United States District Court, D. Utah, Central Division
MEMORANDUM DECISION AND ORDER GRANTING
PLAINTIFF'S MOTION FOR SUMMARY JUDGMENT AND DENYING
DEFENDANT'S MOTION FOR SUMMARY JUDGMENT
NUFFER DISTRICT JUDGE.
case involves a claim for long-term disability
(“LTD”) benefits through a group insurance plan.
Plaintiff Terri Lyn Williams (“Williams”) brought
a claim for breach of contract against Defendant Hartford
Life and Accident Insurance Company (“Hartford”)
after it terminated her LT D benefits and denied her
subsequent appeal. The parties filed cross motions for
summary judgment on March 31, 2015,  but stipulated that the case
be decided by the court, as the trier of fact, on the record
evidence and the parties' summary judgment
memoranda.Upon careful review of the evidence,
briefing, and oral arguments, and for the reasons stated more
fully below, Williams's Motion is GRANTED and
Hartford's Motion is DENIED.
of Contract Claim Element 1: Existence of a Contractual Duty
Plan and Group Policy Provisions
of Contract Claim Element 2: Performance of the Contract by
Williams .............. 9
of Contract Claim Element 3: Breach of the Contract by
Hartford ...................... 10
Administration of Williams's LTD Claim After the Initial
Approval .. 12
Any Occupation Investigation
Determination of Williams's Appeal
of Contract Claim Element 4: Damages
Denial of Williams's Claim for LTD Benefits
of Williams's Appeal
of Medical Evidence
of Medical Opinions Regarding Williams's Restrictions and
has a contractual duty to pay LTD benefits to Williams
performed her duties under the Plan and Group Policy
properly applied for LTD benefits
provided Hartford with timely and satisfactory Proof of Loss
was and is under the Regular Care of a Physician
breached its contractual duty to Williams by denying her
claim for LTD
has a qualifying Disability that is not excluded from
coverage and became Disabled while insured under the Plan and
Group Policy ........... 66
remained Disabled beyond of the effective date of the Plan
and Group Policy's Any Occupation provision
suffered damages as a result of Hartford's breach
was employed as a teacher for the Sevier School District in
Richfield, Utah until March 2011, when she stopped working
due to a claimed disability. She applied for, and was granted,
LT D benefits, which Hartford paid until June 2013, when it
terminated her benefits based on the insurance policy's
narrowing of the definition of “Disability” after
24 months of benefit payments.
appealed Hartford's termination decision, alleging that
she continued to be disabled under the insurance policy's
terms . She had several physical impairments in
the first 24 months of disability payments and alleges a
variety of current physical impairments, the greatest of
which is fibromyalgia. Williams's treating physician, Dr.
Dwight Inouye, found her totally disabled due to
appeal, Hartford referred Williams's claim file to Dr.
Joseph Rea for review. Dr. Rea did not personally examine
Williams. In his report, Dr. Rea opined that
Williams's work-related abilities were limited by a hip
impairment, but acknowledged that she consistently complained
of fibromyalgia. Dr. Rea concluded that
“fibromyalgia does not stand as an objective clinical
entity (upon which impairment and resultant physical
limitations can be based)[.]” Therefore, he assigned
Williams's work-related limitations to her hip
impairment, specifically excluding any limitations related to
fibromyalgia. Hartford adopted Dr. Rea's opinion,
at least to the extent of his limitations, and denied
Williams's appeal. Hartford maintains that although it
adopted Dr. Rea's limitations, it rejected his opinion
relating to fibromyalgia.
policy itself does not exclude coverage for disabilities
caused by fibromyalgia, nor does it affirmatively require a
claimant to provide objective evidence of impairment and
limitation. Similarly, the policy does not exclude
coverage for these types of impairments.None of
Hartford's referred health care professionals ever
personally examined Williams.
asserts a single cause of action for breach of contract
against Hartford for its denial of her claim for LTD
benefits. Williams's claim against Hartford is
not governed by the Employee Retirement Income Security Act
of 1974 (ERISA). The parties agree that because employee
welfare benefit plans administered by government entities are
specifically precluded from ERISA pre-emption, Williams's
claim against Hartford is simply one for breach of a
contract's express terms. The parties filed cross
motions for summary judgment on March 31, 2015. On May 1,
2015, the parties filed response memoranda,  and on May
18, 2015, the parties filed reply memoranda. Oral argument
was heard on June 23, 2015.
collection of Undisputed Facts is distilled from the
parties' summary judgment briefing. Hartford's Motion
provided a statement of background facts and a statement of
elements which refers generally to the background
facts. Williams's Motion also provided a
statement of elements followed by a factual
background. Williams's Response stated that
“[t]he parties have conferred about the resolution of
this case, have agreed that this case should be decided on
the evidence of record, and that there is no material dispute
about any facts in this case.” In Hartford's
Response, it agreed that “there is no dispute about any
material fact in this case.” Hartford also submitted
the administrative record and a CD of video
parties' statements of facts did not comply with DUCivR
56-1(b)(2)(C), which requires:
Under each element, a concise statement of the material facts
necessary to meet that element as to which the moving party
contends no genuine issue exists…. Each asserted fact
must be presented in an individually numbered paragraph that
cites with particularity the evidence in the record
supporting each factual assertion.
18, 2015, an email was sent to counsel with a summary set of
undisputed facts incorporating the parties' filings and
complying with the local rule. That summary was reviewed at
the start of the June 23, 2015 hearing. This
collection of undisputed facts was finalized based on
discussion at the hearing. The headings in these
Undisputed Facts are descriptive, not declaratory or
substantive, and are taken from the elements of a claim for
breach of contract.
of Contract Claim Element 1: Existence of a Contractual
Plan and Group Policy Provisions
case arises under the Utah School Boards Association Group
Benefit Plan (the “Plan”),  Group Policy
No. GLT-034943 (“Group Policy”), issued by
Hartford to the Utah School Boards Association in order to
fund the Plan's LTD benefits.
Plan and Group Policy provide LTD benefits to eligible
employees of the Utah School Boards Association, including
the Sevier School District.
Benefits paid under the Group Policy are equal to
662/3% of a claimant's Pre-Disability
Earnings, reduced by Other Income Benefits as defined by the
Plan and Group Policy.
Benefits are payable under the terms of the Plan and Group
1. [The participant] become[s] Disabled while insured under
2. [The participant is] disabled throughout the Elimination
3. [The participant] remain[s] Disabled [90 days] beyond the
4. [The participant is], and ha[s] been during the
elimination Period, under the Regular Care of a Physician;
5. [The participant] submit[s] Proof of Loss satisfactory to
Plan defines “Disability” or
[D]uring the Elimination Period and for the next 24 months,
[the participant is] prevented by:
1. accidental bodily injury;
3. Mental Illness;
4. Substance Abuse; or
from performing one or more of the Essential Duties of [the
participant's own] Occupation, and as a result [the
participant's] Current Monthly Earnings are no more than
80% of [the participant's] Indexed Pre-disability
After that, [the participant] must be so prevented from
performing one or more of the Essential Duties of Any
Plan defines “Essential Duty” as:
[A] duty that:
1. is substantial, not incidental;
2. is fundamental or inherent to the occupation; and
3. cannot be reasonable omitted or changed.
To be at work for the number of hours in [the
participant's] regularly scheduled workweek is also an
Plan defines “Any Occupation” as:
[A]n occupation for which [the participant is] qualified by
education, training or experience, and that has an earnings
potential greater than the amount equal to the lesser of the
product of [the participant's] Indexed Pre-disability
Earnings and the Benefit Percentage and the Maximum Monthly
Benefit shown in the Schedule of Insurance.
Certain conditions are excluded from coverage under the Plan
and Group Policy:
Are there any other limitations on coverage?
No benefit will be payable under the [P]lan for a Disability
that is due to, contributed to by, or results from a
What Disabilities are not covered?
The [P]lan does not cover, and no benefit shall be paid for
1. unless [the participant is] under the Regular Care of a
2. that is caused or contributed to by act of war (declared
3. caused by [the participant's] commission of or attempt
to commit a felony, or to which a contributing cause was [the
participant] being engaged in an illegal occupation; or
4. caused or contributed to by an intentionally self
If you are receiving or are eligible for benefits for a
Disability under a prior disability [P]lan that:
1. was sponsored by the Employer, and
2. was terminated before the Effective Date of this [P]lan,
no benefits will be payable for the Disability under this
claimant for LTD benefits must submit a Proof of
Proof of Loss includes documentation about the basis for the
claim, including, among other things, the cause of the
disability and “any and all medical
Proof of Loss “must be satisfactory” to
Hartford. Hartford is authorized to “request
Proof of Loss throughout [a claimant's]
Based on Williams's age at the time of her claim for LTD
benefits, her maximum period of LTD benefits would be her
normal retirement age of 66.
However, the Plan provides that LTD benefits will end on the
date when a claimant is “no longer Disabled as
Plan and Group Policy govern the “[f]inal
interpretation of all provisions and
of Contract Claim Element 2: Performance of the Contract by
March 2011, Williams was employed by the Sevier School
District as a Third Grade teacher and therefore a participant
under the Plan.
Williams's last day of work for the Sevier School
District was March 29, 2011, after which she submitted a
claim for LTD benefits under the Plan.
Pursuant to the terms of the Plan and Group Policy, Williams
applied for LTD benefits alleging disability beginning in
July 6, 2011, Hartford received Williams's claim for LTD
benefits. The application for LTD benefits
contained information from Williams, Williams's employer,
and Williams's treating physicians.
Williams based her disability claim on “[p]ain and
limited mobility in [her] right hip & leg - lower back
Williams offered proof of her disability satisfying the
policy's definition of
of Contract Claim Element 3: Breach of the Contract by
Williams's family doctor, Dr. Dwight Inouye, completed an
Attending Physician's Statement of Functionality
(“APS”) dated April 25, 2011.
Inouye listed Williams's primary diagnoses as
osteoarthritis of the right hip with a secondary diagnosis of
Inouye indicated that Williams could not engage in prolonged
sitting, standing, and bending.
Alan Colledge, Williams's orthopedist, completed an APS
dated May 5, 2011.
Colledge indicated Williams's primary diagnoses as
degenerative disk disease and osteoarthritis in the hip with
a secondary diagnosis of hypothyroidism.
Colledge reported that, among other things, Williams was
capable of sitting up to 30 minutes at a time up to 8 hours
with breaks, and standing for 20 minutes at a time up to 2
hours with breaks.
July 15, 2011, Hartford summarized the information received
with Williams's LTD claim.
Hartford found that “[b]ased on the medical
documentation, the [restrictions and limitations] appear
reasonable and prevent [Williams] from performing her own
occ[upation] throughout and beyond the [Elimination
Hartford noted that “[Williams] has a progressive
condition which appears to be more tolerable while not
working (standing/walking) however, it appears that she can
perform sed[entary]/light work with changing of
Hartford decided to approve LTD benefits for Williams through
Hartford also decided to refer the file to one of its
vocational rehabilitation specialists for review “as it
appears that [Williams] has at least sed[entary]/light work
Hartford noted that “it is likely that [Williams] will
not remain disabled throughout and beyond” the time of
the change to the “Any Occupation”
July 15, 2011, Hartford informed Williams of its initial
claim determination that her claim for LTD benefits was
Hartford summarized the Plan's terms applicable to
Williams's continued receipt of LTD benefits and informed
Williams that the “Any Occupation” definition
would take effect on June 13, 2013.
Administration of Williams's LTD Claim After the Initial
September 7, 2011, a Hartford Rehabilitation Case Manager
interviewed Williams by telephone.
Williams stated that she had undergone surgery and treatment
for thyroid cancer.Williams told the Rehabilitation Case
Manager that her cancer treatments had prevented medical
treatment on her hip, and that she probably would need
additional surgery for her parathyroidism.
September 7, 2011, the Rehabilitation Case Manager provided
her recommendations based on the telephone interview with
Rehabilitation Case Manager closed the file from a vocational
rehabilitation perspective for the time being because of the
need for Williams's additional medical issues to be
Rehabilitation Case Manager recommended obtaining updated
medical records, and left open the possibility of considering
vocational rehabilitation again in the future based on the
status of Williams's treatment.
September 22, 2011, Hartford's assigned Ability Analyst
contacted Williams by telephone.
Ability Analyst and Williams discussed the status of
Williams's medical condition and
Ability Analyst explained the change to the “Any
Occupation” definition. Williams stated that she
“hope[d] to [return to work] in some capacity in the
future, ” but did not “expect to [return to work
in her] own occ[upation].”
September 24, 2011, the Ability Analyst summarized her
conclusions about the status of Williams's
found that it “remains reasonable that [Williams] is
unable to perform her own occ[upation] as a teacher due to
the prolonged/walking standing required.”
Ability Analyst indicated that she would follow up after
Williams's surgery to re-evaluate whether Williams
continued to be disabled.
September 29, 2011, the Ability Analyst's Manager
reviewed and agreed with the Ability Analyst's
November 18, 2011, the Ability Analyst again called Williams
to check on her status.
Williams reported that she was still waiting to be released
for hip surgery. Williams stated that she had received a
diagnosis of fibromyalgia.
Ability Analyst told Williams that “the restrictions we
have for her hip while disabling for her occ[upation] allow
for sedentary work.”
November 18, 2011, the Ability Analyst summarized her plan of
action on Williams's claim in light of her telephone
conversation with Williams.
outlined the information received from Williams and expressed
her view that Williams “does not appear to be medically
Ability Analyst noted that she would seek updated medical
Ability Analyst stated that “[o]nce [Williams] is
stable medically, [we]
need to determine her limitations for possible referral to
November 21, 2011, the Ability Analyst's Manager
summarized the future course of action regarding the claim
based on the latest conversation with Williams.
Manager indicated that she had requested updated medical
information “to clarify [Williams's]
Manager also noted that it would call Williams about issues
relating to Social Security Disability Insurance
December 22, 2011, the Ability Analyst called Williams for an
update on her condition.
December 23, 2011, the Ability Analyst recorded her
conclusions and plan based on her conversation with
Ability Analyst felt that the evidence continued to support
Williams not being able to perform the duties of her own
occupation as a teacher.
Ability Analyst indicated that she would “[c]ontinue to
monitor [Williams's] condition[s] and
Inouye completed another APS dated December 2,
Inouye changed Williams's primary diagnoses to
fibromyalgia and right hip degeneration.
Inouye also added a secondary diagnosis of parathyroid
Inouye indicated that Williams was capable to sitting up to
4-5 hours per day, standing 1-2 hours per day, and walking up
to 20 minutes.
Inouye reported that Williams did not have any psychiatric or
Inouye reported that Williams could not “participate in
vocational rehabilitation services[, ]” including
“worksite accommodations, identifying alternative work,
and or retraining assistance[.]”
a letter dated December 6, 2011, Hartford requested
additional information from Dr. Inouye.
Hartford noted that Dr. Inouye's functional restrictions
and limitations for Williams “would appear to allow
[Williams] to work at least part time
Hartford requested information to support Dr. Inouye's
statement that Williams was incapable of participating in
December 27, 2011, Hartford's Ability Analyst had two
telephone conversations with Williams about the need for a
response from Dr. Inouye, and Williams said that Dr. Inouye
would not be in the office until her next office visit on
January 3, 2012.
December 30, 2012, the Hartford Team Leader, who supervised
the Ability Analyst assigned to Williams's claim,
summarized the status of Hartford's claim review, noting
that Hartford would continue to seek updated information from
Dr. Inouye, and that it was “unclear why [Williams] is
unable to participate in [vocational
January 8, 2012, Hartford sent a second request by fax to Dr.
Inouye asking him “to clarify why [Williams] cannot
participate in [vocational rehabilitation] within [the
restrictions and limitations] provided on [his] prior
APS” and requesting updated medical
January 11, 2012, Dr. Inouye sent his response to
Inouye described Williams as “very weak and fatigues
Inouye stated that Williams had “chronic pain (moderate
to severe)” which was “probably
Inouye reported that Williams used a wheelchair on “any
Inouye added that Williams “is not a malingerer in any
January 19, 2012, the Ability Analyst recorded her assessment
of the information received from Dr. Inouye and summarized
Dr. Inouye's characterization of Williams's
Ability Analyst indicated that she would refer the file to a
Medical Care Manager (“MCM”) “to determine
if the [restrictions and limitations] as provided on the APS
are supported and prevent [Williams] from even participating
in [vocational rehabilitation].”
Ability Analyst also decided to refer the file to
Hartford's Investigation Unit, because Williams's
“reported activity does not appear to be consistent
with [Dr. Inouye's] note of req[uired] sitting down after
100 [feet] or less of walking, or use of
January 24, 2012, the MCM reported on her review of the
medical records that Hartford had received from
Williams's medical providers. The MCM found:
insufficient medicals during the life of the claim to make an
accurate functional assessment at this time. There is a gap
in time between 4/25/11 to 10/24/11… when there are no
medicals from Dr. Inouye ([Family Physician]) likely due to
referral to Dr. Susan Maturlo (Endocrinology). Medicals
needed to further clarify [Williams's] cancerous
endocrine conditions, surgical involvement [with] need for
radiation [treatment] and prognosis. Missing are Dr.
[Richard] Jackson (Ortho[pedist]) medicals as appears per Dr.
Inouye ([Family Physician]) this is [Williams's] current
[treating] ortho[pedist] who may consider scoping
[Williams's] right hip.
MCM returned the file to the Ability Analyst in order to
obtain additional medical records.
Ability Analyst promptly followed up with Williams to obtain
the contract information for her endocrinologist, Dr.
Maturlo, and orthopedist, Dr. Jackson.
Ability Analyst then contacted Dr. Jackson and Dr. Maturlo to
obtain their records on Williams.
Ability Analyst also requested updated medical records from
Dr. Colledge, Dr. Inouye, and Dr. Jeffrey
Multiple requests were necessary before Hartford received the
requested medical records from Williams's
January 23 and 24, 2012, Triad Investigations, Inc.
(“Triad”) conducted video surveillance of
Williams's activities at the request of
March 7 and 8, 2012, Triad conducted a second video
surveillance of Williams.
April 19, 2012, a Hartford Field Investigator, Mike Morrell,
interviewed Williams at her home.
discussing her level of functionality, Williams said that
various activities caused pain, but Williams denied needing
any “special equipment.”
Morrell observed that Williams “was stable upon her
feet and she stood without support[, ]” and that
“[w]hile viewing the functionality videos, [she] stood
for the entire 20 minutes it took to view the
though Williams “mentioned that many normal movements
or body functions cause her a lot of pain[, she] never
spontaneously complained of fatigue in [Mr. Morrell's]
presence, and she did not display any objective signs of
fatigue in [Mr. Morrell's] presence.”
Williams “did not display any objective signs of
cognitive impairment, confusion, inability to concentrate, or
lack of focus in [Mr. Morrell's]
Williams viewed and commented on the surveillance
Williams “noted that the things she did on the videos
caused her a lot of pain, and we couldn't see
Williams later sent a letter dated April 25, 2012, to Mr.
Morrell in which she provided further comments on her
activities during the video surveillance.
a letter dated April 27, 2012, Williams sent a new APS to
Hartford, which Dr. Inouye had completed.
Inouye indicated that Williams could sit for 30 minutes at a
time with breaks and changes of position for 4-6
Inouye opined that Williams could stand for 30 minutes at a
time with breaks and changes of position for a total of 2
Inouye stated that Williams's degree of functionality
“depends on [the] day[.]”
July 10, 2012, the Ability Analyst summarized the medical and
investigative evidence in Williams's file,  noting
that he would refer the file to an “MCM to review
medical records, surveillance investigation findings and
interview statement to help clarify [Williams's] current
restrictions and limitations and her ability to return to
work in [her] Own Occupation.”
August 9, 2012, the MCM reported on her assessment of the
file materials and provided a detailed summary of the
MCM stated that the medical evidence “could support
some degree of discomfort secondary to the underlying
inflammatory processes however the findings do not support an
impairment to function, nor the severe limitation to function
as reported by [Dr. Inouye].”
MCM felt that “[Williams's] observed activities and
time away from home are in contrast to her self-reported
limitations of walking 5 minutes and standing for 15-20 then
needing to rest.”
MCM had learned from Dr. Jackson's office that Williams
had undergone a surgical procedure on her hip, but the office
“could not confirm [the] specific procedure nor were
they able to locate any activity
MCM reported that additional medical information was
necessary in order to determine Williams's
September 11, 2012, Hartford received and reviewed Dr.
Jackson's medical records, showing that Williams had a
right hip arthroscopy on June 11, 2012. Dr.
Jackson reported that as of July 31, 2012, Williams was
September 14, 2012, the MCM provided an updated assessment of
Williams's medical records.
MCM confirmed that Williams did not have future appointments
scheduled with Dr. Jackson.
MCM noted that she would contact Dr. Inouye and Dr. Jackson
“for clarification of [Williams's]
MCM stated that “[i]n light of the successful hip
procedure [the] MCM [is] anticipating improvement in overall
capabilities, less reported pain and no findings to support
an inability to perform the sit/stand/walk activity required
of a teacher.”
MCM also indicated that Hartford would send the video
surveillance to Dr. Inouye and Dr. Jackson for their review
Hartford decided that it needed an additional opinion
“to clarify/update [Williams's] current maximum
functional abilities[, ]” and contemplated scheduling
an independent medical examination (“IME”) by an
However, Hartford learned that there were “no
orthopedic IME providers within 78 miles of [Williams's
Hartford concluded that the available IME providers were too
far away from Williams's home to require her
participation in an IME, and therefore, decided to arrange
for a physician peer review of Williams's
October 12, 2012, Hartford referred Williams's file to a
third party vendor, BMI, in order to obtain an independent
Hartford requested that the peer reviewer opine about
Williams's level of functionality based on the medical
evidence and other information provided.
Hartford also asked the peer reviewer to “observe and
note any consistencies/inconsistencies in comparing the
subjective and objective findings versus the level of
activity as seen in the surveillance
Robert Green, a Board Certified Orthopedic Surgeon, licensed
to practice medicine in Florida, performed the peer review of
Williams's claim for BMI and provided a report dated
November 1, 2012.
Green spoke with Dr. Inouye.
i. Dr. Inouye stated that Williams's “main problem
ii. Dr. Inouye noted that surgery had addressed
Williams's hyperparathyroidism and right hip pathology,
and that surgery on the left hip was scheduled.
iii. Dr. Inouye expressed his view that Williams is incapable
of “return[ing] to the workforce in any capacity”
due to fibromyalgia.
Green also spoke with Dr. Jackson who felt that Williams
“certainly can return to a sedentary-type job as far as
her hips are concerned, especially after she has the other
hip [surgery] if he finds it necessary after doing an MRI and
working her up.”
Green concluded that fibromyalgia was “a limiting
Green opined that Williams “should be able to start at
four hours a day or 20 hours a week” with limitations
relating to lifting, stooping, squatting, pushing, and
Green noted that “[i]t is possible that [Williams] may
eventually be able to increase the amount of time per day she
is able to function.”
November 8, 2012, the MCM reviewed and summarized Dr.
MCM returned the file for continued
MCM identified Williams's primary diagnosis as
osteoarthritis with a secondary diagnosis of
December 21, 2012, the Ability Analyst reviewed the status of
Ability Analyst noted Dr. Green's opinion that Williams
had the capacity to return to part-time sedentary
Ability Analyst also indicated that it was “not clear
if [Williams] will regain enough capability to do full time
sedentary work by [the effective date of the Plan's
Ability Analyst documented his plan to begin the
investigation of whether Williams would continue to be
disabled under the Plan's “Any Occupation”
Any Occupation Investigation
December 21, 2012, the Ability Analyst took several actions
to begin the investigation of whether Williams would continue
to be disabled under the Plan's “ Any
Ability Analyst sent a letter to Williams informing her that
the Plan's “Any Occupation” definition would
take effect on June 17, 2013.
Ability Analyst summarized the applicable terms of the Plan
and requested updated information.
Ability Analyst also sent letters to Williams's
physicians requesting updated information.
Ability Analyst also sent a letter to Williams requesting her
assistance in obtaining the updated records from Dr. Inouye
and Dr. Jackson.
Ability Analyst also interviewed Williams by telephone
regarding her medical condition.
January 4, 2013, the Ability Analyst's Manager reviewed
the issues relating to the Any Occupation
Based on the information received from Williams's
treating physicians and Dr. Green's the independent peer
review, the Manager noted that Williams's “return
to part time sedentary functionality would be anticipated
around [January to February 2013]” if the scheduled
November 16, 2012 surgery on her left hip
Manager indicated that the claim would be transferred to a
new Ability Analyst with a specialty appropriate to
Manager recommended obtaining Dr. Jackson's latest office
visit notes in order to evaluate “if functionality has
returned to [part-time] or [full-time] sedentary
January 30, 2013, the new Ability Analyst documented the
status of the Any Occupation investigation and summarized the
information received and information still
Ability Analyst stated that “[o]nce we receive all
[medical records], it appears an IME would be the most
appropriate step to confirm that [restrictions and
limitations] are supported.”
Ability Analyst noted that Williams “has been
participating in [part-time work], so it appears that [she]
would have had improvement in functionality greater than
part-time sed[entary] work.”
Ability Analyst outlined a planned future course of conduct
in the Any Occupation investigation.
February 19, 2013, the Ability Analyst summarized the
information on file regarding Williams's claim in
anticipation of a “Roundtable”
February 21, 2013, the Manger and the Ability Analyst had a
“Roundtable” discussion of Williams's
Manager and the Ability Analyst decided to “refer
[Williams's file] to [the] MCM to clarify what is
impacting functionality with regards to finger/handle and
Manager noted that Dr. Inouye had “not really addressed
the objective testing to validate these
Ability Analyst would ask the MCM “whether any change
in functionality would be expected from the past peer review,
” and “if no change in functionality would be
expected and restrictions [are] reasonable, ” the
Analyst Ability would refer Williams's file for an
Employability Analysis Report.
February 22, 2013, the Ability Analyst referred
Williams's file to the MCM.
February 28, 2013, the MCM reported on her review of
MCM summarized the medical evidence.
MCM noted that she would contact Dr. Inouye in an attempt to
clarify Williams's functionality.
MCM observed that “[i]t is possible that [Williams] may
have had some increases in her functionality since the prior
peer review [of Dr. Green] was
February 20, 2013, the MCM sent a fax to Dr. Inouye
requesting clarification of Williams's
March 7, 2013, the MCM contacted Dr. Inouye's office to
follow up on the request, and resent the
March 14, 2013, the MCM again contacted Dr. Inouye's
office to confirm receipt of the request.
March 21, 2013, the MCM reported that she had not yet
received a response from Dr. Inouye to her request seeking
classification of Williams's functionality.
MCM indicated that she would discuss with the Ability Analyst
about whether to refer Williams's file to a peer review
vendor “to further clarify functionality of any
Ability Analyst agreed with the plan to refer Williams's
file “for peer review as we have not received response
from [Dr. Inouye] to clarify [restrictions and
April 2, 2013, Hartford referred the file to a third party
vendor, MES Solutions, in order to obtain a new independent
medical peer review and sent letters to Dr. Inouye and
Dr. Jackson notifying them to expect a telephone call from
the independent medical consultant.
Solutions assigned the peer review to Dr. Siva Ayyar, who is
Board Certified in Occupational Medicine and has licenses to
practice medicine in California, Florida, Ohio, Tennessee,
Ayyar submitted a detailed report dated April 24,
Ayyar left voice mail messages for Dr. Inouye, but the calls
were not returned.
Ayyar was able to speak with Dr. Jackson.
i. Dr. Jackson reported that Williams's “hip issues
have essentially been treated to
ii. Dr. Jackson told Dr. Ayyar that “[h]e is not a
proponent of [Williams's] LTD claim.”
iii. Dr. Jackson suggested that Dr. Ayyar contact Dr. Joseph
Richey, who was treating Williams's low back
Ayyar noted that Dr. Jackson “affirmed [his] conclusion
that the hip issues were a temporarily limiting concern, as
opposed to a continuously limiting
Ayyar summarized the medical records.
Ayyar stated that Williams would not have been able to
perform any work for two weeks immediately following her hip
surgery on November 16, 2012.
Ayyar identified restrictions and limitations relating to the
postoperative recovery period, “December 1, 2012 to
March 31, 2013[.]”
Ayyar indicated that he lacked sufficient medical evidence to
extend the restrictions and limitations beyond April 1,
Ayyar stated that the nature of Williams's
“functional, technical, and/or anatomic outcomes”
would determine what, if any, restrictions and limitations
would be appropriate after April 1, 2013.
April 25, 2013, the MCM reviewed and summarized Dr.
Ayyar's report and sent a letter to Dr. Inouye asking
Dr. Inouye to review the summary and provide any comments and
April 25, 2013, the MCM also called Dr. Inouye's office
in order to confirm receipt of her letter dated April 25,
April 30, 2013, the Ability Analyst spoke with Williams about
the status of the claim review.
Ability Analyst informed Williams of Dr. Ayyar's
conclusions, and that Hartford was awaiting Dr. Inouye's
Williams asked whether her receipt of SSDI benefits played a
role in Hartford's determination.
Ability Analyst explained that “the SSA and Hartford
have different definitions of disability and different ways
to make a decision[, ]” and that Hartford “do[es]
not make [its] decision based on [the] SSA[']s
May 1, 2013, Williams again spoke with the Ability
Williams discussed her referral to Dr. Richey regarding her
back pain and said that she was scheduled to see him on May
7, 2013, regarding the results of an MRI.
Williams asked whether Hartford considered her “whole
Ability Analyst responded that Hartford “would take
into consideration [the] totality of all medical
Williams stated that Dr. Inouye disagreed with Dr. Ayyar, and
that he would provide a response.
Based on her conversation with Williams, the Ability Analyst
noted that she would seek the records of Dr. Jackson and Dr.
Richey referenced by Williams.
Ability Analyst commented that “Hartford will need this
information as it could potentially change [the Any
Inouye responded to the MCM's letter by letter dated
April 30, 2013.
Inouye provided a short overview of Williams's
Inouye neither addressed any specific points in Dr.
Ayyar's report nor cited any medical evidence supporting
Instead, Dr. Inouye generally attacked the ability of a peer
review physician to comment on Williams's medical
Inouye reiterated his opinion that Williams “is
disabled currently[, and that s]he cannot in any way continue
to work as a teacher.”
May 8, 2013, the MCM documented her review of Dr.
Inouye's response, noting that he had not
provided “additional medical records… for
May 9, 2013, Williams and the Ability Analyst spoke about
Williams's recent visit with Dr. Richey.
Ability Analyst noted that Hartford was continuing its review
of whether Williams would continue to be disabled after June
17, 2013, under the “Any Occupation”
Williams expressed her view that her back condition would
prevent her from doing any type of work.
Ability Analyst told Williams that she would need to review
the medical information from Dr. Richey.
May 15, 2013, the Ability Analyst received a letter from
Williams and medical records from Dr. Jackson and Dr. Richey,
and forwarded the new materials to the MCM.
May 15, 2013, Williams called the Ability Analyst to tell her
that additional medical information would be available the
following week. Hartford and Williams had follow up
telephone conversations about the status of those
May 21, 2013, Hartford received the additional medical
records, and the Ability Analyst referred them to the MCM for
MCM reviewed the additional medical records and recommended
their referral to Dr. Ayyar for an addendum
Hartford then referred the additional medical records to MES
Solutions for an addendum review.
June 4, 2013, Dr. Ayyar submitted an addendum
Ayyar again tried to speak with Dr. Inouye, but was
Ayyar reviewed and summarized the 101 pages of new
Ayyar found evidence of fatigue attributable to
Williams's hypothyroidism and recommended some activity
limitations for the period of May 6, 2013 to June 6, 2013, to
allow a month for adjustment of Williams's hypothyroidism
Ayyar stated that Williams's hip condition may
“cause intermittent limitations and
Ayyar found no evidence to support restrictions or
limitations attributable to Williams's back condition,
citing the fact that the lumbar MRI was “essentially
Ayyar found that “[Williams's] thyroid cancer has
seemingly been treated to resolution[.]”
June 6, 2013, the Ability Analyst sent a letter to Dr. Inouye
summarizing the findings in Dr. Ayyar's addendum report,
 and referred the file for the
preparation of an Employability Analysis
June 11, 2013, Sandra Shelton, MA, CRC prepared an
Employability Analysis Report for Hartford,  based on
the limitations offered by Dr. Ayyar and on the June 6, 2013
report of MCM-RN Michelle McNamara.
According to the Employability Analysis Report, Ms. Shelton
considered the following limitations:
sit unlimited; stand/walk no more than 15 minutes
continuously for total of 30 cumulative minutes per hour,
maximum of 4 cumulative hours per day; lift up to 25 [pounds]
up to 3 cumulative [hours] per day, up to 26 [pounds] or more
up to 30 cumulative minutes per day; occasionally kneel,
squat, bend or stoop maximum of 2 [hours] per day; activity
not formally limited above should be considered unlimited.
Ms. Williams is able to perform Sedentary demands 8 hours per
day, 40 hours per week. There is no evidence to support
cognitive and/or mental restrictions.
Shelton “identified 6 occupations within the Closest
level; no occupations within the Good level; 77 occupations
within the Fair level; and 205 occupations within the
Potential level[, ]” and provided a
“representative sample of occupations that meet
Shelton opined that Williams could perform work as a Teacher,
Elementary School-Williams's past occupation; Teacher,
Mentally Impaired; Teacher; Vocational Training; and Teacher,
Shelton also opined Williams could perform work as a Jacket
Preparer, which was categorized as a “Potential”
level occupation. According to the Employability
Analysis Report's Transferability Table, a
“Potential” level occupation has low
transferability, requiring plan development and training, and
training in tools and materials is required.
Shelton stated that “[e]ach occupation is within the
restrictions/limitations provided by Dr.
Shelton also stated that the job of Jacket Preparer
“requires no experience or education” and
“can be performed with short on-the-job training”
despite its classification as a “Potential” level
June 13, 2013, Hartford informed Williams of its
determination that she was “not Disabled from [her own]
Occupation effective [June 12, 2013] and will not be Disabled
from Any Occupation as of [June 17,
Hartford acknowledged that Williams had received SSDI
benefits, but stated that “[t]he standards governing
these public and private benefits are different in critical
Hartford indicated that it had considered “the
SSA's disability determination as one piece of relevant
evidence, ” but added that “the SSA's
determination is not conclusive.”
Hartford went on to summarize the relevant terms of the Plan
and the information it considered.
Hartford determined that the payment of LTD benefits to
Williams would end on June 12, 2013.
According to the termination, Williams could perform her own
occupation as a Teacher, Elementary School, as well as other
occupations, listed as: Teacher, Mentally Impaired; Teacher;
Vocational Training; Teacher, Learning Disabled; and Jacket
Determination of Williams's Appeal
a letter dated November 19, 2013, Williams's counsel
submitted an appeal of the claim determination, arguing that
Williams's medical records show that she has continuing
problems with hypothyroidism, hip osteoarthritis, pain, and
weakness. Williams's counsel enclosed a
Functional Capacity Evaluation,  as further proof of
Hartford referred the file to a third party vendor, Reliable
Review Services, for a new independent peer
Reliable Review Services assigned the peer review project to
Dr. Joseph L. Rea, who is Board Certified in Occupational
Medicine with licenses to practice medicine in Alabama and
Rea provided a report dated January 10, 2014.
Rea summarized Williams's clinical history.
Rea concluded that Williams should be capable of full-time
work with various noted activity limitations from June 11,
2013, to the present.
January 13, 2014, Hartford issued its determination on
Hartford noted the arguments on which Williams based her
appeal and summarized the conclusions of Dr.
Hartford stated that “[a]lthough our previous decision
was supported by the information we had at the time, we will
reopen [Williams's] claim an extend benefits through
[June 16, 2013, ]” an additional five days,
after which it denied Williams's appeal.
Hartford again concluded that “the medical information
does not establish that [Williams] remained Disabled from
performing [A]ny [O]ccupation as defined by the [Plan and
Hartford found that “the weight of the information in
[Williams's] file viewed as a whole supports that [she]
is medically capable of performing at least full time
sedentary work within the above noted limitations [of Dr.