United States District Court, D. Idaho
MEMORANDUM DECISION AND ORDER
B. LYNN WINMILL, Chief District Judge.
Plaintiff Clay Scott Baker brings this action against Defendant Hartford Life and Accident Insurance Company claiming wrongful denial of disability benefits under 29 U.S.C. § 1132(a)(1)(B). The parties have filed cross-motions for summary judgment. The motions were argued on February 17, 2015, and taken under advisement. Having considered the record and pleadings, the Court will grant Defendant's Motion for Summary Judgment and deny Plaintiff's Motion for Summary Judgment.
This is an Employment and Retirement Income Security Act ("ERISA") case. Hartford Life and Accident Insurance Company issued a group long term disability ("LTD") Plan to Intermountain Medical Clinic. Admin. Rec. at 39, Dkt. 23-1. Baker is a former dermatologist of Intermountain who submitted a claim for LTD benefits under the Plan based on mycotoxicosis, which is exposure to mold toxins. Admin. Rec. at 1155-63, 1174-75, Dkt. 23-25. To be eligible for coverage, the Plan requires, in relevant part, that:
Your Disability must be the result of:
1) accidental bodily injury;
2) sickness; [or]
3) Mental Illness;
Mental Illness means a mental disorder as listed in the current version of the Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association. A Mental Illness may be caused by biological factors or result in physical symptoms or manifestations.
R., 30-31, Dkt. 23-1. However, the Plan limits benefits as follows:
Mental Illness And Substance Abuse Benefits: Are benefits limited for Mental Illness? If You are Disabled because of:
1) Mental Illness that results from any cause; [or]
2) any condition that may result from Mental Illness;
then subject to all other provisions of The Policy, We will limit the Maximum Duration of Benefits.
Benefits will be payable:
1) for as long as you are confined in a... place licensed to provide medical care for the disabling condition; or
2) if not confined, or after you are discharged and still Disabled, for a total of 24 month(s) for all such disabilities during your lifetime.
Id. at 21.
Hartford engaged two of its medical professionals, a Medical Care Manager ("MCM") and a Behavioral Health Care Manager ("BHCM"), to evaluate Baker's medical records. Admin. Rec. at 86-87, Dkt. 23-2. The BHCM, after speaking with Baker and his psychiatrist, Dr. Soofi, ordered an independent psychiatric review from the third party vendor MES Solutions ("MES"). Id. at 77-79. Dr. Jean Dalpe, a psychiatrist engaged by MES, determined that Baker's disability was due to psychiatric conditions. Admin. Rec. at 577, Dkt. 23-13. In Hartford's denial letter, dated May 30, 2013, Hartford indicated that it had reviewed records and reports from Drs. Soofi, Reichman, Sponangle, Hooper, Kennedy, Dalpe, the MCM, and the BHCM, as well as lab reports, diagnostic tests, medical records, and conversations with Dr. Soofi. Admin. Rec. at 126, Dkt. 23-3.
On July 16, 2013, Baker submitted additional materials from his providers. Admin. Rec. at 545, 555, Dkts. 23-12, 23-13. Hartford reviewed the materials, again denied coverage, and encouraged Baker to submit an appeal. Admin. Rec. at 122, Dkt. 23-3. Over the next three months, Baker appealed and submitted a neuropsychological report by Dr. Didriksen, as well as records from Drs. Rea and Soofi. Admin. Rec. at 220, 252, Dkts. 23-5, 23-6. Upon receiving the additional documentation, Hartford engaged the third party vendor University Disability Consortium ("UDC") to review Baker's file. Admin. Rec. at 211-12, Dkt. 23-5. UDC assigned the review to three physicians with different specialties: Dr. Ruffell (psychiatry), Dr. King (neurology), and Dr. Caruso (occupational medicine). Admin. Rec. at 180, 194, 210, Dkts. 23-4, 23-5. Based upon his review, Dr. Ruffell diagnosed Baker with Bipolar Affective Disorder. Admin. Rec. at 209, Dkt. 23-5. Dr. King found that Baker would not, from a neurological perspective, be precluded from work." Admin. Rec. at 193, Dkt. 23-4. And Dr. Caruso questioned the accuracy of the testing and methods used to diagnose Baker with mycotoxicosis. See id. at 169-76.
On November 26, 2013, Hartford concluded that Baker "meets the definition of disability and is eligible for LTD benefits." Admin. Rec. at 113, Dkt. 23-3. Two weeks later, Hartford issued an appeal letter in which it found that "Dr. Baker was unable to perform the Essential Duties of his occupation due to symptoms and impairment resulting from Major Depression. The Appellate Review further shows there is no supported Disability from a physical perspective." Admin. Rec. at 108-10, Dkt. 23-3. Accordingly, Hartford limited LTD benefits to the 24-month period set forth in the Plan. Id.
Baker submitted a second appeal on March 11, 2014, but failed to submit any new medical evidence. Admin. Rec. at 161-62, Dkt. 23-4. In Hartford's response to the second appeal, it explained:
since we have determined that Dr. Baker was not physically precluded from working and has already exhausted the maximum duration of benefits payable due to any Mental Illnesses he may suffer from, we are maintaining the prior determination to terminate this [sic] LTD benefits as of December 28, 2103. This determination regarding eligibility for ...