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Tortora v. Hartford Life and Accident Insurance Co.

United States District Court, D. South Carolina, Greenville Division

February 8, 2016

Ralph J. Tortora, Plaintiff,
v.
Hartford Life and Accident Insurance Company, Defendant.

          OPINION & ORDER

          HENRY M. HERLONG, Jr., Senior District Judge.

         This matter is before the court for review of the claim administrator's decision to deny long-term disability ("LTD") benefits to Ralph J. Tortora ("Tortora") under an LTD insurance policy ("Policy") governed by ERISA.[1] The Policy is insured and administered by Hartford Life and Accident Insurance Company ("Hartford"). Tortora seeks LTD benefits pursuant to 29 U.S.C. § 1132(a)(1)(B) and attorneys' fees and costs pursuant to 29 U.S.C. § 1132(g). (Joint Stipulation ("J.S.") ¶ 1, ECF No. 23.) The parties have filed a joint stipulation and memoranda in support of judgment pursuant to the court's Specialized Case Management Order for ERISA benefits cases. The parties agree that the court may dispose of this matter consistent with the joint stipulation and memoranda. (Id. ¶ 8, ECF No. 23.) The parties further agree that the court should resolve the following issues: (1) whether Hartford's claim decision was proper under the applicable standard of review and factors made relevant by Champion v. Black & Decker (U.S.) Inc., 550 F.3d 353 (4th Cir. 2008); (2) if the claim decision was improper, whether benefits should be awarded pursuant to 29 U.S.C. § 1132(a)(1)(B), or whether the case should be remanded to Hartford for further evaluation of Tortora's claim; and (3) if remand is necessary, whether resolution of the issue of retroactive benefits and attorneys' fees should be deferred until after further evaluation is conducted. (J.S. ¶ 7, ECF No. 23.) For the reasons set forth below, the court remands the case to Hartford for further consideration.

         I. FACTUAL AND PROCEDURAL HISTORY

         Tortora's claim arises under a group disability policy that was issued by Hartford to Tortora's former employer, Macro Plastic, Incorporated ("MPI"). (Compl. ¶ 4, ECF No. 1.) Tortora was employed by MPI as a sales and marketing manager until January 4, 2006, when he ceased working due to a back injury caused by a fall at home, which required a spinal fusion of T-10 to L-3. (Def. Mem. Supp. J. 4, ECF No. 27.) As an employee of MPI, Tortora was covered by the Policy as a participant in the employee benefits plan. (Id. at 1, ECF No. 27.) Under the employee benefits plan and the Policy, MPI vested Hartford with discretionary authority to interpret Policy terms and make benefit determinations. ( Id., ECF No. 27.)

         Tortora applied for LTD benefits on February 18, 2006. (J.S. Exs., ECF No. 24-15, AR 1117-22.) Hartford approved LTD benefits under the Policy and notified Tortora by letter dated March 21, 2006. (Id. Exs., ECF No. 24-16, AR 1266-68.) Between 2007 and 2014, Tortora completed several Claimant Questionnaire forms upon Hartford's request, in which he reported working as a part-time realtor fluctuating between ten to twelve or ten to fifteen hours per week. (Id. Exs., ECF No. 24-13, AR 898-900; Id . Exs., ECF No. 24-13, AR 879-81; Id . Exs., ECF No. 24-10, AR 532-34.) On October 2, 2014, Hartford denied Tortora continuing LTD benefits, finding that Tortora no longer had a "Disability" as that term is defined under the Policy. (Id. Exs., ECF No. 24-16, AR 1145-50.) The decision was upheld on appeal and became final on June 10, 2015. (Id. Exs., ECF No. 24-16, AR 1129-32.) Tortora alleges that he is disabled and that Hartford abused its discretion in terminating his LTD benefits.

         The Policy provides in pertinent part as follows:

When do benefits become payable?
You will be paid a monthly benefit if:
1. you become Disabled while insured under this plan;
2. you are Disabled throughout the Elimination Period;
3. you remain Disabled beyond the Elimination Period;
4. you are, and have been during the Elimination Period, under the Regular Care of a Physician; and
5. you submit Proof of Loss satisfactory to us.
* * *
When will benefit payments terminate?
We will terminate benefit payment on the first to occur of:
1. the date you are no longer Disabled as defined;
* * *
Any Occupation means an occupation for which you are qualified by education, training or experience, and that has an earnings potential greater than an amount equal to the lesser of the product of your Indexed Pre-disability Earnings and the Benefit Percentage and the Maximum Monthly Benefit shown in the Schedule of Insurance.
* * *
Disability or Disabled means that during the Elimination Period ...

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