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Mawa v. Hartford Life & Accident Insurance Co.

United States District Court, D. Utah

January 18, 2019

BRENNA L. MAWA, Plaintiff,
v.
HARTFORD LIFE & ACCIDENT INSURANCE COMPANY, Defendant.

          MEMORANDUM DECISION AND ORDER

          Dale A. Kimball, District Judge

         Before the court are cross motions for summary judgment in an ERISA case. Plaintiff Brenna Mawa claims to be disabled primarily due to fatigue, dizziness, and shortness of breath. Mawa asserts a claim for long term disability benefits under the Group Long Term Disability Plan for Employees of LHC Group, Inc. (“Plan”). The motions will be decided based on the administrative record.

         THE PLAN

         Hartford is the claim administrator responsible for the determination of Long-Term Disability (“LTD”) claims under the Plan. The plan has delegated to Hartford the “discretion to determine eligibility for benefits and to interpret the terms of the benefit plan.

         The Plan requires a claimant to submit proof of loss showing that the claimant is disabled under the Plan's terms and conditions. The proof of loss “must be satisfactory” to Hartford. The payment of LTD benefits will end on “the date [a claimant is] no longer Disabled” under the Plan's terms.

         The Plan's definition of disability focuses on whether a claimant can perform the duties of her own occupation. After a claimant receives 24 months of LTD benefits, the test for disability changes to whether the claimant is able to perform any occupation. The Plan defines “Any Occupation” as “any occupation for which you are qualified by education, training or experience…” Rec. 34.

         BACKGROUND

         Plaintiff Brenna Mawa was a nurse and worked as a Branch Director and Clinical Director of LHC Group, Inc. (“LHC”). Mawa stopped working for LHC due to symptoms related to peripartum cardiomyopathy and subsequently applied for LTD benefits. On June 5, 2015, Hartford approved Mawa's claim for LTD. In the approval letter, Hartford advised Mawa that the test for disability would change to the Any Occupation Definition effective February 8, 2017.

         On May 20, 2016, Roxann Koelln, an on-staff Hartford Nurse, interviewed Mawa by telephone about her status. Mawa reported that she had worsening symptoms of extreme fatigue/tired, feeling like she is going to black out upon standing which can last for prolonged period of times, shortness of breath with exertion, dizziness with bending and slight edema in legs and feet as the day goes on. She also reported that she cared for her four-year-old child who she can lift, but not carry around. Mawa further noted that she had lost 101 pounds since lap band placement in January 2016 and did light exercise.

         Nurse Koelln asked Mawa whether she could return to work in a sedentary capacity. Mawa did not believe she could sit for more than a couple of hours due to her taking of coumadin. Nurse Koelln told Mawa that individuals work while on coumadin therapy and that seated work generally allows for the ability to stand and stretch, and to walk around when needed. Mawa said she would think about returning to work in some capacity once her symptoms were better controlled.

         On June 27, 2016, Nurse Koelln called Mawa for an update. Mawa said that she had an echocardiogram on June 15, 2016. Mawa reported continued issues with blood pressure and dizziness. On June 28, 2016, Nurse Koelln sent a letter to Dr. Kristin Scott-Tillery, Mawa's attending physician, asking Dr. Scott-Tillery to comment on Mawa's work capacity. On July 12, 2016, Assistant Nurse Practitioner Terri Hancock responded on behalf of Dr. Scott-Tillery. Hancock indicated that Mawa was capable of part time sedentary work. Hancock noted that Mawa had pre-syncope episodes and hypertension, and that she had “significant limitations at this time.”

         On September 7, 2016, Dr. Stehlik examined Mawa. At the examination, Mawa reported less near syncope, but she still had some lightheadedness. Mawa told Dr. Stehlik that she tries to walk, and does some exercise videos for activity, and is thinking about purchasing a stationary bike. Stehlik's review of symptoms during the examination was negative for malaise/fatigue, claudication, dyspnea on exertion, near-syncope, orthopnea, shortness of breath, and muscle weakness. Rec. 281. Mawa tested positive for light-headedness based on her self-report. Mawa had a normal heart rate, regular rhythm, normal heart sounds, and intact distal pulses. Mawa exhibited normal psychiatric conditions with normal cognition and memory.

         On September 28, 2016, Nurse Koelln sent a letter to Dr. Scott-Tillery asking whether Mawa was able to perform sedentary work on a full-time basis, and requested information supporting Dr. Scott-Tillery's opinion. On October 4, 2016, Hartford learned that Dr. Scott-Tillery had left the medical practice and moved to Montana. Mawa's new primary treating physician was Dr. Joseph Stehlik.

         On October 6, 2016, Hartford referred the medical records for an independent physician peer review. Hartford provided 342 pages of medical records with the referral. Dr. Mark Eaton summarized some of the medical records that he had reviewed. Dr. Eaton pointed out the inconsistency between a provider's statement regarding Mawa's inability to ...


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