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Kagen v. Hartford Life and Accident Insurance Co.

August 13, 2007

HERSHEL KAGEN PLAINTIFF
v.
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY DEFENDANT



The opinion of the court was delivered by: James M. Moody United States District Judge

ORDER

Plaintiff Hershel Kagen was insured through his employer under a disability insurance policy issued by Defendant Hartford Life and Accident Insurance Company (the "Plan"). On or about February 20, 2002, Plaintiff applied for long-term disability benefits under the Plan. Plaintiff's claim was approved by the Defendant and he began receiving benefits. However, by letter dated December 12, 2003, Defendant advised Plaintiff that his benefits were being terminated because he did not meet the definition of "disability" any longer. Plaintiff appealed the decision. The Defendant affirmed its decision to deny benefits on May 12, 2004. Plaintiff filed suit against the Defendant in the Circuit Court of Jackson County, Arkansas on August 13, 2004. Hartford removed the case to this Court pursuant to 28 U.S.C. § 1441(a) and (b) because the action arises under Section 502(a)(1)(b) of the Employee Retirement Income Security Act of 1974 ("ERISA"). Defendant filed a counterclaim against Plaintiff for reimbursement of overpayment of benefits. The administrative record has been provided to the Court and the parties have each briefed the issues. For the reasons set forth below, the Court finds that the Defendant's decision to terminate Plaintiff's disability benefits was reasonable.

Standard of Review

ERISA provides for judicial review of disability benefit denial decisions. The Supreme Court has recognized that a deferential standard of review is appropriate under 29 U.S.C. § 1132(a)(1)(B), if "the benefit plan gives the administrator or fiduciary discretionary authority to determine eligibility for benefits or to construe the terms of the plan." Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989). The Plan provides that Hartford has "full discretion and authority to determine eligibility for benefits and to construe and interpret all terms and provisions of the Group Insurance Policy." (AR 016). In other words, the Plan gives discretion to the Defendant. Therefore, the decisions of Defendant Hartford are subject to review for abuse of discretion by this Court. King v. Hartford Life and Acc. Ins. Co., 414 f.3d 994 (8th Cir. 2005).

In applying an abuse of discretion standard, the reviewing Court must affirm if a "reasonable person could have reached a similar decision, given the evidence before him, not that a reasonable person would have reached that decision." Ferrari v. Teachers Ins. and Annuity Ass'n, 278 F.3d 801, 807 (8th Cir. 2002). A reasonable decision is one based on substantial evidence that was actually before the plan administrator. Substantial evidence is defined as "more than a scintilla but less than a preponderance." Schatz v. Mutual of Omaha Ins. Co., 220 F.3d 944, 949 (8th Cir. 2000). A reviewing court may consider both the quantity and the quality of evidence before a plan administrator.

Plaintiff contends that a reasonable person could not have reached the same decision as Hartford because (1) the vocational analysis and medical reports relied upon by Hartford are not credible and (2) Hartford did not take evidence of Plaintiff's psychiatric condition into account in making its decision.

The Plan defines disability as follows:

Disability or Disabled means that during the Elimination Period and for the next 24 months you are prevented by:

1. Accidental bodily injury;

2. Sickness;

3. Mental illness;

4. Substance abuse; or

5. Pregnancy, from performing one or more of the Essential Duties of Your Occupation, and as a result your Current Monthly Earnings are no more than 80% of your Indexed Pre-disability Earnings.

After that, you must be so prevented from performing one or more of the Essential Duties of Any Occupation. (AR017). ...


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