Quarles v. Hartford Life

Filing 59

MEMORANDUM AND OPINION by Senior Judge Charles R. Simpson III on 3/20/2019. The Court will GRANT Defendant's Motion for Judgment (DN 49 ) and DENY Plaintiff's Motion for Judgment (DN 48 ).cc: Counsel (MEJ)

UNITED STATES DISTRICT COURT
WESTERN DISTRICT OF KENTUCKY
AT LOUISVILLE

EMMANUEL J. QUARLES

PLAINTIFF

vs.

CIVIL ACTION NO. 3:15-CV-00372-CRS-CHL

HARTFORD LIFE & ACCIDENT
INSURANCE COMPANY

DEFENDANT

MEMORANDUM OPINION
I. INTRODUCTION
This matter is before the Court on cross-motions for judgment on the administrative
record.1 DN 48; DN 49. Plaintiff requests oral argument on the Parties’ competing motions
“[b]ased on the factually intensive nature of the issues presented, as well as the confusion that can
occur when parties are filing competing motions.” DN 54, at 39. Plaintiff’s request will be denied,
as this Court finds oral argument unnecessary. The issues are clearly presented in the Parties’
thorough briefs. These issues are ripe for review. For the reasons set forth below, the Court will
GRANT Defendant’s Motion for Judgment (DN 49) and DENY Plaintiff’s Motion for Judgment
(DN 48).
II. FACTUAL BACKGROUND
Plaintiff, Emmanuel J. Quarles (“Quarles”), brought suit against Defendant, Hartford Life
and Accident Insurance Company (“Hartford”) alleging wrongful termination of his long-term

Although Plaintiff characterizes his motion as seeking “summary judgment,” it is more appropriately captioned as a
motion for judgment on the administrative record. See Univ. Hosps. v. Emerson Elec. Co., 202 F.3d 839, 845 n. 2 (6th
Cir. 2000) (“[S]ummary judgment generally is an inappropriate mechanism for adjudicating ERISA claims for
benefits.”) (citing Wilkins v. Baptist Healthcare Sys., Inc., 150 F.3d 609, 617–19 (6th Cir. 1998)). Indeed, Plaintiff
acknowledges his motion for “summary judgment” should be construed as a “motion for judgment on the
administrative record.” See DN 54, at 3 n.1.
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disability (“LTD”) benefits and waiver of premiums (“WOP”) of his basic life and accidental death
and dismemberment (“AD&D”) coverages under the Employment Retirement Income Security
Act of 1974 (“ERISA”). The Administrative Record (“AR”) of this matter has been filed. DN 21.
The AR consists of 700 numbered pages which will be cited as “AR (page number).”
A. Relevant Plan Provisions
In 2012, Quarles began to work as a Selector for Gordon Food Service, Inc. (“Gordon”).
AR 621. Hartford issued Group Insurance Policies GL-395259, GLT-395259, and ADD-507325
to Gordon to insure the life insurance, LTD, and AD&D components, respectively, of the
employee welfare benefit plan established and maintained by Gordon (the “Plan”). AR 1–112.
By virtue of his employment with Gordon, Quarles was insured under the Life Policy, LTD Policy,
and the AD&D Policy (collectively, the “Policies”). Each policy provides a benefit in the event
Quarles became “Disabled.” Id.
1. The LTD Policy
The LTD Policy pays disability benefits if participants:
1)
2)
3)
4)

become Disabled while insured under The Policy;
are Disabled throughout the Elimination Period;
remain Disabled beyond the Elimination Period; and
submit Proof of Loss to Us.

AR 22.2 “Disability” for purposes of a participant’s eligibility for disability benefits under the
LTD Policy is defined as follows:
Disability or Disabled means You are prevented from performing one or more of
the Essential Duties of:
1) Your Occupation during the Elimination Period;

Under all the Policies, “We, Our, or Us means the insurance company named on the face page of The Policy.” (i.e.,
Hartford). AR 1, 15, 33, 40, 58, 75, 93 (emphasis in original). “You or Your means the person to whom this
certificate is issued” and “Your Occupation means Your Occupation as it is recognized in the general workplace.
Your Occupation does not mean the specific job You are performing for a specific employer or at a specific location.”
AR 33, 58, 93 (emphasis in original).
2

2

2) Your Occupation, for the 24 month(s) following the Elimination Period, and as
a result Your Current Monthly Earnings are less than 80% of Your Indexed Predisability Earnings; and
3) After that, Any Occupation.
AR 30.
The LTD Policy provides that benefits terminate under the following relevant
circumstances:
Termination of Payment: When will my benefit end?
Benefit payments will stop on the earliest of:
…
2) the date You fail to furnish Proof of Loss; [or]
…
8) the date Your Current Monthly Earnings exceed:
a) 80% of Your Indexed Pre-disability Earnings if You are receiving benefits for being
Disabled from Your Occupation; or
b) the product of Your Indexed Pre-disability Earnings and the Benefit
percentage if You are receiving benefits for being Disabled from Any
Occupation…
AR 23 (emphasis in original).
Under the LTD Policy, Hartford “may request Proof of Loss throughout Your Disability.
In such cases, [Hartford] must receive the proof within 30 day(s) of the request.” AR 27. Proof
of Loss is used to assist Hartford in determining if a participant is disabled under the conditions
entitling participant to benefits under the LTD Policy. AR 26. The LTD Policy sets out a
nonexclusive list of what Proof of Loss may include:
1) documentation of:
a) the date Your Disability began;
b) the cause of Your Disability;
c) the prognosis of Your Disability;
d) Your Pre-disability Earnings, Current Monthly Earnings or any income,
including but not limited to copies of Your filed and signed federal and state
tax returns; and
e) evidence that You are under the Regular Care of a Physician;
2) any and all medical information, including x-ray films and photocopies of
medical records, including histories, physical, mental or diagnostic
examinations and treatment notes;
3) the names and addresses of all:
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a) Physicians or other qualified medical professionals You have consulted;
b) hospitals or other medical facilities in which You have been treated; and
c) pharmacies which you have filled Your prescriptions within the past three
years;
4) Your signed authorization for Us to obtain and release:
a) medical, employment and financial information; and
b) any other information We may reasonably require;
5) Your signed statement identifying all Other Income Benefits; and
6) proof that You and Your dependents have applied for all Other Income Benefits
which are available.
AR 26. The definition further explains that all “proof submitted must be satisfactory” to Hartford.
Id.
The LTD Policy provides that in the event a claim for benefits is denied, Hartford will
provide “You” with written notification of the decision. AR 27. This written notification will:
1) give the specific reason(s) for the denial:
2) make specific reference to The Policy provisions on which the denial is based;
3) provide a description of any additional information necessary to perfect a claim
and an explanation of why it is necessary; and
4) provide an explanation of the review procedure.
Id. In order to appeal this decision, the participant:
1) must request a review upon written application within:
a) 180 days of receipt of claim denial if the claim requires Us to make a
determination of disability; or
b) 60 days of receipt of claim denial if the claim does not require Us to make
a determination of disability; and
2) may request copies of all documents, records, and other information relevant to
Your claim; and
3) may submit written comments, documents, records and other information
relating to Your claim.
Id. Hartford “will respond to You in writing with Our final decision on the claim.” Id.
2. The Life and AD&D Policies
The Life and AD&D Policies provide for “Non-Contributory Coverage.” AR 42, 76. NonContributory Coverage “means coverage for which You are not required to contribute toward the
cost.” AR 57, 92. Under the Life Policy, the Non-Contributory Coverage offered was Basic Life
Insurance and Basic Dependent Life Insurance. AR 42. Similarly, under the AD&D Policy, Basic
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AD&D Insurance and Basic Dependents’ AD&D Insurance were offered as Non-Contributory
Coverage. AR 76.
Participants of the Life and AD&D Policies can also enroll for “Contributory Coverage,”
which “means coverage for which You are required to contribute toward the cost.” AR 57, 91.
The Life Policy offered Supplemental Life Insurance and Supplemental Dependent Life Insurance
as Contributory Coverage. AR 42. Similarly, under the AD&D Policy, Supplemental AD&D
Insurance and Supplemental Dependents’ AD&D Insurance were offered as Contributory
Coverage. AR 76.
The Life and AD&D Policies provide for a waiver of premium (“WOP”) benefit in the
event a participant becomes disabled while insured:
Waiver of Premium: Does coverage continue if I am Disabled?
Waiver of Premium is a provision which allows You to continue Your and Your
Dependent’s [] Insurance coverage without paying premium, while You are
Disabled and qualify for Waiver of Premium.
AR. 49, 81 (emphasis in original). In order to qualify for WOP benefits, “You” must:
1) be covered under The Policy and be under age 60 when You become Disabled;
2) be Disabled and provide Proof of Loss that You have been Disabled for 6
consecutive month(s), starting on the date You were last Actively at Work; and
3) provide such proof within one year of Your last day of work as an Active
Employee.
AR. 49, 82. The Life and AD&D Policies both define “Disabled” as follows:
Disabled means You are prevented by injury or sickness from performing one of
more of the Essential Duties of:
1) Your Occupation, for 24 month(s); and
2) After that, Any Occupation.
AR 49, 81. The Life and AD&D Policies do not provide WOP benefits during the first six months
a participant is Disabled. AR 49, 82. Once effective, WOP benefits continue “while You remain
Disabled, until the date You attain Normal Retirement Age if Disabled prior to age 60.” AR 50,

5

82. Like the LTD Policy, the Life and AD&D Policies have continuing requirements to provide
Proof of Loss:
We have the right to … require Proof of Loss that You are disabled. … If You fail
to submit any required Proof of Loss…, then Waiver of Premium ceases.
AR 49–50; 82. The Life and AD&D Policies include a similar nonexclusive list of what Proof of
Loss may include:
1)
2)
3)
4)
5)

6)

7)

8)

9)

a completed claim form;
a certified copy of the death certificate (if applicable);
Your Enrollment form;
Your Beneficiary Designation (if applicable);
documentation of:
a) the date Your Disability began;
b) the cause of Your Disability;
c) the prognosis of Your Disability;
any and all medical information, including x-ray films and photocopies of
medical records, including histories, physical, mental or diagnostic
examinations and treatment notes;
the names and addresses of all:
a) Physicians or other qualified medical professionals You have consulted;
b) hospitals or other medical facilities in which You have been treated; and
c) pharmacies which you have filled Your prescriptions within the past three
years;
Your signed authorization for Us to obtain and release medical, employment
and financial information (if applicable); or
a) Any other information We may reasonably require;
Any additional information required by Us to adjudicate the claim.

AR 54, 89. Like the LTD Policy, “[a]ll proof submitted must be satisfactory” to Hartford. Id.
B. Quarles’s Medical History
In November 2012, Quarles stopped working due to knee and back pain from a workrelated injury. AR 622. Quarles applied for LTD benefits on September 30, 2013, shortly after
his worker’s compensation benefits ended. AR 167, 481–92. On October 10, 2013, a WOP claim
review was initiated under the Life and AD&D Policies. AR 529. A summary of Quarles’s
medical history follows.

6

Shortly after Quarles’s injury, Quarles’s primary care physicians ordered thoracic, lumbar,
and right knee MRIs, which were completed on January 4, 2013. AR 436–38, 442–48. Dr. Anbu
Nadar, an orthopedic surgeon, reviewed the right knee MRI and discussed possible arthroscopic
evaluation of the knee. AR 441. This surgery was ultimately performed by Dr. Nadar on May 25,
2013. AR 420–21. Dr. Charles Crawford, a spine surgeon, reviewed the lumbar MRI on February
11, 2013 and recommended physical therapy and epidural steroid injections. AR 450–51. Dr.
Crawford recommended surgery if those methods failed. AR 451. During a follow-up evaluation
on May 17, 2013, after a second opinion with Dr. George Raque, Dr. Crawford concluded
Quarles’s “pain was not concordant with [his] previous diagnosis” and there was “no good
indication for spine surgery.” AR 461–62, 459.
On April 23, 2013, as part of his worker’s compensation claim, Quarles underwent an
Independent Medical Examination (“IME”) conducted by Dr. Thomas M. Loeb. AR 338–48. Dr.
Loeb diagnosed Quarles with a “medial meniscus tear in the right knee” and “degenerative disc
disease of the lumbosacral spine.” AR 344. Dr. Loeb concluded that Quarles had reached
“maximum medical improvement” with regard to his lumbar spine, but not with his right knee.
AR 344–45. However, Dr. Loeb opined that under certain circumstances, Quarles “could very
well possibly return to his job as a Selector at Gordon Food Service.” AR 348. Dr. Loeb further
stated that Quarles would have “no problem whatsoever returning to his job as a disc jockey.” AR
348. Dr. Loeb also noted that Quarles was using his cane on the “opposite side he should be using
the cane for maximal assistance.” AR 339.
On September 17, 2013, Dr. Nadar completed the “Attending Physician’s Statement of
Disability,” which was submitted with Quarles’s application for LTD benefits. AR 491–92. Mr.
Quarles’s primary diagnosis was a “torn medial meniscus right knee” with a secondary diagnosis

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of “chondromalacia medial femoral condyle right knee.” AR 491. Dr. Nadar stated Quarles had
“[r]ecovered” from the May 25, 2013 knee surgery. AR 491. Next, Dr. Nadar assessed Quarles’s
functional capabilities “based on [Dr. Nadar’s] clinical assessment at the time [Quarles]
stopped working or reduced work schedule.” AR 492 (emphasis in original). Dr. Nadar
concluded that Quarles can sit four hours at a time for a total of eight hours in a day, stand one
hour at a time for a total of three hours a day, and walk one hour at a time for a total of three hours
a day. AR 492. Quarles can frequently lift 20 pounds, occasionally lift 50 pounds, but is unable
to lift over 50 pounds. AR 492. Dr. Nadar noted that Quarles’s progress had “[i]mproved.” AR
492.
On October 8, 2013, Quarles underwent a Functional Capacity Evaluation (“FCE”). AR
361–68. The FCE results indicated Quarles “performed in the Light Work Category” which “does
not meet the physical demands of the job according to the formal report of job duties.” AR 362.
The main limiting factors during testing were complaints of low back pain and pain in bilateral
knees. AR 362. The FCE also indicated that Quarles tested “significant for inconsistencies,
indicating [Quarles] did not provide maximum and or consistent effort during testing.” AR 363.
C. Hartford’s Approval of LTD and WOP Benefits
Hartford concluded the medical records supported Quarles’s standing, walking, and lifting
impairments, and he was disabled from performing his occupation which was classified as medium
(exerting force of 20-50 pounds occasionally; 10-25 pounds frequently; or up to 10 pounds
constantly). AR 157. Hartford noted that Quarles had a “significant degree of functionality” and
rehab referral may be appropriate depending on the FCE results, which Hartford had yet to receive.
AR 157.

8

By letter dated October 9, 2013, Hartford approved LTD benefits effective May 29, 2013.
AR 213–17. Hartford also approved WOP benefits for “Basic” non-contributory coverages under
the Life and AD&D Policies by letters dated October 24, 2013 and October 15, 2013, respectively.
AR 498–503, AR 543–48. However, Hartford denied Quarles’s claims for “Supplemental”
contributory coverages under the Life and AD&D Policies for “non-payment of premium” by
letters dated October 24, 2013 and October 23, 2013, respectively. AR 504, AR 549–59. The
denial letters informed Quarles about his right to appeal Hartford’s decision:
If you do not agree with the reason why your claim was denied, in whole or part,
and you wish to appeal your decision, [] write to us within one hundred eighty (180)
days of the date of this letter.
AR 553, 558.
D. Hartford’s Continuing Review of Quarles’s Claims
On January 3, 2014, Hartford received the results of the October 8, 2013 FCE and noted
the results show that Quarles “did demonstrate some inconsistences but his overall functional level
was scored in the light work category.” AR 143–44. Hartford put in a request for Quarles’s April
23, 2013 IME results conducted by Dr. Loeb, which Hartford received on January 31, 2014. AR.
144, 138–39. Upon review of the IME results, Hartford noted the IME indicated Quarles “is a disc
jockey and that he is capable of performing his DJ job.” AR 139. Because Quarles did not mention
any other employers or any other income in his application for benefits, Hartford marked this
discrepancy as a “red flag” in Quarles’s record and ultimately referred his claim to its Special
Investigations Unit (“SIU”). AR 139.

9

Hartford’s SIU conducted four days of surveillance on Quarles between February 7, 2014
and March 10, 2014. AR 307, 319–26. The surveillance footage3 from March 10, 2014 captured
Quarles working at the restaurant Southern Express Soul Food located at 418 Oak Street in
Louisville, Kentucky. AR 322. From the footage, Quarles can be seen taking out the garbage,
standing behind the counter with other employees, and serving food to customers. AR 322; SV
12:54-14:30 [3/10 – 11:26-11:28] (loading and taking out garbage can), SV 17:10-19:20 [3/10 –
13:32-13:35] (serving customers food from behind the counter), SV 19:20-25:02 [3/10 – 13:3613:42] (standing behind the counter with other employees), SV 25:08-26:05 [3/10 – 13:43-13:44]
(serving customers food from behind the counter), SV 26:05-27:00 [3/10 – 16:01-16:02] (taking
out garbage can).
The investigation continued with an in-person interview with Quarles on April 2, 2014,
during which SIU confirmed Quarles as the subject of the surveillance videos. AR 280, 307.
During the interview, Quarles stated that the last time he performed as a DJ was March or April of
2013. AR 298. When Hartford probed Quarles about his employment while receiving disability
benefits, Quarles circumvented questions and ultimately denied any recent work:
Q: Okay. Have you worked for any company, store, person, business or selfemployed business while being on long term disability?
A: Like worked as far as…
Q: Any kind of…
A: I mean, I go to restaurants and eat and chat, but you know…
Q: Do you go to a restaurant to work?
A: Like as far as…
Q: Well, I mean, work, like a…either as an employee or a manager or…
A: Oh, I’m not…
3

The March 2014 surveillance footage was filed under seal as part of a supplement to the Administrative Record. DN
22. It will be cited as “SV __:__ [3/10 – __:__]” with the relevant minutes and seconds of the 28.5-minute video,
followed in brackets by the internal date and time-stamp.

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Q: …in any way, shape or form. Do you go…do you do any of that?
A: I mean, I’ve put applications in, but I haven’t, no.
Q: And I want to be clear on making sure I’m understanding your answer.
A: Mm hmm.
Q: And correct me if I’m wrong. You don’t work in a restaurant or have not
worked in a restaurant, is that correct?
A: I put applications in.
Q: Right. But you haven’t actually worked there.
A: No.
Q: And you haven’t actually been an employee, been hired, told to come in and do
whatever. You just put applications…
A: Yes.
Q: You applied for work.
A: Right.
Q: But you’re not working.
A: Right.
AR 299–300.
On May 27, 2014, SIU called Southern Express Soul Food and “was advised that the
claimant works there” but was not working that day. AR 687. SIU sent a letter to Southern Express
Soul Food requesting information about Quarles’s date of hire, hours per week, wages and hours,
and description of job title, duties, and required physical demands, but the restaurant did not
respond. AR 187, 687. SIU also sent three letters to Quarles over the span of two months
requesting the same information. AR 186 (letter dated June 19, 2014), AR 185 (letter dated July
16, 2014), AR 183 (letter dated August 7, 2014). The last letter warned “benefits will not be paid
beyond August 28, 2014 if the requested information is not received,” and failure to provide the
information “may result in termination of your claim.” AR 183.
On August 27, 2014, Quarles called Hartford and asserted that his phone was “temporarily
not working,” and he “just checked his p.o. box” and saw the letters. AR 120. Quarles further

11

denied ever working at Southern Express Soul Food and asserted he was not currently working
anywhere. AR 120. Hartford informed him that it had a video of him working and therefore
needed his employment information to continue processing his claim. AR 120. If Hartford did
not receive the information by the following day, it would close Quarles’s claim. AR. 120.
Hartford further advised Quarles he could reopen the claim by either submitting the requested
information or appealing the termination.

AR 120.

Instead of submitting the requested

information, Quarles submitted a letter, dated August 27, 2014, requesting a full copy of his file,
including the surveillance video. AR 250–51. By letter dated September 11, 2014, Hartford
provided a copy of the Administrative Record to Quarles. AR 176.
E. Hartford’s Termination of Quarles’s Benefits
Nearly two weeks later, after receiving no additional information from Quarles, Hartford
terminated Quarles’s LTD and WOP benefits. The termination letters, each dated September 9,
2014, set out the relevant Plan provisions, including Proof of Loss and noted Quarles had not
provided information regarding his employment with Southern Express Soul Food despite three
letters requesting such information. AR 177–82 (letter re termination of LTD benefits), AR 534–
37 (letter re termination of AD&D WOP benefits), AR 538–42 (letter re termination of Life WOP
benefits). The letters explained that without such information, Hartford was unable to evaluate
Quarles’s disability. AR 181, 536, 541. Hartford advised Quarles that he may perfect his claims
by submitting the previously requested information. AR 181, 536, 541. “Specifically, [Quarles]
should send information regarding [his] employment with Southern Express Soul Food, to include
[his] date of hire, hours worked per week, record of wages and hours worked, and description of
[his] job title, essential duties and physical demands.” AR 536, 541. See also AR 181. The letters

12

also advised Quarles of his right to appeal the decision without providing the requested
information. AR 181, 537, 542.
F. Quarles’s Appeal of Hartford’s Decision to Terminate Benefits
Quarles, through counsel, submitted a letter on February 16, 2015 appealing the
termination of his LTD and WOP benefits. AR 563–68. The letter included “a non-exhaustive
summary of the records supporting [Quarles’s] ongoing disability,” but did not provide the
requested employment information. AR 563–68. Quarles’s appeal letter further stated Hartford
failed to provide reasons why it denied his claims and what information it needed to approve his
claims. AR 566. Hartford upheld its terminations, by letters dated March 11, 2015, on the same
grounds as stated in the original termination letters. AR 172–73, AR 530–33. On March 16, 2015,
Quarles initiated this action for benefits under 29 U.S.C. §§ 1132(a)(1)(B) and (a)(3). DN 1, at 3.
This Court dismissed Quarles’s § 1132(a)(3) claim in its May 17, 2016 Memorandum Opinion and
Order. DN 37. The Court turns now to address Quarles’s § 1132(a)(1)(B)4 claim for benefits.
III. STANDARD OF REVIEW
In adjudicating an ERISA action, the Court reviews the merits of the action based solely
upon the administrative record. Wilkins v. Baptist Healthcare Sys., Inc., 150 F.3d 609, 619 (6th
Cir. 1998). Instead of applying the summary judgment standard, the Court applies either a de
novo, or arbitrary and capricious standard based upon the policy language. Id. at 616. The Parties
have stipulated to de novo review for purposes of this action. See DN 33. Therefore, the Court
reviews the administrative record before Hartford at the time it made its decision and determines
whether that decision was correct under the terms of the Plan. See Perry v. Simplicity Eng’g., 900

Section 1132(a)(1)(B) enables a participant or beneficiary of an insurance plan to bring a suit to “recover benefits
due to him under the terms of his plan, to enforce his rights under the terms of the plan, or to clarify his rights to
future benefits under the terms of the plan.” 29 U.S.C. § 1132(a)(1)(B).
4

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F.2d 963, 966 (6th Cir. 1990).

The administrator’s decision is accorded no deference or

presumption of correctness. Shelby Cnty. Health Care Corp. v. Majestic Star Casino, 581 F.3d
355, 368 (6th Cir. 2009) (quoting Hoover v. Provident Life and Acc. Ins. Co., 290 F.3d 801, 808–
09 (6th Cir. 2002)).
IV. DISCUSSION
A. Quarles Failed to Exhaust His Supplemental Life and AD&D Claims
The first issue we address is whether Quarles’s claims for WOP benefits under the
Supplemental Life and AD&D policies is properly before this Court. At the time Quarles stopped
working at Gordon, he was covered under Basic Life and Basic AD&D paid by Gordon, and
Supplemental Life and Supplemental AD&D paid by Quarles. AR 514, 517. During the WOP
review, however, Gordon informed Hartford that Plaintiff had stopped paying premiums on his
Supplemental Life and Supplemental AD&D coverage as of March 15, 2013. AR 505, 577. Under
the terms of the policies, WOP benefits were not effective during the first six months of Quarles’s
disability and his coverage terminated when premiums were “due but not paid.” AR 47–48, 49,
80, 82. Because Quarles stopped paying premiums on the Supplemental coverages well before the
six-month waiting period before WOP benefits were effective, Hartford terminated the
Supplemental coverages and denied WOP benefits for those coverages by letters dated October
23, and 24, 2013. AR 549–58. Because Quarles did not appeal those determinations, the claims
are not exhausted, and the Court will not consider the claims for Supplemental coverage. Miller
v. Metro. Life Ins. Co., 925 F.2d 979, 986 (6th Cir. 1991) (“The administrative scheme of ERISA
requires a participant to exhaust his or her administrative remedies prior to commencing suit in
federal court.”).

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Quarles does not dispute that he did not administratively appeal those adverse benefit
determinations. Instead, Quarles counters that the claim should be deemed exhausted because “an
appeal would be futile” given Hartford’s determinations regarding the Basic Life and AD&D
coverages. DN 54, at 7 (citing Durand v. Hanover Ins. Grp., Inc., 560 F.3d 436, 443 (6th Cir.
2009) (“Administrative review of Durand’s claim would be futile; and litigation of its merits
should proceed without delay.”)). This assumption is without merit. Hartford terminated the WOP
benefits under the Supplemental and Basic coverages at separate times and for different reasons.
Hartford denied the Supplemental claims in October of 2013 for nonpayment of premiums. AR
549–58. The Basic claims were not denied until nearly a year later, September of 2014, for failure
to provide Proof of Loss. AR 534–42. Quarles does not provide the required “clear and positive
indication of futility, such that it is certain that his claim will be denied on appeal.” Watkins v.
Matrix Absence Mgmt., Inc., No. 3:15-CV-00716-JHM, 2015 WL 6480145, at *3 (W.D. Ky. Oct.
27, 2015). Accordingly, the Court finds that Quarles’s ERISA claims with respect to the denial of
WOP benefits under the Supplemental Life and AD&D coverages are precluded by Quarles’s
failure to exhaust his administrative remedies. The Court’s remaining analysis focuses on his
ERISA claims for LTD benefits under the LTD policy and WOP benefits under the Basic Life and
Basic AD&D coverages.
B. Hartford’s Decision to Terminate Benefits was Correct
As then District Court Judge Thapar put it: “[I]n an ERISA case, a plaintiff’s claim ‘stands
or falls’ on the terms of the deal he struck.” Carter v. Guardian Life Ins. Co. of Am., Civ. No. 113-ART, 2012 WL 4793690, at *4 (E.D. Ky. Oct. 9, 2012) (citing Kennedy v. Plan Adm’r for
DuPont Sav. & Inv. Plan, 555 U.S. 285, 300 (2009). And in this ERISA case, Quarles’s claims
fall.

15

Under the terms of the Plan, Hartford had the right to request Proof of Loss throughout
Quarles’s disability. AR 27, 49, 82. Hartford exercised this right after surveillance footage
discovered Quarles working at a restaurant, which he not only failed to disclose to Hartford, but
also subsequently dodged and denied when Hartford specifically asked him at the in-person
interview. AR 299–300, 322. Quarles frames the surveillance as a malicious attempt to “discredit”
Quarles (DN 48, at 23), but a close review of the Administrative Record paints a different story.
Hartford initially approved Quarles’s claims in October 2013. AR 213–16, 543–44, 546–
48. However, on January 31, 2014, Hartford received Quarles’s IME results conducted by Dr.
Loeb. AR 139. Because those results indicated that Quarles was a disc jockey – a job that Quarles
previously failed to disclose – Hartford referred his claim to SIU. AR 139. This record alone was
sufficient to give rise to a suspicion that Quarles had been withholding information regarding his
employment activities. The surveillance footage of Quarles taking out the garbage, standing
behind the counter, and serving customers at a restaurant, not only confirmed the suspicion that
Quarles had been withholding information regarding his employment activities, but also gave rise
to new suspicions regarding Quarles’s physical capabilities.
Once SIU confirmed Quarles was in-fact an employee of Southern Express Soul Food (AR
687), Hartford commenced what later proved to be an impossible task of seeking Proof of Loss
from Quarles in the form of information concerning his employment with the restaurant. Hartford
sent Quarles three letters over the span of two months requesting highly specific information
regarding his employment:
1.
2.
3.
4.

Date of Hire
Hours worked per week
Record of wages and hours
Description of job title, duties, and required physical demands

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See AR 186 (letter dated June 19, 2014), AR 185 (letter dated July 16, 2014), AR 183 (letter dated
August 7, 2014). When Quarles failed to provide the requested information, Hartford determined
that he was no longer in compliance with the Proof of Loss requirements of the Plan, and without
this information Hartford was unable to determine if Quarles continued to meet the policy
definitions of Disabled. AR 180, 536, 541. Hartford terminated Quarles’s benefits, but gave him
the option to perfect his claims by providing the requested information. AR 181, 536, 541.
Quarles continuously makes the bold assertion that Hartford conceded that Quarles is
Disabled under the terms of the policies. See e.g., DN 48, at 32 (“At no point has Hartford disputed
that Mr. Quarles remains functionally unable to perform the essential duties of his occupation and
is Disabled under the terms of the policies.”). The termination letters clearly state that because
Quarles failed to provide sufficient Proof of Loss, Hartford was “unable to determine if [Quarles]
continue[d] to meet the policy definition of Disabled.” AR 180 (emphasis added); See also AR
536, 541. At no point did Hartford concede that Quarles was Disabled under the terms of the
policy. Rather, Quarles’s failure to provide Proof of Loss – which is required under the terms of
the Plan – prevented Hartford from evaluating whether Quarles was Disabled. As was Hartford’s
right under the Plan.
Quarles further contends that given its prior approval of benefits, Hartford was required to
prove a change in Quarles’s physical capabilities to support reversing its position. DN 56, at 11–
12. In support of this argument, Quarles relies on McCollum v. Life Insurance Co. of North
America, 495 Fed. Appx. 694 (6th Cir. 2012). However, McCollum is explicit that Sixth Circuit
precedent “does not create a rule that when a plan administrator suddenly changes course, the
administrator must have new evidence of improvement.” Id. at 704 (citing Kramer v. Paul Revere
Life Ins. Co., 571 F.3d 499 (6th Cir. 2009)). Rather, where a plan administrator has classified a

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claimant as disabled for years and suddenly changes its determination, “the plan administrator
must have some reason for the change based on any number of factors.” Id. The Sixth Circuit
went on to reverse the denial of benefits holding that the plan administrator had not provided any
convincing reason for the change where it relied on the opinions of non-treating physicians who
never physically examined the claimant; failed to conduct a physical examination of claimant when
the only evidence in the record about the claimant’s limitations were reports from his treating
physicians who opined that he was disable; and conflated the distinction between light and
sedentary work. Id. at 703–04.
McCollum is completely inapposite to the case here. First, Hartford had only been
providing benefits for a little over a year compared to the eleven years in McCollum. Id. at 703.
But more importantly, Hartford was never able to make a determination of whether Quarles
continued to remain Disabled under the terms of the Plan because he failed to provide sufficient
Proof of Loss. It cannot be said that Hartford suddenly changed its course. Instead, Hartford was
employing its right to enforce the terms of the Plan.
Under the terms of the Plan, Quarles must continue to supply proof of continuing disability
upon the request of Hartford. The Plan’s terms specify that Proof of Loss is a conditioned
precedent to the receipt of benefits and permits Hartford to request Proof of Loss throughout
Quarles’s disability. Requesting Proof of Loss is not only Hartford’s right, but also its duty to all
claimants. See Dougherty v. Indiana Bell Tel. Co., 440 F.3d 910, 917 (7th Cir. 2006) (“The plan
had a duty to all of its beneficiaries and participants to investigate ongoing claims…making sure
to avoid paying benefits to claimants who were not entitled to receive them.”); Barnhart v. UNUM
Life Ins. Co. of Am., 179 F.3d 583, 589 (8th Cir. 1999) (“A company failing to conduct proper
inquiries into claims for benefits breaches its duty to all claimants as a fiduciary of the benefit

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funds when it grants claims to unqualified claimants.”). Quarles’s failure to comply with threshold
provisions, namely the Proof of Loss provisions, of the Plan is therefore sufficient grounds to
terminate his claims for benefits. See Wooden v. Alcoa, Inc., 511 App’x 477, 483 n.5 (6th Cir.
2013) (rejecting argument that review was improper because the plan terms grant the claim
administrator a right of periodic examination to determine continued eligibility); Miller v. Metro.
Life Ins. Co., 925 F.2d 979, 985–86 (6th Cir. 1991) (rejecting argument that, once disability
benefits are conferred, the burden of proof shifts to the claim administrator to prove that the
claimant can return to work); Carter, Civ. No. 11-3-ART, 2012 WL 4793690, at *3 (E.D. Ky. Oct.
9, 2012) (claim administrator had no obligation to pay benefits where claimant failed to submit
proof of loss).5 Based upon a review of the administrative record, the Court finds that Hartford’s
decision to terminate Quarles’s LTD and WOP benefits was correct under the terms of the Plan.
C. Hartford’s Full and Fair Review
Next, Quarles asserts he was not provided a full and fair review under 29 U.S.C. § 1331
because Hartford failed to comply with certain provisions of the claims-procedure regulations in
29 C.F.R. § 2560.503-1.
29 U.S.C. § 1331 provides every employee benefit plan must:
(1) provide adequate notice in writing to any participant or beneficiary whose claim
for benefits under the plan has been denied, setting forth the specific reasons for
such denial, written in a manner calculated to be understood by the participant, and
(2) afford a reasonable opportunity to any participant whose claim for benefits has
been denied for a full and fair review by the appropriate named fiduciary of the
decision denying the claim.
The essential purpose of 29 U.S.C. § 1133 is twofold: “(1) to notify the claimant of the specific
reasons for a claim denial, and (2) to provide the claimant an opportunity to have that decision

5

Although these cases applied an arbitrary and capricious standard of review, this Court reaches the same conclusion
applying the more stringent de novo standard in this case.

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reviewed by the fiduciary.” Wenner v. Sun Life Assurance Co. of Can., 482 F.3d 878, 882 (6th Cir.
2007) (emphasis omitted).
The regulations under Section 1133 require that the notification of adverse benefit
determination include, in pertinent part:
(i) The specific reason or reasons for the adverse determination;
(ii) Reference to the specific plan provisions on which the determination is based;
(iii) A description of any additional material or information necessary for the
claimant to perfect the claim and an explanation of why such material or
information is necessary; …
29 C.F.R. § 2560.503-1(g)(1).
In determining whether a denial notice is sufficient, the Sixth Circuit has adopted a
“substantial compliance” test that considers all the communications between the claim
administrator and claimant and rests on the “crucial” determination of whether the administrator
fulfilled the statute’s “essential purpose” of notifying the claimant of the reasons for denying his
claims and affording him a fair opportunity for review. McCartha v. Nat’l City Corp., 419 F.3d
437, 444 (6th Cir. 2005).
Specifically, Quarles argues he was deprived a full and fair review because Hartford
allegedly failed to inform him of the specific information it needed to perfect the claim and why
the information was necessary. DN 48, at 32–37. After an extensive review of the Administrative
Record, the Court finds that the claim communications are sufficient to fulfill the purpose of
Section 1133. Each termination letter provides the relevant plan provisions and explains that the
adverse decision is “based on a lack of sufficient proof of loss required to enable us to evaluate
your disability.” AR 181. See also AR 536, 541. The termination letter for Quarles’s LTD
benefits quoted the Plan’s definition of, inter alia, Disabled requiring him to be unable to perform
one or more of the Essential Duties of his occupation and meet the earnings requirement; noted

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that Hartford had obtained footage of Quarles working at a restaurant and had requested
information related to his employment with Southern Express Soul Food, specifically information
regarding his: date or hire, hours worked per week, record of wages and hours worked, and
description of job title, essential duties, and physical demands; and informed him that this
information was necessary to determine whether he continues to be Disabled under the terms of
policy. AR 177–82.
Similarly, the termination letters for Quarles’s WOP benefits quoted the Plan’s definition
of, inter alia, Disabled requiring him to be unable to perform one or more of the Essential Duties
of his occupation; noted that Hartford had previously requested the “description of your job title,
essential duties and physical demands;” and informed him that this information was necessary to
determine whether he continues to be Disabled under the terms of policy. AR 534–37, 538–42.
All three termination letters inform Quarles that he can perfect his claim by providing the requested
information, or his right to appeal the decision without providing the information. AR 181, 536–
37, 541–42. Accordingly, the Court concludes that Hartford’s communications sufficiently
advised Quarles’s of reasons for the denial of his claims, as well as his rights to review the decision.
See Lukpetris v. Hartford Life and Acc. Ins. Co., No. 5:05-cv-181, 2007 WL 1565759, at *8 (W.D.
Mich. May 29, 2007) (concluding denial notice sufficient where claim administrator sent three
letters explaining the plan requirement to the participant and advising him that his refusal to
participate in the program was the reason for the termination).
D. Hartford’s “Open Dialogue”
Finally, Quarles chides Hartford for its alleged violation of the spirit of ERISA regulations
by failing to have an “open dialogue” with Quarles. Frankly, the Court is not clear how Quarles
can assert such a violation where Hartford sent three letters over the span of two months requesting

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highly specific information regarding his employment that was necessary to determine whether
Quarles continued to be Disabled under the terms of the Plan (AR 183, 185, 186) and gave him
ample opportunity to respond without a formal appeal (AR 120, 181, 536, 541). Quarles was on
notice that Hartford was seeking his employment information for two-and-a-half months prior to
Hartford terminating his claims. Nevertheless, Quarles ignored those non-adversarial requests.
When Hartford informed Quarles it was terminating his claims for failure to provide the previously
requested information, which was necessary to determine his continued eligibility under the Plan
(AR 181, 536, 541), Quarles appealed the decision without so much as an acknowledgement of
Hartford’s previous requests for his employment information (AR 563–68). If anyone closed the
dialogue it was Quarles through his contumacy of the terms of the Plan.
V. CONCLUSION
Accordingly, the Court will GRANT Defendant’s Motion for Judgment (DN 49) and
DENY Plaintiff’s Motion for Judgment (DN 48).

March 20, 2019

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