dated April 15, 2011. Her appeal letter discussed at length her medical history and physical limitations. She also included with her letter additional medical records that had not been considered in connection with the initial decision.
United of Omaha referred Soares' appeal to Dr. Thomas Reeder, Senior Vice President and Medical Director with United of Omaha. In his report, which was completed on May 17, 2011, Dr. Reeder states that, in addition to the records that had been reviewed by Dr. Schlanger, he also reviewed records from five additional doctors, as well as physical therapy records, MRI results, and the detailed appeal letter from Soares. Dr. Reeder's report includes an extensive discussion of the medical evidence (approximately 3 1/2 single-space pages in length). Dr. Reeder concluded that, "Total disability as defined per Waiver of Premium as [sic] not supported. The activities described by the Insured are consistent with part-time sedentary to light work." (Doc. # 37-13, at 6).
United of Omaha adopted Dr. Reeder's recommendation and denied Soares' appeal. In a letter dated June 2, 2011, United of Omaha notified Soares that her appeal had been denied. The June 2, 2011, letter identified and reviewed the medical evidence that was considered during the appeal process and concluded that "the medical documentation in your file does not support that you are totally disabled as required by the policy. As a result, we are unable to overturn our previous decision, and your appeal for continuance of group life insurance has been denied." (Doc. # 37-14, at 4). That letter advised Soares that she had "exhausted all administrative rights to appeal, " and that "[i]f your plan is governed by the Employee Retirement Income Security Act (ERISA), you have the right to bring a civil action suit once all administrative rights to review have been exhausted." (Id.). All parties agree that the Plan is governed by ERISA.
The Complaint in the instant action was filed in the Connecticut Superior Court. The United of Omaha defendants removed the matter to the United States District Court ...