Williams v. Hartford Life and Accident Insurance

Filing 27

MEMORANDUM DECISION AND ORDER denying 17 Motion for Summary Judgment; granting 18 Motion for Summary Judgment. Status Report due by 2/28/2017. Signed by Judge David Nuffer on 2/8/17 (alt)

IN THE UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF UTAH, CENTRAL DIVISION

TERRI LYN WILLIAMS,
Plaintiff,
v.
HARTFORD LIFE AND ACCIDENT
INSURANCE COMPANY,
Defendant.

MEMORANDUM DECISION AND
ORDER GRANTING PLAINTIFF’S
MOTION FOR SUMMARY JUDGMENT
AND DENYING DEFENDANT’S MOTION
FOR SUMMARY JUDGMENT
Case No. 2:14-CV-304-DN
District Judge David Nuffer

This case involves a claim for long-term disability (“LTD”) benefits through a group
insurance plan. Plaintiff Terri Lyn Williams (“Williams”) brought a claim for breach of contract
against Defendant Hartford Life and Accident Insurance Company (“Hartford”) after it
terminated her LTD benefits and denied her subsequent appeal. 1 The parties filed cross motions
for summary judgment on March 31, 2015, 2 but stipulated that the case be decided by the court,
as the trier of fact, on the record evidence and the parties’ summary judgment memoranda. 3
Upon careful review of the evidence, briefing, and oral arguments, and for the reasons stated
more fully below, Williams’s Motion is GRANTED and Hartford’s Motion is DENIED.

1

Complaint, docket no. 2-2, filed Apr. 23, 2014.

2

Hartford’s Combined Motion for Summary Judgment and Opening Supporting Memorandum (“Hartford’s
Motion”), docket no. 17; Plaintiff’s Motion for Summary Judgment (“Williams’s Motion”), docket no. 18.

3

Hartford’s Response Memorandum in Opposition to Williams’ Motion for Summary Judgment [ECF No. 18]
(“Hartford’s Response”) at 1, docket no. 19, filed May 1, 2015; Opposition to Defendant’s Combined Motion for
Summary Judgment and Opening Supporting Memorandum (“Williams’s Response”) at 2, docket no. 20, filed
May 1, 2015; Transcript of Proceedings dated June 15, 2015 (“Hearing Transcript”) at 3:24-4:7, 4:13-17, docket no.
26, filed Jan. 6, 2017.

TABLE OF CONTENTS
TABLE OF CONTENTS ................................................................................................................ 2
BACKGROUND ............................................................................................................................ 3
UNDISPUTED FACTS .................................................................................................................. 5
Breach of Contract Claim Element 1: Existence of a Contractual Duty............................. 6
The Plan and Group Policy Provisions ................................................................... 6
Breach of Contract Claim Element 2: Performance of the Contract by Williams .............. 9
Proof of Loss ........................................................................................................... 9
Breach of Contract Claim Element 3: Breach of the Contract by Hartford ...................... 10
Williams’s LTD Claim .......................................................................................... 10
Hartford’s Administration of Williams’s LTD Claim After the Initial Approval .. 12
Hartford’s Any Occupation Investigation ............................................................. 26
Hartford’s Determination of Williams’s Appeal ................................................... 39
Breach of Contract Claim Element 4: Damages ............................................................... 41
Initial Denial of Williams’s Claim for LTD Benefits ............................................ 41
Denial of Williams’s Appeal ................................................................................. 42
Summaries......................................................................................................................... 44
Summary of Medical Evidence ........................................................................... 44
Summary of Medical Opinions Regarding Williams’s Restrictions and Limitations
................................................................................................................... 46
STANDARD OF REVIEW .......................................................................................................... 52
DISCUSSION ............................................................................................................................... 54
Hartford has a contractual duty to pay LTD benefits to Williams .................................... 55
Williams performed her duties under the Plan and Group Policy .................................... 57
Williams properly applied for LTD benefits ......................................................... 57
Williams provided Hartford with timely and satisfactory Proof of Loss .............. 58
Williams was and is under the Regular Care of a Physician ................................ 65
Hartford breached its contractual duty to Williams by denying her claim for LTD benefits
............................................................................................................................... 66
Williams has a qualifying Disability that is not excluded from coverage and
became Disabled while insured under the Plan and Group Policy ........... 66
Williams remained Disabled beyond of the effective date of the Plan and Group
Policy’s Any Occupation provision .......................................................... 69
Williams suffered damages as a result of Hartford’s breach............................................. 77
CONCLUSION ............................................................................................................................. 78
ORDER ......................................................................................................................................... 78

BACKGROUND
Williams was employed as a teacher for the Sevier School District in Richfield, Utah
until March 2011, when she stopped working due to a claimed disability. 4 She applied for, and
was granted, LTD benefits, which Hartford paid until June 2013, when it terminated her benefits
based on the insurance policy’s narrowing of the definition of “Disability” after 24 months of
benefit payments. 5
Williams appealed Hartford’s termination decision, alleging that she continued to be
disabled under the insurance policy’s terms. 6 She had several physical impairments in the first 24
months of disability payments and alleges a variety of current physical impairments, the greatest
of which is fibromyalgia. 7 Williams’s treating physician, Dr. Dwight Inouye, found her totally
disabled due to fibromyalgia. 8
On appeal, Hartford referred Williams’s claim file to Dr. Joseph Rea for review. 9 Dr. Rea
did not personally examine Williams. 10 In his report, Dr. Rea opined that Williams’s workrelated abilities were limited by a hip impairment, but acknowledged that she consistently
complained of fibromyalgia. 11 Dr. Rea concluded that “fibromyalgia does not stand as an
objective clinical entity (upon which impairment and resultant physical limitations can be

4

Hartford’s Submission of the Administrative Record (“Administrative Record”) at 1195-1210, docket no. 14-12
and docket no. 14-13, filed Mar. 5, 2015.
5

Id. at 199-205, docket no. 14-2 and docket no. 14-3, 345-47, docket no. 14-4, 1195-1210, docket no. 14-12 and
docket no. 14-13.
6

Id. at 368-70, docket no. 14-4.

7

Id. at 184, docket no. 14-2, 865, docket no. 14-9, 1146-70, docket no. 14-12, 1195-1210, docket no. 14-12 and
docket no. 14-13, 1203-05, docket no. 14-13, 1209-10, docket no. 14-13, 1238, docket no. 14-13.
8

Id. at 865, docket no. 14-9.

9

Id. at 354-61, docket no. 14-4.

10

Id.

11

Id. at 354-56, docket no. 14-4.
3

based)[.]” 12 Therefore, he assigned Williams’s work-related limitations to her hip impairment,
specifically excluding any limitations related to fibromyalgia. 13 Hartford adopted Dr. Rea’s
opinion, at least to the extent of his limitations, and denied Williams’s appeal. 14 Hartford
maintains that although it adopted Dr. Rea’s limitations, it rejected his opinion relating to
fibromyalgia. 15
The policy itself does not exclude coverage for disabilities caused by fibromyalgia, nor
does it affirmatively require a claimant to provide objective evidence of impairment and
limitation. 16 Similarly, the policy does not exclude coverage for these types of impairments. 17
None of Hartford’s referred health care professionals ever personally examined Williams.
Williams asserts a single cause of action for breach of contract against Hartford for its
denial of her claim for LTD benefits. 18 Williams’s claim against Hartford is not governed by the
Employee Retirement Income Security Act of 1974 (ERISA). 19 The parties agree that because
employee welfare benefit plans administered by government entities are specifically precluded
from ERISA pre-emption, Williams’s claim against Hartford is simply one for breach of a
contract’s express terms. 20 The parties filed cross motions for summary judgment on March 31,

12

Id. at 357, 358, docket no. 14-4.

13

Id.

14

Id. at 190-92, docket no. 14-2.

15

Hartford’s Response at 12-18, docket no. 19, filed May 1, 2015; Hartford’s Reply in Further Support of Its
Combined Motion for Summary Judgment and Opening Supporting Memorandum, [ECF No. 17] (“Hartford’s
Reply”) at 6, docket no. 22, filed May 18, 2015.
16

Administrative Record at 10, 11, 19, 21, 22, 24, 25, 29, docket no. 14-1, filed Mar. 5, 2015.

17

Id.

18

Complaint, docket no. 2-2, filed Apr. 23, 2014.

19

Id. ¶ 2.

20

Id. (citing 29 U.S.C. § 1003(b)(1)), Hartford’s Answer ¶ 2, docket no. 5, filed Apr. 30, 2014.
4

2015. 21 On May 1, 2015, the parties filed response memoranda, 22 and on May 18, 2015, the
parties filed reply memoranda. 23 Oral argument was heard on June 23, 2015. 24
UNDISPUTED FACTS
This collection of Undisputed Facts is distilled from the parties’ summary judgment
briefing. Hartford’s Motion provided a statement of background facts and a statement of
elements which refers generally to the background facts. 25 Williams’s Motion also provided a
statement of elements followed by a factual background. 26 Williams’s Response stated that “[t]he
parties have conferred about the resolution of this case, have agreed that this case should be
decided on the evidence of record, and that there is no material dispute about any facts in this
case.” 27 In Hartford’s Response, it agreed that “there is no dispute about any material fact in this
case.” 28 Hartford also submitted the administrative record 29 and a CD of video surveillance. 30
The parties’ statements of facts did not comply with DUCIVR 56-1(b)(2)(C), which
requires:
Under each element, a concise statement of the material facts necessary to meet
that element as to which the moving party contends no genuine issue exists….
Each asserted fact must be presented in an individually numbered paragraph that

21

Hartford’s Motion, docket no. 17; Williams’s Motion, docket no. 18.

22

Hartford’s Response, docket no. 19; Williams’s Response, docket no. 20.

23

Plaintiff’s Reply to Hartford’s Response Memorandum in Opposition to Williams’ Motion for Summary Judgment
(“Williams’s Reply”), docket no. 21; Hartford’s Reply, docket no. 22.
24

Minute Order, docket no. 24, entered June 23, 2015.

25

Hartford’s Motion at 2-23, docket no. 17, filed Mar. 31, 2015.

26

Williams’s Motion at 5-14, docket no. 18, filed Mar. 31, 2015.

27

Williams’s Response at 2, docket no. 21, filed May 1, 2015.

28

Hartford’s Response at 4, docket no. 19, filed May 1, 2015.

29

Administrative Record, docket nos. 14-1 through 14-14, filed Mar. 5, 2015.

30

Hartford’s Notice of Conventional Filing of Video Surveillance CD, docket no. 15, filed Mar. 6, 2015.
5

cites with particularity the evidence in the record supporting each factual
assertion. 31
On June 18, 2015, an email was sent to counsel with a summary set of undisputed facts
incorporating the parties’ filings and complying with the local rule. That summary was reviewed
at the start of the June 23, 2015 hearing. 32 This collection of undisputed facts was finalized based
on discussion at the hearing. 33 The headings in these Undisputed Facts are descriptive, not
declaratory or substantive, and are taken from the elements of a claim for breach of contract.
Breach of Contract Claim Element 1: Existence of a Contractual Duty
The Plan and Group Policy Provisions
1.

This case arises under the Utah School Boards Association Group Benefit Plan

(the “Plan”), 34 Group Policy No. GLT-034943 (“Group Policy”), issued by Hartford to the Utah
School Boards Association in order to fund the Plan’s LTD benefits. 35
2.

The Plan and Group Policy provide LTD benefits to eligible employees of the

Utah School Boards Association, including the Sevier School District. 36
3.

Benefits paid under the Group Policy are equal to 662/3% of a claimant’s Pre-

Disability Earnings, reduced by Other Income Benefits as defined by the Plan and Group
Policy. 37

31

DUCIVR 56-1(b)(2)(C).

32

Minute Order, docket no. 24, entered June 23, 2015.

33

Id.

34

Administrative Record at 1-48, docket no. 14-1, filed Mar. 5, 2015.

35

Id. at 6, 37, docket no. 14-1.

36

Id. at 6, docket no. 14-1.

37

Id. at 6, 13, docket no. 14-1.
6

4.

Benefits are payable under the terms of the Plan and Group Policy when:
1.
2.
3.
4.

[The participant] become[s] Disabled while insured under th[e] Plan;
[The participant is] disabled throughout the Elimination Period;
[The participant] remain[s] Disabled [90 days] beyond the Elimination Period;
[The participant is], and ha[s] been during the elimination Period, under the
Regular Care of a Physician; and
5. [The participant] submit[s] Proof of Loss satisfactory to [Hartford]. 38

5.

The Plan defines “Disability” or “Disabled” as:
[D]uring the Elimination Period and for the next 24 months, [the
participant is] prevented by:
1.
2.
3.
4.
5.

accidental bodily injury;
sickness;
Mental Illness;
Substance Abuse; or
Pregnancy,

from performing one or more of the Essential Duties of [the participant’s
own] Occupation, and as a result [the participant’s] Current Monthly
Earnings are no more than 80% of [the participant’s] Indexed Predisability Earnings.
After that, [the participant] must be so prevented from performing one or
more of the Essential Duties of Any Occupation. 39
6.

The Plan defines “Essential Duty” as:
[A] duty that:
1. is substantial, not incidental;
2. is fundamental or inherent to the occupation; and
3. cannot be reasonable omitted or changed.
To be at work for the number of hours in [the participant’s] regularly
scheduled workweek is also an Essential Duty. 40

7.

The Plan defines “Any Occupation” as:
[A]n occupation for which [the participant is] qualified by education,
training or experience, and that has an earnings potential greater than the
amount equal to the lesser of the product of [the participant’s] Indexed

38

Id. at 10, docket no. 14-1.

39

Id. at 29, docket no. 14-1.

40

Id.
7

Pre-disability Earnings and the Benefit Percentage and the Maximum
Monthly Benefit shown in the Schedule of Insurance. 41
8.

Certain conditions are excluded from coverage under the Plan and Group Policy:
Are there any other limitations on coverage?
No benefit will be payable under the [P]lan for a Disability that is due to,
contributed to by, or results from a Pre-existing Condition[.] 42
What Disabilities are not covered?
The [P]lan does not cover, and no benefit shall be paid for any Disability:
1. unless [the participant is] under the Regular Care of a Physician;
2. that is caused or contributed to by act of war (declared or not);
3. caused by [the participant’s] commission of or attempt to commit a
felony, or to which a contributing cause was [the participant] being
engaged in an illegal occupation; or
4. caused or contributed to by an intentionally self inflicted injury.
If you are receiving or are eligible for benefits for a Disability under a
prior disability [P]lan that:
1. was sponsored by the Employer, and
2. was terminated before the Effective Date of this [P]lan, no benefits
will be payable for the Disability under this [P]lan. 43

9.

A claimant for LTD benefits must submit a Proof of Loss. 44

10.

The Proof of Loss includes documentation about the basis for the claim,

including, among other things, the cause of the disability and “any and all medical
information[.]” 45
11.

The Proof of Loss “must be satisfactory” to Hartford. 46 Hartford is authorized to

“request Proof of Loss throughout [a claimant’s] Disability.” 47

41

Id. at 28, docket no. 14-1.

42

Id. at 19, docket no. 14-1.

43

Id. at 21, docket no. 14-1.

44

Id. at 24, docket no. 14-1.

45

Id.

46

Id.

47

Id. at 25, docket no. 14-1.
8

12.

Based on Williams’s age at the time of her claim for LTD benefits, her maximum

period of LTD benefits would be her normal retirement age of 66. 48
13.

However, the Plan provides that LTD benefits will end on the date when a

claimant is “no longer Disabled as defined.” 49
14.

The Plan and Group Policy govern the “[f]inal interpretation of all provisions and

coverages.” 50
Breach of Contract Claim Element 2: Performance of the Contract by Williams
Proof of Loss
15.

In March 2011, Williams was employed by the Sevier School District as a Third

Grade teacher and therefore a participant under the Plan. 51
16.

Williams’s last day of work for the Sevier School District was March 29, 2011, 52

after which she submitted a claim for LTD benefits under the Plan. 53
17.

Pursuant to the terms of the Plan and Group Policy, Williams applied for LTD

benefits alleging disability beginning in March 2011. 54
18.

On July 6, 2011, Hartford received Williams’s claim for LTD benefits. 55 The

application for LTD benefits contained information from Williams, Williams’s employer, and
Williams’s treating physicians. 56

48

Id. at 7-8, docket no. 14-1.

49

Id. at 11, docket no. 14-1.

50

Id. at 6, docket no. 14-1.

51

Id. at 1195, 1197, docket no. 14-12.

52

Id. at 1195, docket no. 14-12.

53

Id. at 1195-1210, docket no. 14-12 and docket no. 14-13.

54

Id.

55

Id. at 188 (July 6, 2011), docket no. 14-2. According to Hartford, the Summary Detail Report documents all of
Hartford’s actions relating to the administration of Williams’s claim, including, among other things, the transmittal
9

19.

Williams based her disability claim on “[p]ain and limited mobility in [her] right

hip & leg – lower back pain.” 57
20.

Williams offered proof of her disability satisfying the policy’s definition of

“Disability.” 58
Breach of Contract Claim Element 3: Breach of the Contract by Hartford
Williams’s LTD Claim
21.

Williams’s family doctor, Dr. Dwight Inouye, completed an Attending Physician’s

Statement of Functionality (“APS”) dated April 25, 2011. 59
a.

Dr. Inouye listed Williams’s primary diagnoses as osteoarthritis of the

right hip with a secondary diagnosis of hyperthyroidism. 60
b.

Dr. Inouye indicated that Williams could not engage in prolonged sitting,

standing, and bending. 61
22.

Dr. Alan Colledge, Williams’s orthopedist, completed an APS dated

May 5, 2011. 62

and receipt of correspondence, Hartford’s telephone conversations with Williams and others, Hartford’s plan of
action, and Hartford’s analysis of the evidence. The Summary Detail Report appears in the Administrative Record
at 49-188, docket no. 14-1 and docket no. 14-2. Multiple entries appear on many of the pages of the Summary Detail
Report. In citations to the Summary Detail Report, the date of the cited entry is indicated parenthetically. When
more than one entry with the same date appears on a page, the time of the cited entry is provided to distinguish it
from other entries of the same date on the cited page. Due to space considerations, not all of Hartford’s actions
concerning Williams’s claim, which the Summary Detail Report documents, are summarized.
56

Id. at 1195-1210, docket no. 14-12 and docket no. 14-13.

57

Id. at 1197, docket no. 14-12.

58

Id. at 24, docket no. 14-1, 371-80, docket no. 14-4, 550, docket no. 14-6, 1000-01, docket no. 14-10 and docket
no. 14-11.
59

Id. at 1203-05, docket no. 14-13.

60

Id. at 1203, docket no. 14-13.

61

Id. at 1205, docket no. 14-13.

62

Id. at 1209-10, docket no. 14-13.
10

a.

Dr. Colledge indicated Williams’s primary diagnoses as degenerative disk

disease and osteoarthritis in the hip with a secondary diagnosis of hypothyroidism. 63
b.

Dr. Colledge reported that, among other things, Williams was capable of

sitting up to 30 minutes at a time up to 8 hours with breaks, and standing for 20 minutes
at a time up to 2 hours with breaks. 64
23.

On July 15, 2011, Hartford summarized the information received with Williams’s

LTD claim. 65
a.

Hartford found that “[b]ased on the medical documentation, the

[restrictions and limitations] appear reasonable and prevent [Williams] from performing
her own occ[upation] throughout and beyond the [Elimination Period.]” 66
b.

Hartford noted that “[Williams] has a progressive condition which appears

to be more tolerable while not working (standing/walking) however, it appears that she
can perform sed[entary]/light work with changing of position.” 67
c.

Hartford decided to approve LTD benefits for Williams through

May 2012. 68
d.

Hartford also decided to refer the file to one of its vocational rehabilitation

specialists for review “as it appears that [Williams] has at least sed[entary]/light work
capacity.” 69

63

Id. at 1209, docket no. 14-13.

64

Id. at 1210, docket no. 14-13.

65

Id. at 186-87 (July 15, 2011), docket no. 14-2.

66

Id. at 187 (July 15, 2011), docket no. 14-2.

67

Id.

68

Id.

69

Id.
11

e.

Hartford noted that “it is likely that [Williams] will not remain disabled

throughout and beyond” the time of the change to the “Any Occupation” definition. 70
24.

On July 15, 2011, Hartford informed Williams of its initial claim determination

that her claim for LTD benefits was approved. 71
25.

Hartford summarized the Plan’s terms applicable to Williams’s continued receipt

of LTD benefits and informed Williams that the “Any Occupation” definition would take effect
on June 13, 2013. 72
Hartford’s Administration of Williams’s LTD Claim After the Initial Approval
26.

On September 7, 2011, a Hartford Rehabilitation Case Manager interviewed

Williams by telephone. 73
27.

Williams stated that she had undergone surgery and treatment for thyroid cancer. 74

Williams told the Rehabilitation Case Manager that her cancer treatments had prevented medical
treatment on her hip, and that she probably would need additional surgery for her
parathyroidism. 75
28.

On September 7, 2011, the Rehabilitation Case Manager provided her

recommendations based on the telephone interview with Williams. 76

70

Id. The abbreviation “TC” in Hartford’s Summary Detail Report refers to the change of the applicable “Disability”
definition from focusing on a claimant’s own occupation to the “Any Occupation” definition.
71

Id. at 345-48, docket no. 14-4.

72

Id.

73

Id. at 183-84 (Sept. 7, 2011 3:54:31 p.m.), docket no. 14-2. A Rehabilitation Case Manager is an on-staff specialist
with training relating to the assessment of vocational and vocational rehabilitation issues.
74

Id. at 184 (Sept. 7, 2011 3:54:31 p.m.), docket no. 14-2.

75

Id.

76

Id. at 183 (Sept. 7, 2011 4:15:07 p.m.), docket no. 14-2.
12

29.

The Rehabilitation Case Manager closed the file from a vocational rehabilitation

perspective for the time being because of the need for Williams’s additional medical issues to be
addressed. 77
30.

The Rehabilitation Case Manager recommended obtaining updated medical

records, and left open the possibility of considering vocational rehabilitation again in the future
based on the status of Williams’s treatment. 78
31.

On September 22, 2011, Hartford’s assigned Ability Analyst contacted Williams

by telephone. 79
a.

The Ability Analyst and Williams discussed the status of Williams’s

medical condition and functionality. 80
b.

The Ability Analyst explained the change to the “Any Occupation”

definition. 81 Williams stated that she “hope[d] to [return to work] in some capacity in the
future,” but did not “expect to [return to work in her] own occ[upation].” 82
32.

On September 24, 2011, the Ability Analyst summarized her conclusions about

the status of Williams’s claim. 83
a.

She found that it “remains reasonable that [Williams] is unable to perform

her own occ[upation] as a teacher due to the prolonged/walking standing required.” 84

77

Id.

78

Id.

79

Id. at 181-82 (Sept. 22, 2011), docket no. 14-2.

80

Id.

81

Id. at 182 (Sept. 22, 2011), docket no. 14-2.

82

Id.

83

Id. at 181 (Sept. 24, 2011), docket no. 14-2.

84

Id.
13

b.

The Ability Analyst indicated that she would follow up after Williams’s

surgery to re-evaluate whether Williams continued to be disabled. 85
33.

On September 29, 2011, the Ability Analyst’s Manager reviewed and agreed with

the Ability Analyst’s assessment. 86
34.

On November 18, 2011, the Ability Analyst again called Williams to check on her

status. 87
a.

Williams reported that she was still waiting to be released for hip

surgery. 88 Williams stated that she had received a diagnosis of fibromyalgia. 89
b.

The Ability Analyst told Williams that “the restrictions we have for her hip

while disabling for her occ[upation] allow for sedentary work.” 90
35.

On November 18, 2011, the Ability Analyst summarized her plan of action on

Williams’s claim in light of her telephone conversation with Williams. 91
a.

She outlined the information received from Williams and expressed her

view that Williams “does not appear to be medically stable yet.” 92
b.

The Ability Analyst noted that she would seek updated medical

information. 93

85

Id.

86

Id. at 180-81 (Sept. 29, 2011), docket no. 14-2.

87

Id. at 179-80 (Nov. 18, 2011 12:10:30 p.m.), docket no. 14-2.

88

Id.

89

Id. at 180 (Nov. 18, 2011 12:10:30 p.m.), docket no. 14-2.

90

Id.

91

Id. at 178-79 (Nov. 18, 2011 12:50:26 p.m.), docket no. 14-2.

92

Id. at 178 (Nov. 18, 2011 12:50:26 p.m.), docket no. 14-2.

93

Id. at 179 (Nov. 18, 2011 12:50:26 p.m.), docket no. 14-2.
14

c.

The Ability Analyst stated that “[o]nce [Williams] is stable medically, [we]

will need to determine her limitations for possible referral to rehab.” 94
36.

On November 21, 2011, the Ability Analyst’s Manager summarized the future

course of action regarding the claim based on the latest conversation with Williams. 95
a.

The Manager indicated that she had requested updated medical

information “to clarify [Williams’s] functionality.” 96
b.

The Manager also noted that it would call Williams about issues relating to

Social Security Disability Insurance (“SSDI”) benefits. 97
37.

On December 22, 2011, the Ability Analyst called Williams for an update on her

condition. 98
38.

On December 23, 2011, the Ability Analyst recorded her conclusions and plan

based on her conversation with Williams. 99
a.

The Ability Analyst felt that the evidence continued to support Williams

not being able to perform the duties of her own occupation as a teacher. 100
b.

The Ability Analyst indicated that she would “[c]ontinue to monitor

[Williams’s] condition[s] and surgery.” 101

94

Id.

95

Id. at 179 (Nov. 21, 2011), docket no. 14-2.

96

Id.

97

Id.

98

Id. at 174-75 (Dec. 22, 2011), docket no. 14-2.

99

Id. at 173-74 (Dec. 23, 2011), docket no. 14-2.

100

Id. at 174 (Dec. 23, 2011), docket no. 14-2.

101

Id.
15

39.

Dr. Inouye completed another APS dated December 2, 2011. 102
a.

Dr. Inouye changed Williams’s primary diagnoses to fibromyalgia and

right hip degeneration. 103
b.

Dr. Inouye also added a secondary diagnosis of parathyroid ademma. 104

c.

Dr. Inouye indicated that Williams was capable to sitting up to 4-5 hours

per day, standing 1-2 hours per day, and walking up to 20 minutes. 105
d.

Dr. Inouye reported that Williams did not have any psychiatric or

cognitive impairment. 106
e.

Dr. Inouye reported that Williams could not “participate in vocational

rehabilitation services[,]” including “worksite accommodations, identifying alternative
work, and or retraining assistance[.]” 107
40.

By a letter dated December 6, 2011, Hartford requested additional information

from Dr. Inouye. 108
a.

Hartford noted that Dr. Inouye’s functional restrictions and limitations for

Williams “would appear to allow [Williams] to work at least part time capacity.” 109
b.

Hartford requested information to support Dr. Inouye’s statement that

Williams was incapable of participating in vocational rehabilitation. 110

102

Id. at 1238-39, docket no. 14-13.

103

Id. at 1238, docket no. 14-13.

104

Id.

105

Id. at 1239, docket no. 14-13.

106

Id.

107

Id.

108

Id. at 340-41, docket no. 14-4.

109

Id. at 341, docket no. 14-4.

110

Id.
16

41.

On December 27, 2011, Hartford’s Ability Analyst had two telephone

conversations with Williams about the need for a response from Dr. Inouye, and Williams said
that Dr. Inouye would not be in the office until her next office visit on January 3, 2012. 111
42.

On December 30, 2012, the Hartford Team Leader, who supervised the Ability

Analyst assigned to Williams’s claim, summarized the status of Hartford’s claim review, noting
that Hartford would continue to seek updated information from Dr. Inouye, and that it was
“unclear why [Williams] is unable to participate in [vocational rehabilitation].” 112
43.

On January 8, 2012, Hartford sent a second request by fax to Dr. Inouye asking

him “to clarify why [Williams] cannot participate in [vocational rehabilitation] within [the
restrictions and limitations] provided on [his] prior APS” and requesting updated medical
records. 113
44.

On January 11, 2012, Dr. Inouye sent his response to Hartford. 114
a.

Dr. Inouye described Williams as “very weak and fatigues very

easily[.]” 115
b.

Dr. Inouye stated that Williams had “chronic pain (moderate to severe)”

which was “probably fibromyalgia.” 116

111

Id. at 173 (Dec. 27, 2011 2:09:55 p.m.; Dec. 27, 2011 5:04:52 p.m.).

112

Id. at 173 (Dec. 30, 2011), docket no. 14-2.

113

Id. at 172 (Jan. 8, 2012), docket no. 14-2.

114

Id. at 1146-70, docket no. 14-12.

115

Id. at 1146, docket no. 14-12.

116

Id.
17

c.

Dr. Inouye reported that Williams used a wheelchair on “any prolonged

trips.” 117
d.
45.

Dr. Inouye added that Williams “is not a malingerer in any way.” 118

On January 19, 2012, the Ability Analyst recorded her assessment of the

information received from Dr. Inouye and summarized Dr. Inouye’s characterization of
Williams’s condition. 119
a.

The Ability Analyst indicated that she would refer the file to a Medical

Care Manager (“MCM”) “to determine if the [restrictions and limitations] as provided on
the APS are supported and prevent [Williams] from even participating in [vocational
rehabilitation].” 120
b.

The Ability Analyst also decided to refer the file to Hartford’s

Investigation Unit, because Williams’s “reported activity does not appear to be consistent
with [Dr. Inouye’s] note of req[uired] sitting down after 100 [feet] or less of walking, or
use of wheelchair.” 121
46.

On January 24, 2012, the MCM reported on her review of the medical records that

Hartford had received from Williams’s medical providers. 122 The MCM found:
insufficient medicals during the life of the claim to make an accurate
functional assessment at this time. There is a gap in time between 4/25/11
to 10/24/11… when there are no medicals from Dr. Inouye ([Family

117

Id.; but see id. at 1231, docket no. 14-13 (Apr. 9, 2012 interview of Williams in which she denied using any
assistive devices).
118

Id. at 1146, docket no. 14-12.

119

Id. at 171-72 (Jan. 19, 2012 10:55:10 a.m.), 171 (Jan. 19, 2012 10:56:56 a.m.), docket no. 14-2.

120

Id. at 172 (Jan. 19, 2012 10:55:10 a.m.), docket no. 14-2. An MCM is an on-staff nurse who assists Hartford’s
claim personnel with the review of medical records.
121

Id. at 171 (Jan. 19, 2012 10:55:56 a.m.), docket no. 14-2.

122

Id. at 169-70 (Jan. 24, 2012 3:00:25 p.m.), docket no. 14-2.
18

Physician]) likely due to referral to Dr. Susan Maturlo (Endocrinology).
Medicals needed to further clarify [Williams’s] cancerous endocrine
conditions, surgical involvement [with] need for radiation [treatment] and
prognosis. Missing are Dr. [Richard] Jackson (Ortho[pedist]) medicals as
appears per Dr. Inouye ([Family Physician]) this is [Williams’s] current
[treating] ortho[pedist] who may consider scoping [Williams’s] right
hip. 123
47.

The MCM returned the file to the Ability Analyst in order to obtain additional

medical records. 124
a.

The Ability Analyst promptly followed up with Williams to obtain the

contract information for her endocrinologist, Dr. Maturlo, and orthopedist, Dr.
Jackson. 125
b.

The Ability Analyst then contacted Dr. Jackson and Dr. Maturlo to obtain

their records on Williams. 126
c.

The Ability Analyst also requested updated medical records from Dr.

Colledge, Dr. Inouye, and Dr. Jeffrey Wallentine. 127
d.

Multiple requests were necessary before Hartford received the requested

medical records from Williams’s doctors. 128
48.

On January 23 and 24, 2012, Triad Investigations, Inc. (“Triad”) conducted video

surveillance of Williams’s activities at the request of Hartford. 129

123

Id. at 170 (Jan. 24, 2012 3:00:25 p.m.), docket no. 14-2.

124

Id.

125

Id. at 169 (Jan. 27, 2012 4:30:41 p.m.; Jan. 27, 2012 5:17:50 p.m.; Jan. 31, 2012 6:06:07 p.m.), docket no. 14-2.

126

Id. at 168-69 (Jan. 31, 2012 6:07:56 p.m.; Jan. 31, 2012 6:08:47 p.m.), docket no. 14-2, 335-38, docket no. 14-4.

127

Id. at 164 (Apr. 10, 2012), 166-67 (Mar. 22, 2012 4:31:51 p.m., Mar. 22, 2012 12:56:53 p.m.), docket no. 14-2,
319-33, docket no. 14-4.
128

Id. at 146-62, docket no. 14-2, 298-99, docket no. 14-3, 301-08, 310-18, docket no. 14-4.

129

Id. at 1226 (video surveillance CD), docket no. 14-13, 1300-25 (Triad’s written report), docket no. 14-14.
19

49.

On March 7 and 8, 2012, Triad conducted a second video surveillance of

Williams. 130
50.

On April 19, 2012, a Hartford Field Investigator, Mike Morrell, interviewed

Williams at her home. 131
a.

In discussing her level of functionality, Williams said that various

activities caused pain, but Williams denied needing any “special equipment.” 132
b.

Mr. Morrell observed that Williams “was stable upon her feet and she

stood without support[,]” and that “[w]hile viewing the functionality videos, [she] stood
for the entire 20 minutes it took to view the videos.” 133
c.

Even though Williams “mentioned that many normal movements or body

functions cause her a lot of pain[, she] never spontaneously complained of fatigue in [Mr.
Morrell’s] presence, and she did not display any objective signs of fatigue in [Mr.
Morrell’s] presence.” 134
d.

Williams “did not display any objective signs of cognitive impairment,

confusion, inability to concentrate, or lack of focus in [Mr. Morrell’s] presence.” 135
e.

Williams viewed and commented on the surveillance video. 136

f.

Williams “noted that the things she did on the videos caused her a lot of

pain, and we couldn’t see that.” 137

130

Id. at 1226 (video surveillance CD), docket no. 14-13, 1326-38 (Triad’s written report), docket no. 14-14.

131

Id. at 1229-35 (Mr. Morrell’s report), 1250-91 (transcript of interview), docket no. 14-13.

132

Id. at 1231, docket no. 14-13.

133

Id.

134

Id. at 1232, docket no. 14-13.

135

Id.

136

Id. at 1234-35, docket no. 14-13.
20

g.

Williams later sent a letter dated April 25, 2012, to Mr. Morrell in which

she provided further comments on her activities during the video surveillance. 138
51.

By a letter dated April 27, 2012, Williams sent a new APS to Hartford, which Dr.

Inouye had completed. 139
a.

Dr. Inouye indicated that Williams could sit for 30 minutes at a time with

breaks and changes of position for 4-6 hours. 140
b.

Dr. Inouye opined that Williams could stand for 30 minutes at a time with

breaks and changes of position for a total of 2 hours. 141
c.

Dr. Inouye stated that Williams’s degree of functionality “depends on [the]

day[.]” 142
52.

On July 10, 2012, the Ability Analyst summarized the medical and investigative

evidence in Williams’s file, 143 noting that he would refer the file to an “MCM to review medical
records, surveillance investigation findings and interview statement to help clarify [Williams’s]
current restrictions and limitations and her ability to return to work in [her] Own Occupation.” 144
53.

On August 9, 2012, the MCM reported on her assessment of the file materials and

provided a detailed summary of the evidence. 145

137

Id. at 1235, docket no. 14-13.

138

Id. at 1008-09, docket no. 14-11.

139

Id. at 999-1001, docket no. 14-10 and docket no. 14-11.

140

Id. at 1000, docket no. 14-10.

141

Id.

142

Id.

143

Id. at 143-45 (July 10, 2012 2:03:02 p.m.), docket no. 14-2.

144

Id. at 145 (July 10, 2012 2:03:02 p.m.), docket no. 14-2.

145

Id. at 140-42 (Aug. 9, 2012 8:58:38 a.m.), docket no. 14-2.
21

a.

The MCM stated that the medical evidence “could support some degree of

discomfort secondary to the underlying inflammatory processes however the findings do
not support an impairment to function, nor the severe limitation to function as reported by
[Dr. Inouye].” 146
b.

The MCM felt that “[Williams’s] observed activities and time away from

home are in contrast to her self-reported limitations of walking 5 minutes and standing
for 15–20 then needing to rest.” 147
c.

The MCM had learned from Dr. Jackson’s office that Williams had

undergone a surgical procedure on her hip, but the office “could not confirm [the]
specific procedure nor were they able to locate any activity restrictions.” 148
d.

The MCM reported that additional medical information was necessary in

order to determine Williams’s functionality. 149
54.

On September 11, 2012, Hartford received and reviewed Dr. Jackson’s medical

records, showing that Williams had a right hip arthroscopy on June 11, 2012. 150 Dr. Jackson
reported that as of July 31, 2012, Williams was “doing well[.]” 151
55.

On September 14, 2012, the MCM provided an updated assessment of Williams’s

medical records. 152

146

Id. at 142 (Aug. 9, 2012 8:58:38 a.m.), docket no. 14-2.

147

Id.

148

Id.

149

Id.

150

Id. at 137 (Sept. 11, 2012 10:20:20 a.m.; Sept. 11, 2012 1:07:32 p.m.), docket no. 14-2.

151

Id. at 137 (Sept. 11, 2012 1:07:32 p.m.), docket no. 14-2.

152

Id. at 133-36 (Sept. 14, 2012), docket no. 14-2.
22

a.

The MCM confirmed that Williams did not have future appointments

scheduled with Dr. Jackson. 153
b.

The MCM noted that she would contact Dr. Inouye and Dr. Jackson “for

clarification of [Williams’s] function[ality].” 154
c.

The MCM stated that “[i]n light of the successful hip procedure [the]

MCM [is] anticipating improvement in overall capabilities, less reported pain and no
findings to support an inability to perform the sit/stand/walk activity required of a
teacher.” 155
d.

The MCM also indicated that Hartford would send the video surveillance

to Dr. Inouye and Dr. Jackson for their review and comment. 156
56.

Hartford decided that it needed an additional opinion “to clarify/update

[Williams’s] current maximum functional abilities[,]” and contemplated scheduling an
independent medical examination (“IME”) by an orthopedic specialist. 157
a.

However, Hartford learned that there were “no orthopedic IME providers

within 78 miles of [Williams’s home].” 158
b.

Hartford concluded that the available IME providers were too far away

from Williams’s home to require her participation in an IME, and therefore, decided to
arrange for a physician peer review of Williams’s claim. 159

153

Id. at 136 (Sept. 14, 2012), docket no. 14-2.

154

Id.

155

Id.

156

Id.

157

Id. at 130 (Oct. 10, 2012), docket no. 14-2.

158

Id. at 129 (Oct. 11, 2012 10:14:08 p.m.), docket no. 14-2.

159

Id.
23

57.

On October 12, 2012, Hartford referred Williams’s file to a third party vendor,

BMI, in order to obtain an independent peer review. 160
a.

Hartford requested that the peer reviewer opine about Williams’s level of

functionality based on the medical evidence and other information provided. 161
b.

Hartford also asked the peer reviewer to “observe and note any

consistencies/inconsistencies in comparing the subjective and objective findings versus
the level of activity as seen in the surveillance [video].” 162
58.

Dr. Robert Green, a Board Certified Orthopedic Surgeon, licensed to practice

medicine in Florida, performed the peer review of Williams’s claim for BMI and provided a
report dated November 1, 2012. 163
a.

Dr. Green spoke with Dr. Inouye. 164
i.

Dr. Inouye stated that Williams’s “main problem is

fibromyalgia[.]” 165
ii.

Dr. Inouye noted that surgery had addressed Williams’s

hyperparathyroidism and right hip pathology, and that surgery on the left hip was
scheduled. 166
iii.

Dr. Inouye expressed his view that Williams is incapable of

“return[ing] to the workforce in any capacity” due to fibromyalgia. 167

160

Id. at 869-70, docket no. 14-9.

161

Id. at 870, docket no. 14-9.

162

Id.

163

Id. at 864-68, docket no. 14-9.

164

Id. at 865, docket no. 14-9.

165

Id.

166

Id.
24

b.

Dr. Green also spoke with Dr. Jackson who felt that Williams “certainly

can return to a sedentary-type job as far as her hips are concerned, especially after she has
the other hip [surgery] if he finds it necessary after doing an MRI and working her up.” 168
c.

Dr. Green concluded that fibromyalgia was “a limiting factor[.]” 169

d.

Dr. Green opined that Williams “should be able to start at four hours a day

or 20 hours a week” with limitations relating to lifting, stooping, squatting, pushing, and
pulling. 170
e.

Dr. Green noted that “[i]t is possible that [Williams] may eventually be

able to increase the amount of time per day she is able to function.” 171
59.

On November 8, 2012, the MCM reviewed and summarized Dr. Green’s report. 172
a.

The MCM returned the file for continued administration. 173

b.

The MCM identified Williams’s primary diagnosis as osteoarthritis with a

secondary diagnosis of fibromyalgia. 174
60.

On December 21, 2012, the Ability Analyst reviewed the status of Williams’s

claim. 175
a.

The Ability Analyst noted Dr. Green’s opinion that Williams had the

capacity to return to part-time sedentary work. 176

167

Id.

168

Id. at 866, docket no. 14-9.

169

Id. at 867, docket no. 14-9.

170

Id.

171

Id. at 867-68, docket no. 14-9.

172

Id. at 125-26 (Nov. 8, 2012 9:41:17 a.m.), docket no. 14-2.

173

Id. at 126 (Nov. 8, 2012 9:41:17 a.m.), docket no. 14-2.

174

Id.

175

Id. at 121-22 (Dec. 21, 2012 12:03:15 p.m.), docket no. 14-2.
25

b.

The Ability Analyst also indicated that it was “not clear if [Williams] will

regain enough capability to do full time sedentary work by [the effective date of the
Plan’s “Any Occupation” definition].” 177
c.

The Ability Analyst documented his plan to begin the investigation of

whether Williams would continue to be disabled under the Plan’s “Any Occupation”
definition. 178
Hartford’s Any Occupation Investigation
61.

On December 21, 2012, the Ability Analyst took several actions to begin the

investigation of whether Williams would continue to be disabled under the Plan’s “Any
Occupation” definition. 179
a.

The Ability Analyst sent a letter to Williams informing her that the Plan’s

“Any Occupation” definition would take effect on June 17, 2013. 180
b.

The Ability Analyst summarized the applicable terms of the Plan and

requested updated information. 181
c.

The Ability Analyst also sent letters to Williams’s physicians requesting

updated information. 182
d.

The Ability Analyst also sent a letter to Williams requesting her assistance

in obtaining the updated records from Dr. Inouye and Dr. Jackson. 183

176

Id. at 122 (Dec. 21, 2012 12:03:15 p.m.), docket no. 14-2.

177

Id.

178

Id.

179

Id. at 120 (Dec. 21, 2012), 121 (Dec. 21, 2012 4:29:35 p.m.), docket no. 14-2, 245-55, docket no. 14-3.

180

Id. at 253-55, docket no. 14-3.

181

Id.

182

Id. at 120 (Dec. 21, 2012), docket no. 14-2, 245-50, docket no. 14-3.
26

e.

The Ability Analyst also interviewed Williams by telephone regarding her

medical condition. 184
62.

On January 4, 2013, the Ability Analyst’s Manager reviewed the issues relating to

the Any Occupation investigation. 185
a.

Based on the information received from Williams’s treating physicians and

Dr. Green’s the independent peer review, the Manager noted that Williams’s “return to
part time sedentary functionality would be anticipated around [January to
February 2013]” if the scheduled November 16, 2012 surgery on her left hip occurred. 186
b.

The Manager indicated that the claim would be transferred to a new

Ability Analyst with a specialty appropriate to Williams’s conditions. 187
c.

The Manager recommended obtaining Dr. Jackson’s latest office visit

notes in order to evaluate “if functionality has returned to [part-time] or [full-time]
sedentary levels.” 188
63.

On January 30, 2013, the new Ability Analyst documented the status of the Any

Occupation investigation and summarized the information received and information still
needed. 189

183

Id. at 251-52, docket no. 14-3.

184

Id. at 121 (Dec. 21, 2012 4:29:35 p.m.), docket no. 14-2.

185

Id. at 119 (Jan. 4, 2013 2:03:31 p.m.), docket no. 14-2.

186

Id.

187

Id.

188

Id.

189

Id. at 110-13 (Jan. 30, 2013), docket no. 14-2.
27

a.

The Ability Analyst stated that “[o]nce we receive all [medical records], it

appears an IME would be the most appropriate step to confirm that [restrictions and
limitations] are supported.” 190
b.

The Ability Analyst noted that Williams “has been participating in [part-

time work], so it appears that [she] would have had improvement in functionality greater
than part-time sed[entary] work.” 191
c.

The Ability Analyst outlined a planned future course of conduct in the Any

Occupation investigation. 192
64.

On February 19, 2013, the Ability Analyst summarized the information on file

regarding Williams’s claim in anticipation of a “Roundtable” discussion. 193
65.

On February 21, 2013, the Manger and the Ability Analyst had a “Roundtable”

discussion of Williams’s claim. 194
a.

The Manager and the Ability Analyst decided to “refer [Williams’s file] to

[the] MCM to clarify what is impacting functionality with regards to finger/handle and
reaching.” 195
b.

The Manager noted that Dr. Inouye had “not really addressed the objective

testing to validate these limitation[s].” 196

190

Id. at 112 (Jan. 30, 2013), docket no. 14-2.

191

Id.

192

Id. at 113 (Jan. 30, 2013), docket no. 14-2.

193

Id. at 104-06 (Feb. 19, 2013 5:00:24 p.m.), docket no. 14-2.

194

Id. at 104 (Feb. 21, 2013), docket no. 14-2.

195

Id.

196

Id.
28

c.

The Ability Analyst would ask the MCM “whether any change in

functionality would be expected from the past peer review,” and “if no change in
functionality would be expected and restrictions [are] reasonable,” the Analyst Ability
would refer Williams’s file for an Employability Analysis Report. 197
66.

On February 22, 2013, the Ability Analyst referred Williams’s file to the MCM. 198

67.

On February 28, 2013, the MCM reported on her review of Williams’s file. 199
a.

The MCM summarized the medical evidence. 200

b.

The MCM noted that she would contact Dr. Inouye in an attempt to clarify

Williams’s functionality. 201
c.

The MCM observed that “[i]t is possible that [Williams] may have had

some increases in her functionality since the prior peer review [of Dr. Green] was
performed.” 202
68.

On February 20, 2013, the MCM sent a fax to Dr. Inouye requesting clarification

of Williams’s functionality. 203
69.

On March 7, 2013, the MCM contacted Dr. Inouye’s office to follow up on the

request, and resent the request. 204

197

Id.

198

Id. at 102-04 (Feb. 22, 2013), docket no. 14-2.

199

Id. at 99-100 (Feb. 28, 2013 3:12:55 p.m.), docket no. 14-1.

200

Id.

201

Id. at 100 (Feb. 28, 2013 3:12:55 p.m.), docket no. 14-1.

202

Id.

203

Id. at 99 (Feb. 28, 2013 3:34:01 p.m.), docket no. 14-1.

204

Id. at 95-96 (Mar. 7, 2013), docket no. 14-1.
29

70.

On March 14, 2013, the MCM again contacted Dr. Inouye’s office to confirm

receipt of the request. 205
71.

On March 21, 2013, the MCM reported that she had not yet received a response

from Dr. Inouye to her request seeking classification of Williams’s functionality. 206
a.

The MCM indicated that she would discuss with the Ability Analyst about

whether to refer Williams’s file to a peer review vendor “to further clarify functionality of
any occ[upation].” 207
b.

The Ability Analyst agreed with the plan to refer Williams’s file “for peer

review as we have not received response from [Dr. Inouye] to clarify [restrictions and
limitations].” 208
72.

On April 2, 2013, Hartford referred the file to a third party vendor, MES

Solutions, in order to obtain a new independent medical peer review 209 and sent letters to Dr.
Inouye and Dr. Jackson notifying them to expect a telephone call from the independent medical
consultant. 210
73.

MES Solutions assigned the peer review to Dr. Siva Ayyar, who is Board Certified

in Occupational Medicine and has licenses to practice medicine in California, Florida, Ohio,
Tennessee, and Texas. 211

205

Id. at 94 (Mar. 14, 2013), docket no. 14-1.

206

Id. at 93-94 (Mar. 21, 2013), docket no. 14-1.

207

Id. at 94 (Mar. 21, 2013), docket no. 14-1.

208

Id. at 92-93 (Mar. 28, 2013; Mar. 25, 2013), docket no. 14-1.

209

Id. at 582-83, docket no. 14-6.

210

Id. at 212-13, docket no. 14-3.

211

Id. at 581, docket no. 14-6.
30

74.

Dr. Ayyar submitted a detailed report dated April 24, 2013. 212
a.

Dr. Ayyar left voice mail messages for Dr. Inouye, but the calls were not

returned. 213
b.

Dr. Ayyar was able to speak with Dr. Jackson. 214
i.

Dr. Jackson reported that Williams’s “hip issues have essentially

been treated to resolution.” 215
ii.

Dr. Jackson told Dr. Ayyar that “[h]e is not a proponent of

[Williams’s] LTD claim.” 216
iii.

Dr. Jackson suggested that Dr. Ayyar contact Dr. Joseph Richey,

who was treating Williams’s low back pain. 217
c.

Dr. Ayyar noted that Dr. Jackson “affirmed [his] conclusion that the hip

issues were a temporarily limiting concern, as opposed to a continuously limiting
concern.” 218
d.

Dr. Ayyar summarized the medical records. 219

e.

Dr. Ayyar stated that Williams would not have been able to perform any

work for two weeks immediately following her hip surgery on November 16, 2012. 220

212

Id. at 576-81, docket no. 14-6.

213

Id. at 576, docket no. 14-6.

214

Id.

215

Id.

216

Id.

217

Id.

218

Id.

219

Id. at 576-79, docket no. 14-6.

220

Id. at 579, docket no. 14-6.
31

f.

Dr. Ayyar identified restrictions and limitations relating to the post-

operative recovery period, “December 1, 2012 to March 31, 2013[.]” 221
g.

Dr. Ayyar indicated that he lacked sufficient medical evidence to extend

the restrictions and limitations beyond April 1, 2013. 222
h.

Dr. Ayyar stated that the nature of Williams’s “functional, technical, and/or

anatomic outcomes” would determine what, if any, restrictions and limitations would be
appropriate after April 1, 2013. 223
75.

On April 25, 2013, the MCM reviewed and summarized Dr. Ayyar’s report 224 and

sent a letter to Dr. Inouye asking Dr. Inouye to review the summary and provide any comments
and remarks. 225
76.

On April 25, 2013, the MCM also called Dr. Inouye’s office in order to confirm

receipt of her letter dated April 25, 2013. 226
77.

On April 30, 2013, the Ability Analyst spoke with Williams about the status of the

claim review. 227
a.

The Ability Analyst informed Williams of Dr. Ayyar’s conclusions, and

that Hartford was awaiting Dr. Inouye’s comments. 228

221

Id. at 579-80, docket no. 14-6.

222

Id. at 580, docket no. 14-6.

223

Id.

224

Id. at 87-89 (Apr. 25, 2013 5:11:13 p.m.), docket no. 14-1.

225

Id. at 209-11, docket no. 14-3.

226

Id. at 87 (Apr. 25, 2013 5:28:13 p.m.), docket no. 14-1.

227

Id. at 85 (Apr. 30, 2013 11:06:10 a.m.), docket no. 14-1.

228

Id.
32

b.

Williams asked whether her receipt of SSDI benefits played a role in

Hartford’s determination. 229
c.

The Ability Analyst explained that “the SSA and Hartford have different

definitions of disability and different ways to make a decision[,]” and that Hartford
“do[es] not make [its] decision based on [the] SSA[’]s decision.” 230
78.

On May 1, 2013, Williams again spoke with the Ability Analyst. 231
a.

Williams discussed her referral to Dr. Richey regarding her back pain and

said that she was scheduled to see him on May 7, 2013, regarding the results of an
MRI. 232
b.

Williams asked whether Hartford considered her “whole health

condition[.]” 233
c.

The Ability Analyst responded that Hartford “would take into

consideration [the] totality of all medical condition[s].” 234
d.

Williams stated that Dr. Inouye disagreed with Dr. Ayyar, and that he

would provide a response. 235
e.

Based on her conversation with Williams, the Ability Analyst noted that

she would seek the records of Dr. Jackson and Dr. Richey referenced by Williams. 236

229

Id. On September 24, 2012, the Social Security Administration (“SSA”) approved the payment of SSDI benefits
to Williams. Id. at 872-77, docket no. 14-9.

230

Id. at 85 (Apr. 30, 2013 11:06:10 a.m.), docket no. 14-1.

231

Id. at 83-84 (May 1, 2013 2:25:25 p.m.), docket no. 14-1.

232

Id. at 83 (May 1, 2013 2:25:25 p.m.), docket no. 14-1.

233

Id.

234

Id. at 83-84 (May 1, 2013 2:25:25 p.m.), docket no. 14-1.

235

Id. at 84 (May 1, 2013 2:25:25 p.m.), docket no. 14-1.

236

Id. at 83 (May 1, 2013 2:35:32 p.m.), docket no. 14-1.
33

f.

The Ability Analyst commented that “Hartford will need this information

as it could potentially change [the Any Occupation] decision.” 237
79.

Dr. Inouye responded to the MCM’s letter by letter dated April 30, 2013. 238
a.

Dr. Inouye provided a short overview of Williams’s diagnoses. 239

b.

Dr. Inouye neither addressed any specific points in Dr. Ayyar’s report nor

cited any medical evidence supporting his opinions. 240
c.

Instead, Dr. Inouye generally attacked the ability of a peer review

physician to comment on Williams’s medical condition. 241
d.

Dr. Inouye reiterated his opinion that Williams “is disabled currently[, and

that s]he cannot in any way continue to work as a teacher.” 242
80.

On May 8, 2013, the MCM documented her review of Dr. Inouye’s response, 243

noting that he had not provided “additional medical records… for further review.” 244
81.

On May 9, 2013, Williams and the Ability Analyst spoke about Williams’s recent

visit with Dr. Richey. 245
a.

The Ability Analyst noted that Hartford was continuing its review of

whether Williams would continue to be disabled after June 17, 2013, under the “Any
Occupation” definition. 246

237

Id.

238

Id. at 561-64, docket no. 14-6.

239

Id. at 564, docket no. 14-6.

240

Id.

241

Id.

242

Id.

243

Id. at 81-82 (May 8, 2013), docket no. 14-1.

244

Id. at 82 (May 8, 2013), docket no. 14-1.

245

Id. at 79-80 (May 9, 2013 2:57:10 p.m.), docket no. 14-1.
34

b.

Williams expressed her view that her back condition would prevent her

from doing any type of work. 247
c.

The Ability Analyst told Williams that she would need to review the

medical information from Dr. Richey. 248
82.

On May 15, 2013, the Ability Analyst received a letter from Williams and medical

records from Dr. Jackson and Dr. Richey, and forwarded the new materials to the MCM. 249
83.

On May 15, 2013, Williams called the Ability Analyst to tell her that additional

medical information would be available the following week. 250 Hartford and Williams had
follow up telephone conversations about the status of those materials. 251
84.

On May 21, 2013, Hartford received the additional medical records, and the

Ability Analyst referred them to the MCM for review. 252
85.

The MCM reviewed the additional medical records and recommended their

referral to Dr. Ayyar for an addendum review. 253
86.

Hartford then referred the additional medical records to MES Solutions for an

addendum review. 254

246

Id. at 80 (May 9, 2013 2:57:10 p.m.), docket no. 14-1.

247

Id.

248

Id.

249

Id. at 77-78 (May 15, 2013 12:59:27 p.m.), docket no. 14-1.

250

Id. at 77 (May 15, 2013 3:27:30 p.m.), docket no. 14-1.

251

Id. at 74 (May 20, 2013 5:23:49 p.m.; May 20, 2013 5:31:50 p.m.), 76 (May 17, 2013 3:49:21 p.m.), docket
no. 14-1.
252

Id. at 73-74 (May 21, 2013 11:25:51 a.m.), docket no. 14-1.

253

Id. at 72-73 (May 21, 2013 3:21:49 p.m.), docket no. 14-1.

254

Id. at 475-77, docket no. 14-5.
35

87.

On June 4, 2013, Dr. Ayyar submitted an addendum report. 255
a.

Dr. Ayyar again tried to speak with Dr. Inouye, but was unsuccessful. 256

b.

Dr. Ayyar reviewed and summarized the 101 pages of new information. 257

c.

Dr. Ayyar found evidence of fatigue attributable to Williams’s

hypothyroidism and recommended some activity limitations for the period of
May 6, 2013 to June 6, 2013, to allow a month for adjustment of Williams’s
hypothyroidism medication. 258
d.

Dr. Ayyar stated that Williams’s hip condition may “cause intermittent

limitations and restrictions.” 259
e.

Dr. Ayyar found no evidence to support restrictions or limitations

attributable to Williams’s back condition, citing the fact that the lumbar MRI was
“essentially negative[.]” 260
f.

Dr. Ayyar found that “[Williams’s] thyroid cancer has seemingly been

treated to resolution[.]” 261
88.

On June 6, 2013, the Ability Analyst sent a letter to Dr. Inouye summarizing the

findings in Dr. Ayyar’s addendum report, 262 and referred the file for the preparation of an
Employability Analysis Report. 263

255

Id. at 462-66, docket no. 14-5.

256

Id. at 462, docket no. 14-5.

257

Id. at 462-64, docket no. 14-5.

258

Id. at 464-65, docket no. 14-5.

259

Id. at 465, docket no. 14-5.

260

Id.

261

Id.

262

Id. at 206-07, docket no. 14-3.

263

Id. at 457-58, docket no. 14-5.
36

89.

On June 11, 2013, Sandra Shelton, MA, CRC prepared an Employability Analysis

Report for Hartford, 264 based on the limitations offered by Dr. Ayyar and on the June 6, 2013
report of MCM-RN Michelle McNamara. 265
a.

According to the Employability Analysis Report, Ms. Shelton considered

the following limitations:
sit unlimited; stand/walk no more than 15 minutes continuously for
total of 30 cumulative minutes per hour, maximum of 4 cumulative
hours per day; lift up to 25 [pounds] up to 3 cumulative [hours] per
day, up to 26 [pounds] or more up to 30 cumulative minutes per
day; occasionally kneel, squat, bend or stoop maximum of 2
[hours] per day; activity not formally limited above should be
considered unlimited. Ms. Williams is able to perform Sedentary
demands 8 hours per day, 40 hours per week. There is no evidence
to support cognitive and/or mental restrictions. 266
b.

Ms. Shelton “identified 6 occupations within the Closest level; no

occupations within the Good level; 77 occupations within the Fair level; and 205
occupations within the Potential level[,]” and provided a “representative sample of
occupations that meet [Williams’s] profile[.]” 267
c.

Ms. Shelton opined that Williams could perform work as a Teacher,

Elementary School—Williams’s past occupation; Teacher, Mentally Impaired; Teacher;
Vocational Training; and Teacher, Learning Disabled. 268
d.

Ms. Shelton also opined Williams could perform work as a Jacket

Preparer, which was categorized as a “Potential” level occupation. 269 According to the

264

Id. at 444-55, docket no. 14-5.

265

Id. at 444, docket no. 14-5.

266

Id.

267

Id. at 445, docket no. 14-5.

268

Id. at 446, docket no. 14-5.

269

Id.
37

Employability Analysis Report’s Transferability Table, a “Potential” level occupation has
low transferability, requiring plan development and training, and training in tools and
materials is required. 270
e.

Ms. Shelton stated that “[e]ach occupation is within the

restrictions/limitations provided by Dr. Ayyar.” 271
f.

Ms. Shelton also stated that the job of Jacket Preparer “requires no

experience or education” and “can be performed with short on-the-job training” despite
its classification as a “Potential” level occupation. 272
90.

On June 13, 2013, Hartford informed Williams of its determination that she was

“not Disabled from [her own] Occupation effective [June 12, 2013] and will not be Disabled
from Any Occupation as of [June 17, 2013].” 273
a.

Hartford acknowledged that Williams had received SSDI benefits, but

stated that “[t]he standards governing these public and private benefits are different in
critical ways.” 274
b.

Hartford indicated that it had considered “the SSA’s disability

determination as one piece of relevant evidence,” but added that “the SSA’s
determination is not conclusive.” 275
c.

Hartford went on to summarize the relevant terms of the Plan and the

information it considered. 276

270

Id. at 450, docket no. 14-5.

271

Id. at 446, docket no. 14-5.

272

Id.

273

Id. at 204, docket no. 14-3.

274

Id. at 199, docket no. 14-2.

275

Id.
38

d.

Hartford determined that the payment of LTD benefits to Williams would

end on June 12, 2013. 277
e.

According to the termination, Williams could perform her own occupation

as a Teacher, Elementary School, as well as other occupations, listed as: Teacher,
Mentally Impaired; Teacher; Vocational Training; Teacher, Learning Disabled; and Jacket
Preparer. 278
Hartford’s Determination of Williams’s Appeal
91.

By a letter dated November 19, 2013, Williams’s counsel submitted an appeal of

the claim determination, arguing that Williams’s medical records show that she has continuing
problems with hypothyroidism, hip osteoarthritis, pain, and weakness. 279 Williams’s counsel
enclosed a Functional Capacity Evaluation, 280 as further proof of Williams’s disability. 281
92.

Hartford referred the file to a third party vendor, Reliable Review Services, for a

new independent peer review. 282
93.

Reliable Review Services assigned the peer review project to Dr. Joseph L. Rea,

who is Board Certified in Occupational Medicine with licenses to practice medicine in Alabama
and Texas. 283

276

Id. at 199-204, docket no. 14-2 and docket no. 14-3.

277

Id. at 199, docket no. 14-2, 204, docket no. 14-3.

278

Id. at 204, docket no. 14-3.

279

Id. at 368-70, docket no. 14-4.

280

Id. at 371-80, docket no. 14-4.

281

Id. at 369, docket no. 14-4.

282

Id. at 55 (Dec. 17, 2013), docket no. 14-2.

283

Id. at 359, docket no. 14-4.
39

94.

Dr. Rea provided a report dated January 10, 2014. 284
a.

Dr. Rea summarized Williams’s clinical history. 285

b.

Dr. Rea concluded that Williams should be capable of full-time work with

various noted activity limitations from June 11, 2013, to the present. 286
95.

On January 13, 2014, Hartford issued its determination on Williams’s appeal. 287
a.

Hartford noted the arguments on which Williams based her appeal and

summarized the conclusions of Dr. Rea. 288
b.

Hartford stated that “[a]lthough our previous decision was supported by

the information we had at the time, we will reopen [Williams’s] claim an extend benefits
through [June 16, 2013,]” 289 an additional five days, after which it denied Williams’s
appeal. 290
c.

Hartford again concluded that “the medical information does not establish

that [Williams] remained Disabled from performing [A]ny [O]ccupation as defined by the
[Plan and Group P]olicy.” 291
d.

Hartford found that “the weight of the information in [Williams’s] file

viewed as a whole supports that [she] is medically capable of performing at least full time

284

Id. at 354-61, docket no. 14-4.

285

Id. at 354-56, docket no. 14-4.

286

Id. at 357-58, docket no. 14-4.

287

Id. at 190-92, docket no. 14-2.

288

Id. at 190-91, docket no. 14-2.

289

Id. at 191, docket no. 14-2.

290

Id. at 192, docket no. 14-2.

291

Id.
40

sedentary work within the above noted limitations [of Dr. Rea] and that she is
vocationally employable at that work level.” 292
e.

Dr. Rea opined that Williams could perform full-time work with the

following limitations:
lifting/pulling/pushing/carrying up to 10 pounds occasionally;
sitting for up to 30 minutes at a time for up to 6 hours of sitting
over an 8 hour day; walking/standing up to 15 minutes at a time for
up to 2 hours over an 8 hour day; occasional kneeling; no
squatting/crawling/crouching/climbing; bending on a rare basis;
and no limitations in
reaching/fingering/handling/grasping/gripping. 293
f.

Hartford’s denial letter also indicated that the June 11, 2013 Employability

Analysis Report determined that Williams “is vocationally employable in a sedentary
occupation.” 294
g.

Hartford’s denial letter stated that “[t]his is [Hartford’s] final

determination on [Williams’s] appeal and [that its] record is closed.” 295
Breach of Contract Claim Element 4: Damages
Initial Denial of Williams’s Claim for LTD Benefits
96.

On June 13, 2013, Hartford informed Williams of its determination that she was

“not Disabled from [her own] Occupation effective [June 12, 2013] and will not be Disabled
from Any Occupation as of [June 17, 2013].” 296

292

Id.

293

Id. at 191, docket no. 14-2, 357-58, docket no. 14-4.

294

Id. at 192, docket no. 14-2, 444, docket no. 14-5.

295

Id. at 192, docket no. 14-2.

296

Id. at 204, docket no. 14-3.
41

a.

Hartford acknowledged that Williams had received SSDI benefits, but

stated that “[t]he standards governing these public and private benefits are different in
critical ways.” 297
b.

Hartford indicated that it had considered “the SSA’s disability

determination as one piece of relevant evidence,” but added that “the SSA’s
determination is not conclusive.” 298
c.

Hartford went on to summarize the relevant terms of the Plan and the

information it considered. 299
d.

Hartford determined that the payment of LTD benefits to Williams would

end on June 12, 2013. 300
e.

According to the termination, Williams could perform her own occupation

as a Teacher, Elementary School, as well as other occupations, listed as: Teacher,
Mentally Impaired; Teacher; Vocational Training; Teacher, Learning Disabled; and Jacket
Preparer. 301
Denial of Williams’s Appeal
97.

On January 13, 2014, Hartford issued its determination on Williams’s appeal. 302
a.

Hartford noted the arguments on which Williams based her appeal and

summarized the conclusions of Dr. Rea. 303

297

Id. at 199, docket no. 14-2.

298

Id.

299

Id. at 199-204, docket no. 14-2 and docket no. 14-3.

300

Id. at 199, docket no. 14-2, 204, docket no. 14-3.

301

Id. at 204, docket no. 14-3.

302

Id. at 190-92, docket no. 14-2.

303

Id. at 191-92, docket no. 14-2.
42

b.

Hartford stated that “[a]lthough our previous decision was supported by

the information we had at the time, we will reopen [Williams’s] claim an extend benefits
through [June 16, 2013,]” 304 an additional five days, after which it denied Williams’s
appeal. 305
c.

Hartford again concluded that “the medical information does not establish

that [Williams] remained Disabled from performing [A]ny [O]ccupation as defined by the
[Plan and Group P]olicy.” 306
d.

Hartford found that “the weight of the information in [Williams’s] file

viewed as a whole supports that [she] is medically capable of performing at least full time
sedentary work within the above noted limitations [of Dr. Rea] and that she is
vocationally employable at that work level.” 307
e.

Dr. Rea opined that Williams could perform full-time work with the

following limitations:
lifting/pulling/pushing/carrying up to 10 pounds occasionally;
sitting for up to 30 minutes at a time for up to 6 hours of sitting
over an 8 hour day; walking/standing up to 15 minutes at a time for
up to 2 hours over an 8 hour day; occasional kneeling; no
squatting/crawling/crouching/climbing; bending on a rare basis;
and no limitations in
reaching/fingering/handling/grasping/gripping. 308

304

Id. at 191, docket no. 14-2.

305

Id. at 192, docket no. 14-2.

306

Id.

307

Id.

308

Id. at 191, docket no. 14-2, 357-58, docket no. 14-4.
43

f.

Hartford’s denial letter also indicated that the June 11, 2013 Employability

Analysis Report determined Williams is vocationally employable in a sedentary
occupation. 309
g.

Hartford’s denial letter stated that “[t]his is [Hartford’s] final

determination on [Williams’s] appeal and [that its] record is closed.” 310
Summaries
Summary of Medical Evidence 311
98.

Williams has been diagnosed with fibromyalgia. 312
a.

Dr. Inouye mapped 17 of 18 positive trigger points consistent with a

diagnosis of fibromyalgia. 313
b.

Throughout her medical records, Williams’s physicians have consistently

reported pain and fatigue due to fibromyalgia. 314

309

Id. at 192, docket no. 14-2, 444, docket no. 14-5.

310

Id. at 192, docket no. 14-2.

311

According to Williams, the Administrative Record contains voluminous medical records dating back over five
years. As Williams was terminated from benefits effective June 2013, only those medical records and opinions
leading up to Hartford’s termination decision and while Williams’s claim was on appeal are summarized herein, and
only those relevant to the parties’ arguments. There is also video surveillance that was filed conventionally by
Hartford, docket no. 15, as well as a summary of Hartford’s surveillance investigation found in the Administrative
Record at 1245-1360, docket no. 14-13 and docket no. 14-14. As the surveillance efforts were never an apparent
basis for Hartford’s determination, they are not summarized.
312

Administrative Record at 126 (Nov. 8, 2012 9:41:17 a.m.), 180 (Nov. 18, 2011 12:10:30 p.m.), docket no. 14-2,
865, 867, docket no. 14-9, 1146, docket no. 14-12, 1238, docket no. 14-13, filed Mar. 5, 2015.
313

Id. at 680, docket no. 14-7; see also SSR 12-2p at 4.

314

See e.g. Administrative Record at 381, docket no. 14-4 (“[Williams’s] problems with fibro[myalgia] seem to be
worsening. Her ability to move about and do things is very limited…. She appears very tired today.”), 524, docket
no. 14-6 (“[Williams’s] fibromyalgia continues to be quite severe, [and] limits her activity. When she over exerts,
she really pays for it…. Generally, [she] continues to suffer with fibromyalgia, she’s very weakened. She continues
to be unable to work. I believe this is a longstanding problem and that it will go on forever.”), 675, docket no. 14-7
(“[T]here’s no question in my mind that she has fairly significant fibromyalgia-type symptoms. She’s not pretending
that these symptoms are causing problems – they are definitely there.”), filed Mar. 5, 2015.
44

99.

Williams has been diagnosed with degenerative joint disease of the hips. 315
a.

On May 3, 2012, Dr. Jackson stated that he believed Williams “would

benefit from an arthroscopic assessment evaluation” of her right hip, which was
scheduled for June 13, 2012. 316
b.

On June 13, 2012, Dr. Jackson performed arthroscopic surgery on

Williams’s right hip for a labral tear with femoral acetabular impingement. 317
c.

On September 13, 2012, Dr. Jackson stated that Williams was doing “very,

very well” post right hip arthroscopy, though her left hip had become “more and more
symptomatic and more painful.” 318
d.

A left hip arthroscopy was planned for November 2012. 319

e.

On November 16, 2012, Dr. Jackson performed arthroscopic surgery on

Williams’s left hip for a labral tear with cam and pincer deformity of the femoral
acetabular impingement. 320
f.

X-rays taken on December 20, 2012, “show[ed] quite an increase in the

degenerative process that has been taking place.” 321
g.

Williams described pain in her hips not only when walking, but when

sitting or at rest. 322

315

Id. at 1209, docket no. 14-13.

316

Id. at 620, docket no. 14-7.

317

Id. at 892-93, docket no. 14-9.

318

Id. at 616, docket no. 14-7.

319

Id.

320

Id. at 622-23, docket no. 14-7.

321

Id. at 614, docket no. 14-7.

322

Id. at 522, docket no. 14-6.
45

h.

On January 8, 2013, Dr. Jackson was encouraged that a total hip

replacement could be avoided at the time, but noted that “it was probabl[y] inevitable that
down the road [it] will be required.” 323
i.

X-rays on September 13, 2013, revealed rapidly advancing degeneration

of the right hip joint with end stage osteoarthritis, thus making Williams a candidate for a
total hip replacement. 324
100.

Dr. Richey diagnosed Williams with lumbar degenerative disc disease, 325 with a

Lumbar MRI revealing mild degenerative changes, 326 but no isolated peripheral neuropathy. 327
Summary of Medical Opinions Regarding Williams’s Restrictions and Limitations
101.

On November 1, 2012, Dr. Green prepared a report for Hartford based on a

review of Williams’s claim file and the surveillance video taken of Williams at the direction of
Hartford. 328
a.

Dr. Green did not examine Williams. 329

b.

Dr. Green concluded that Williams was currently limited to part-time work

activity, though he did not rule out a return to full-time sedentary work in the future. 330
c.

Dr. Green concluded that based on a review of the records and

surveillance video, there was no “symptom magnification” displayed. 331

323

Id. at 521, docket no. 14-6.

324

Id. at 383, docket no. 14-4.

325

Id. at 406, docket no. 14-5.

326

Id. at 481, docket no. 14-5.

327

Id. at 395, docket no. 14-4.

328

Id. at 864-68, docket no. 14-9.

329

Id.

330

Id. at 867-68, docket no. 14-9.

331

Id. at 868, docket no. 14-9.
46

102.

On April 24, 2013, Dr. Ayyar submitted a report to Hartford based on a review of

Williams’s claim file. 332
a.

Dr. Ayyar did not examine Williams. 333

b.

Dr. Ayyar stated that Williams’s diagnoses were:
Bilateral hip arthritis/bilateral hip impingement syndrome with a
history of labral tearing, fibromyalgia/chronic pain syndrome, low
back pain, headaches secondary to temporomandibular joint
syndrome (TMJ), history of thyroid cancer with postoperative
hypothyroidism and hypoparathyroidism status post thyroidectomy
and parathyroidectomy, obstructive sleep apnea (OSA), and
hemorrhoids. 334

c.

Despite Williams’s diagnoses, Dr. Ayyar opined that she would have only

temporary limitations related to surgery, and that her work capacity would be unlimited
after April 1, 2013. 335
103.

On May 7, 2013, Williams saw Dr. Richey for an evaluation of lumbar spine

pain. 336
a.

Dr. Richey placed Williams on restrictions of:
no lifting more than 25 pounds on an infrequent basis and no
lifting more than 20 pounds on a frequent basis…. 20 minutes of
walking, 20 minutes of sitting and 20 minutes of standing during
each one hour period…. no repetitive bending, stooping, squatting,
or pushing with respect to her lumbar spine. 337

332

Id. at 576-81, docket no.14-6.

333

Id.

334

Id. at 579, docket no. 14-6.

335

Id. at 579-80, docket no. 14-6.

336

Id. at 406-10, docket no. 14-5.

337

Id. at 406, 408, docket no. 14-5.
47

b.

Dr. Richey’s restrictions were related only to Williams’s lumbar spine

impairment. 338
c.

While Dr. Richey did not believe surgery would be beneficial, he

recommended that Williams “procure disability benefits if possible.” 339
104.

On May 10, 2013, in response to Dr. Ayyar’s report, Dr. Inouye opined that

Williams was unable to perform sedentary work on a part time basis. 340
105.

In a letter dated April 30, 2013, Dr. Inouye explained that he had been treating

Williams for 20 years, and that her health had declined over the past two years. 341
a.

After Williams had been treated for thyroid cancer, Dr. Inouye made a

diagnosis of fibromyalgia based on Williams’s muscle pain and severe weakness. 342
b.

Dr. Inouye went on to state:
This patient has never been a malingerer in my extensive
association with her and it seems to be “absurd” that the insurance
company which is determining her disability; can hire a physician
who has never seen the patient and never known the patient’s
circumstances and declare that the patient is no longer disabled.
It’s incredible to me that someone can do this to a person! I’ve
recommended that the patient seek legal advice and get this
adjudicated by someone other than the insurance company. I would
also recommend to her that they ask for damages because this is an
egregious farce that they’re placing on this patient. I’m tired of
filling-out their disability forms. The patient is disabled currently.
She cannot in any way continue to work as a teacher. When she
exerts a little bit of activity at all, she’s in bed the next day or so
because of the severe weakness. This is an extreme example of

338

Id.

339

Id. at 407, 409, docket no. 14-5.

340

Id. at 547-48, docket no. 14-6.

341

Id. at 550, docket no. 14-6.

342

Id.
48

what an insurance company can do to a person. I believe it is unfair
and unjust! 343
106.

On May 21, 2013, Dr. Ayyar prepared an addendum to his April 24, 2013

report. 344
a.

Dr. Ayyar altered his opinion of Williams’s restrictions and limitations,

“but only superficially.” 345
b.

Dr. Ayyar opined that for a brief period, from May 6, 2013 through

June 6, 2013, Williams would have the following restrictions and limitations:
Standing and walking are limited to no more than 15 minutes
continuously maximum of 30 cumulative minutes per hour and
maximum of four cumulative hours per an eitht-hour day; lifting
limited to 25 pounds or less for up to 3 cumulative hours per 8hour day.
Lifting is limited to those articles weighing 25 or less for up to
three cumulative hours per eight-hour day.
Lifting of articles weighing 26 pounds or more should be limited to
no more than 30 cumulative minutes per eight-hour day.
Kneeling, squatting, bending, and/or stooping are limited to
occasional and a maximum of two cumulative hours per eight-hour
day. 346
c.

Dr. Ayyar stated that “[a]ny activity not formally limited above should be

considered unlimited. E.g., sitting is unlimited here.” 347
d.

Dr. Ayyar’s amended restrictions and limitations for the one-month period

were related only to Williams’s thyroid impairment. 348

343

Id. (emphasis in original).

344

Id. at 462-66, docket no. 14-5.

345

Id. at 464, docket no. 14-5.

346

Id. at 465, docket no. 14-5.

347

Id.

348

Id.
49

107.

On October 28, 2013, Williams underwent a Functional Capacity Evaluation

secondary to fibromyalgia and bilateral hip pain with continued difficulty with mobility and pain
affecting daily activities. 349
a.

Occupational Therapist Marc Rosello performed a variety of tests on

Williams, including validity testing. 350
b.

Mr. Rosello stated that Williams “[a]ppeared to give full volitional effort”

during testing, as objectified through validity testing. 351
c.

Mr. Rosello noted that “[a]fter 5 minutes rest, [Williams’s] ending heart

rate was 123 beats per minute and 96% O2 saturation[, with a p]ain level was 7/10 in her
right hip, back, shoulders and feet.” 352
d.

Mr. Rosello concluded that “[Williams] does not appear capable of

performing work, even in the sedentary category, secondary to deconditioning, increasing
pain and muscle weakness.” 353
108.

On January 4, 2014, Dr. Inouye prepared as assessment of Williams’s work-

related capabilities at the request of Hartford. 354
a.

Dr. Inouye stated Williams’s primary diagnoses were fibromyalgia and

low back pain, with secondary diagnoses of hyperparathyroidism, sleep apnea, and
irritable bowel syndrome. 355

349

Id. at 371-80, docket no. 14-4.

350

Id.

351

Id. at 380, docket no. 14-4.

352

Id.

353

Id.

354

Id. at 708-09, docket no. 14-8.

355

Id. at 708, docket no. 14-8.
50

b.

Among other restrictions and limitations, Dr. Inouye opined Williams

could only sit for a total of 2-3 hours per workday, stand for a total of 1 hour per
workday, and walk for a total of 1 hour per workday. 356
c.

Thus, Dr. Inouye suggested restrictions and limitations that would

effectively allow Williams to work a maximum of about 4 hours per day. 357 This
represented a decrease in functioning from April 23, 2012, when Dr. Inouye completed
the same form for Hartford. 358 In the earlier form, Dr. Inouye suggested restrictions and
limitations that would effectively allow Williams to work potentially 7 hours per day,
depending on the amount of time she could sit during the day. 359
109.

Dr. Rea reviewed Williams’s claim file for Hartford and prepared a report dated

January 10, 2014. 360
a.

Dr. Rea did not examine Williams. 361

b.

Dr. Rea stated that:
While fibromyalgia does not stand as an objective clinical entity
(upon which impairment and resultant physical limitations can be
based) and the degenerative low back spinal condition is not
objectively significant, there is a more solid, objective
underpinning for impairment stemming from advanced-level right
hip osteoarthritis. 362

356

Id. at 709, docket no. 14-8.

357

Id.

358

Id. at 999-1000, docket no. 14-10.

359

Id. at 1000, docket no. 14-10.

360

Id. at 354-61, docket no. 14-4.

361

Id.

362

Id. at 357, 358, docket no. 14-4.
51

c.

Dr. Rea opined that “[b]ased on the hip involvement,” Williams would

have the following restrictions:
Lifting/pulling/pushing/carrying up to 10 pounds on an occasional
basis[;]
Sitting for up to 30 minutes at a time for up to 6 hours of sitting
over an 8-hour day[;]
Walking/standing up to 15 minutes at a time, for up to 2 hours of
walking/standing over an 8-hour day[;]
Kneeling on an occasional basis[;]
No squatting, crawling, crouching, or climbing[;]
Bending on a rare basis[;]
There would be no limitations on reaching[; and]
There would be no limitations for hand usage, such as
fingering/handling/grasping/gripping. 363
STANDARD OF REVIEW
Generally, summary judgment is appropriate “if the movant shows that there is no
genuine dispute as to any material fact and the movant is entitled to judgment as a matter of
law.” 364 A factual dispute is genuine when “there is sufficient evidence on each side so that a
rational trier of fact could resolve the issue either way[,]” 365 or “if a reasonable jury could return
a verdict for the nonmoving party.” 366 In determining whether there is a genuine dispute of
material fact, courts “examine the factual record and reasonable inferences therefrom in the light
most favorably to the party opposing summary judgment.” 367

363

Id.

364

FED. R. CIV. P. 56(a).

365

Alder v. Wal-Mart Stores, Inc., 144 F.3d 664, 670 (10th Cir. 1998)

366

Universal Money Ctrs., Inc. v. Am. Tel. & Tel. Co., 22 F.3d 1527, 1529 (10th Cir. 1994) (internal quotations
omitted).

367

Id. (internal quotations omitted).
52

The moving party “bears the burden of showing the absence of a genuine issue of
material fact[.]” 368 The movant “need not negate the nonmovant’s claim, but need only point out
to the district court that there is an absence of evidence to support the nonmoving party’s
case.” 369 Upon such a showing, the nonmoving party “may not rest upon mere allegations or
denials of his pleading, but must set forth specific facts showing that there is a genuine issue for
trial as to those dispositive matters for which it carries the burden of proof.” 370 “The mere
existence of a scintilla of evidence in support of the [nonmovant’s] position will be insufficient
to defeat a properly supported motion for summary judgment.” 371
However, this is not the usual summary judgment case. “The parties … conferred about
the resolution of th[e] case, [and] agreed that th[e] case should be decided on the evidence of
record, and that there is no material dispute about any facts in th[e] case.” 372 “The sole issue is
the interpretation of the evidence and the application of the law to the evidence of [record].” 373
Therefore, the parties “asked the [c]ourt to decide th[e] case based on the evidence submitted to
the [c]ourt and the parties’ summary judgment memoranda.” 374 Accordingly, “this isn’t just a
summary judgment [proceeding] on two motions, but it is a stipulation to a record from which
[the court] as the factfinder [will] decide the case.” 375

368

Id. at 1529.

369

Id. (internal quotations omitted).

370

Id. (internal quotations and citations omitted; emphasis in original).

371

Id. (internal quotations omitted).

372

Williams’s Response at 2, docket no. 20, filed May 1, 2015.

373

Id.

374

Hartford’s Response at 1, docket no. 19 , filed May 1, 2015.

375

Hearing Transcript at 3:24-4:1, docket no. 26, filed Jan. 6, 2017.
53

DISCUSSION
“In Utah, a plaintiff may sue on a contract for: (1) breach of the contract’s express terms;
and/or (2) breach of the covenant of good faith and fair dealing, which is an implied duty that
inheres in every contractual relationship.” 376 Williams’s Complaint asserts a single claim for
breach of the Plan and Group Policy’s express terms through the improper denial of her claim
from LTD benefits. 377 Nevertheless, the majority of Hartford’s arguments rest on principles
relating to a claim for breach of the covenant of good faith and fair dealing, such as whether
Hartford diligently investigated Williams’s claim for LTD benefits, whether Williams’s claim for
LTD benefits was fairly debatable, and whether Hartford acted reasonably and promptly. 378
Hartford’s arguments are irrelevant to Williams’s claim for breach of the Plan and Group Policy’s
express terms. 379
While appellate opinions include discussion analyzing both types of claims, claims for
breach of express terms and breach of implied covenant of good faith and fair dealing are distinct
and require different considerations and elements of proof. 380 “[T]he former claim is confined to
the obligations imposed by the contract itself, [but] the latter is not so constrained.” 381 The claim
for breach of the implied covenant of good faith and fair dealing contemplates that “the insurer
will diligently investigate the facts to enable it to determine where a claim is valid, will fairly

376

Blakely v. USAA Cas. Ins. Co., 633 F.3d 944, 947 (10th Cir. 2011).

377

Complaint at 3-4, docket no. 2-2, filed Apr. 23, 2014.

378

Hartford’s Motion at 24-31, docket no. 17, filed Mar. 31, 2015; Hartford’s Response at 4-6, 12, docket no. 19,
filed May 1, 2015; Hartford’s Reply at 2-5, docket no. 22, filed May 18, 2015.
379

Blakely, 633 F.3d at 947; Machan v. UNUM Life Ins. Co. of America, 2005 UT 37, ¶¶ 17-21, 116 P.3d 342.

380

Id. at 947-50; Jones v. Farmers Ins. Exchange, 2012 UT 52, ¶ 8, 286 P.3d 301; Prince v. Bear River Mut. Ins. Co.,
2002 UT 68, ¶¶ 25-29, 33-36, 56 P.3d 524; Billings v. Union Bankers Ins. Co., 918 P.2d 461, 466-69 (Utah 1996);
Beck v. Farmers Ins. Exchange, 701 P.2d 795, 800-02 (Utah 1985); see also Borandi v. USAA Cas. Ins. Co., 2014
WL 7369891, *4 (D. Utah 2014) (relying on Jones, 2012 UT 52).
381

Blakely, 633 F.3d at 947.
54

evaluate the claim, and will thereafter act promptly and reasonably in rejecting or settling the
claim.” 382 Therefore, Hartford’s arguments relating to these principles lack merit and are not
relevant Williams’s allegations that Hartford breached the express terms of the Plan and Group
Policy by denying her claim for LTD benefits.
The law relevant to the breach of a contract’s express terms governs Williams’s claim
against Hartford. Under Utah law, “[t]he elements of a prima facie case for breach of [the express
terms of a] contract are (1) a contract, (2) performance by the party seeking recovery, (3) breach
of the contract by the other party, and (4) damages.” 383 These elements are addressed in turn with
respect to Williams’s claim against Hartford.
Hartford has a contractual duty to pay LTD benefits to Williams
The record evidence demonstrates, and there is no dispute among the parties, that a
contract existed between Williams and Hartford. Williams was employed by the Sevier School
District in Richfield, Utah as a Third Grade teacher until March 2011. 384 At all relevant times,
the Utah School Boards Association had a Plan and Group Policy issued by Hartford in order to
fund the Plan’s LTD benefits. 385 The Plan and the Group Policy provide LTD benefits to eligible
employees of the Utah School Boards Association, including the Sevier School District. 386
Therefore, as an employee of the Sevier School District, Williams was a participant in the Plan
and covered by the Group Policy issued by Hartford. 387

382

Id. at 948; Prince, 2002 UT 68, ¶¶ 27-29, 33-36; Morris v. Health Net of California, Inc., 1999 UT 95, ¶ 7, 988
P.2d 940; Beck, 701 P.2d at 800-01.
383

Bair v. Axiom Design, LLC, 2001 UT 20, ¶ 14, 20 P.3d 388.

384

Administrative Record at 1195, 1197, docket no. 14-12, filed Mar. 5, 2015.

385

Id. at 1-48, docket no. 14-1.

386

Id. at 6, docket no. 14-1.

387

Id. at 1-48, docket no. 14-1, 1195, 1197, docket no. 14-12.
55

The Plan and Group Policy govern the “[f]inal interpretation of all provisions and
coverages.” 388 LTD benefits are payable under the terms of the Plan and Group Policy when:
1. [The participant] become[s] Disabled while insured under th[e] Plan;
2. [The participant is] disabled throughout the Elimination Period;
3. [The participant] remain[s] Disabled [90 days] beyond the Elimination
Period;
4. [The participant is], and ha[s] been during the elimination Period, under
the Regular Care of a Physician; and
5. [The participant] submit[s] Proof of Loss satisfactory to [Hartford]. 389
The Plan and Group Policy, however, excludes coverage for “a Disability that is due to,
contributed to by, or results from a Pre-existing Condition[.]” 390 Coverage is also excluded if the
participant is receiving or eligible for benefits for a Disability under a prior disability plan. 391
And no benefits are paid under the Plan for any Disability:
1. unless [the participant is] under the Regular Care of a Physician;
2. that is caused or contributed to by act of war (declared or not);
3. caused by [the participant’s] commission of or attempt to commit a felony, or to
which a contributing cause was [the participant] being engaged in an illegal
occupation; or
4. caused or contributed to by an intentionally self inflicted injury. 392
LTD benefits terminate on the date the participant is “no longer Disabled as defined” by the
Plan. 393
Therefore, Hartford owes Williams a contractual duty to pay LTD benefits to her if she
has a qualifying Disability that is not excluded from coverage, became Disabled while insured
under the Plan and Group Policy, remains Disabled, was and is under the Regular Care of a

388

Id. at 6, docket no. 14-1.

389

Id. at 10, docket no. 14-1.

390

Id. at 19, docket no. 14-1.

391

Id. at 21, docket no. 14-1.

392

Id.

393

Id. at 11, docket no. 14-1.
56

Physician, and has provided Hartford with satisfactory Proof of Loss. 394 Accordingly, the first
element of Williams’s breach of contract claim against Hartford is satisfied.
Williams performed her duties under the Plan and Group Policy
Williams properly applied for LTD benefits
Williams’s duties under the Plan and Group Policy required her to give Hartford or its
authorized agent “written notice a [her] claim within 30 days after [her] Disability start[ed,]” or
as soon as possible if the notice could not be given within that time. 395 Williams’s notice was
required to include her name, address, and the Group Policy number. 396 The record evidence
undisputedly establishes that Williams submitted a written application for LTD benefits under the
Plan and Group Policy following her last day of work for the Sevier School District. 397
Williams’s application asserted that her last day of work before the disability was
March 18, 2011, 398 and alleged that her disability was based on “[p]ain and limited mobility in
[her] right hip & leg – lower back pain.” 399 Hartford received the application on July 6, 2011. 400
The application contained all the information about Williams, Williams’s employer, and
Williams’s treating physicians required by the Plan and Group Policy. 401 Therefore, Williams
complied with her duty to apply for LTD benefits.

394

Id. at 6, 10, 13, 19, 21, docket no. 14-1.

395

Id. at 23, docket no. 14-1.

396

Id.

397

Id. at 1195-1210, docket no. 14-12 and docket no. 14-13.

398

Id. at 1198, docket no. 14-12.

399

Id. at 1197, docket no. 14-12.

400

Id. at 188 (July 6, 2011), docket no. 14-2.

401

Id. at 1195-1210, docket no. 14-12 and docket no. 14-13.
57

Williams provided Hartford with timely and satisfactory Proof of Loss
The Plan and Group Policy required Williams to provide timely and satisfactory Proof of
Loss to Hartford. 402 Proof of Loss consists of forms provided by Hartford and “any other written
proof which fully describes the nature and extent of [a] claim.” 403 Proof of Loss includes, but is
not limited to:
1. documentation of:
a) the date [the] Disability began;
b) the cause of [the] Disability;
c) the prognosis of [the] Disability;
d) [the claimant’s] Earnings or income, including but not limited to
copies of [the claimant’s] filed and signed federal and state tax
returns; and
e) evidence that [the claimant is] 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:
a) Physicians and practitioners of healing arts [the claimant has] seen
or consulted;
b) hospitals or other medical facilities in which [the claimant has]
been seen or treated; and
c) pharmacies which have filled [the claimant’s] prescriptions within
the past three years;
4. [the claimant’s] signed authorization for [Hartford] to obtain and release:
a) medical, employment and financial information; and
b) any other information [Hartford] may reasonably require;
5. [the claimant’s] signed statement identifying all Other Income Benefits;
and
6. proof that [the claimant] and [the claimant’s] dependents have applied for
all Other Income Benefits which are available. 404

402

Id. at 24-25, docket no. 14-1.

403

Id. at 24, docket no. 14-1.

404

Id.
58

Williams was also required to provide additional Proof of Loss at the request of Hartford
throughout her Disability, including her attendance and participation in additional
examinations. 405
The record evidence demonstrates that Williams provided Hartford with written Proof of
Loss satisfying the Plan’s “Proof of Loss” definition. Williams’s family doctor, Dr. Inouye,
completed an APS dated April 25, 2011, that was provided to Hartford with Williams’s
application for LTD benefits. 406 Williams’s orthopedist, Dr. Colledge, completed an APS dated
May 5, 2011, that was also provided to Hartford with Williams’s application. 407 Based on the
information within Williams’s application for LTD benefits and the APS of her medical
providers, Hartford initially approved Williams for LTD benefits through May 2012. 408
In furtherance of her Proof of Loss, Williams participated in a telephonic interview with
Harford’s Rehabilitation Case Manager on September 7, 2011. 409 Williams also participated in
telephonic interviews with Hartford’s Ability Analyst on September 22, 2011, 410 November 18,
2011, 411 and December 22, 2011. 412 Dr. Inouye provided Hartford with a second APS dated
December 2, 2011, 413 and follow-up information on January 11, 2012. 414 In late January 2012,
Williams further provided Hartford with the contact information for her endocrinologist, Dr.

405

Id. at 25, docket no. 14-1.

406

Id. at 1203-06, docket no. 14-13.

407

Id. at 1209-10, docket no. 14-13.

408

Id. at 187 (July 15, 2011), docket no. 12-2, 345-47, docket no. 14-4.

409

Id. at 183-84 (Sept. 7, 2011 3:54:31 p.m.), docket no. 14-2.

410

Id. at 181-82 (Sept. 22, 2011), docket no. 14-2.

411

Id. at 179-80 (Nov. 18, 2011), docket no. 14-2.

412

Id. at 174-75 (Dec. 22, 2011), docket no. 14-2.

413

Id. at 1238-39, docket no. 14-13.

414

Id. at 1146-70, docket no. 14-12.
59

Maturlo, and orthopedist, Dr. Jackson, following Hartford’s request for additional information. 415
Williams also participated in an interview with Hartford’s Field Investigator on April 19,
2012, 416 and provided follow-up information by letter dated April 25, 2012. 417 Williams further
provided Hartford with a third APS prepared by Dr. Inouye on April 27, 2012. 418 Dr. Jackson
provided Hartford with Williams’s updated medical records on September 11, 2012. 419 Williams
also provided Hartford with proof that she had applied for and received an award of SSDI
benefits from the SSA. 420 Williams’s medical providers were also made available to speak with
third party vendors performing peer reviews of Williams’s medical records for Hartford. 421
Additionally, Williams participated in telephonic interviews with Hartford’s Ability
Analyst on December 21, 2012, April 30, 2013, May 1, 2013, and May 9, 2013. 422 Ultimately,
Williams continued to assist Hartford in obtaining additional information from Dr. Inouye, Dr.
Jackson, and Dr. Richey until the denial of her claim. 423
Based on the additional Proof of Loss Williams provided, Hartford extended the payment
of LTD benefits to Williams through June 16, 2013. 424 Hartford’s initial approval of LTD
benefits for Williams and its extension of payment of LTD benefits to Williams demonstrate that

415

Id. at 169 (Jan. 27, 2012 4:30:41 p.m.; Jan. 27, 2012 5:17:50 p.m.; Jan. 31, 2012 6:06:07 p.m.), docket no. 14-2.

416

Id. at 1229-35 (Mr. Morrell’s report), 1250-91 (transcript of interview), docket no. 14-13.

417

Id. at 1008-09, docket no. 14-11.

418

Id. at 999-1001, docket no. 14-10 and docket no. 14-11.

419

Id. at 137 (Sept. 11, 2012 10:20:20 a.m.; Sept. 11, 2012 1:07:32 p.m.), docket no. 14-2.

420

Id. at 85 (Apr. 30, 2013 11:09:02 a.m.), docket no. 14-1, 872-76, docket no. 14-9.

421

Id. at 576, docket no. 14-6, 865-66, docket no. 14-9.

422

Id. at 79-80 (May 9, 2013 2:57:10 p.m.), 83-84 (May 1, 2013 2:25:25 p.m.), 85 (Apr. 30, 2013 11:06:10 a.m.),
docket no. 14-1, 121 (Dec. 21, 2012 4:29:35 p.m.), docket no. 14-2.
423

Id. at 77-78 (May 15, 2013 12:59:27 p.m.), 83-84 (May 1, 2013 2:25:25 p.m.), docket no. 14-1, 199-204, docket
no. 14-2 and docket no. 14-3, 561-64, docket no. 14-6.
424

Id. at 191, docket no. 12-2.
60

Williams’s Proof of Loss was timely and satisfactory to Hartford. There is no evidence
suggesting that Williams failed to provide any of the necessary documentation regarding her
disability claim, or that Williams failed to timely comply with any of Hartford’s requests for
additional Proof of Loss throughout the claims process. Indeed, Hartford’s denial of Williams’s
claim was not due to her failure to provide satisfactory Proof of Loss, but rather its determination
that “the medical information does not establish that [Williams] remained Disabled from
performing [A]ny [O]ccupation as defined by the [Plan and Group P]olicy.” 425
Hartford nevertheless argues that Williams failed to provide satisfactory Proof of Loss. 426
Hartford premises its argument on its reading of the Plan’s definition of “Proof of Loss,” which
requires that “[a]ll proof submitted must be satisfactory to [Hartford].” 427 In Hartford’s view,
Proof of Loss is only satisfactory when Hartford determines that a claimant is entitled to LTD
benefits. 428 In other words, Hartford’s view attempts to wrap the merits of Williams’s contract
claim into the Proof of Loss requirement. Hartford then maintains that because it diligently
investigated Williams’s claim and because its denial of the claim was reasonable, Williams failed
to provide sufficient satisfactory Proof of Loss. 429
Hartford’s reading of the Plan, however, ignores the plain language of the Plan’s
definition of “Proof of Loss.” The proper construction of the “Proof of Loss” definition is that
the requirement is one of technical compliance through the submission of sufficient paperwork

425

Id. at 192, docket no. 12-2.

426

Hartford’s Motion at 3, 24-31, docket no. 1, filed Mar. 31, 2015; Hartford’s Response at 4-6, 12, docket no. 19,
filed May 1, 2015.
427

Administrative Record at 24, docket no. 14-1, filed Mar. 5, 2015.

428

Hartford’s Motion at 24-31, docket no. 17, filed Mar. 31, 2015; Hartford’s Response at 4-6, 12, docket no. 19,
filed May 1, 2015.
429

Hartford’s Motion at 24-31, docket no. 17, filed Mar. 31, 2015; Hartford’s Response at 4-6, 12, docket no. 19,
filed May 1, 2015.
61

and information to permit Hartford to render a determination on a claim. 430 The “Proof of Loss”
definition does not render a claim insufficient based on Hartford’s determination that a claimant
does not have a Disability. The plain language of the “Proof of Loss” definition refers to the
submission of information on forms provided by Hartford and other documentation
demonstrating the basis for the claim and the cause of the claimed Disability. 431 In context, that
Proof of Loss must be “satisfactory” to Hartford means that the information submitted to
Hartford must be sufficient to enable Hartford to make a determination on a claim, and that
Hartford may request additional documentation, information, and examinations to make its
determination. 432 The ultimate successful outcome of the claim is determined by the Plan and
Group Policy’s terms of coverage and facts demonstrating a claimed Disability, not the Proof of
Loss alone. Therefore, the Proof of Loss requirement is one of form, as opposed to a grant of
discretion and deference to Hartford and its decision to approve or deny LTD benefits. 433
This reading of the Plan and Group Policy’s Proof of Loss requirement is support by the
general principle that “[i]f a policy stipulates that ‘satisfactory proof’ shall be furnished, the
insurer cannot demand proof other than what is reasonable and just, and ordinarily such a
provision will be considered complied with when there has be furnished such proof as establishes
the fact of the loss and of the right of the claimant to recover.” 434 “An insurer has ‘satisfactory

430

Administrative Record at 24, docket no. 14-1, filed Mar. 5, 2015.

431

Id.

432

Id. at 24-25, docket no. 14-1.

433

Id.

434

13 Couch on Ins. § 189:59 (3d ed. Dec. 2016 Update) (citing Prudential Ins. Co. of America v. Litzke, 36 Del.
592, 179 A. 492 (Super. Ct. 1934); Barrett v. Northwestern Mut. Life Ins. Co., 124 Neb. 864, 248 N.W. 391 (1933)).
62

proof of loss,’ where proof is sufficient to fully apprise [the] insurer of [the] insured’s claim.” 435
This reading is also supported by Tenth Circuit precedent recognizing that “[a]s a general rule, a
proof of loss requirement is valid and may be considered as a condition precedent to recovery[,]”
but is a “technical policy requirement[.]” 436
It is true that the Tenth Circuit has also interpreted nearly identical language to the
language within Plan’s “Proof of Loss” definition as conveying discretion to a plan administrator
in finding the facts relating to disability. 437 However, this interpretation was made in the context
of a plan governed by ERISA, where the Tenth Circuit “[has] been comparatively liberal in
construing language to trigger the more deferential standard of review under ERISA.” 438 The
Plan and Group Policy in this case is not governed by ERISA. 439 Rather, Williams’s claim is for
breach of the express terms of the Plan and Group Policy, 440 and the interpretation of the Plan
and Group Policy is guided by general principles relating to the interpretation of insurance
contracts. 441 “Because ‘an insurance policy is a classic example of an adhesion contract,’ Utah
courts have long held that ‘insurance policies should be construed liberally in favor of the
insured and their beneficiaries so as to promote and not defeat the purpose of insurance.’” 442
Therefore, the liberal interpretation of a plan to afford insurer deference that applies in ERISA

435

Id. (citing Fontana v. Louisiana Sheriffs’ Auto. Risk Program, 697 So.2d 1037 (La. Ct. App. 1st Cir. 1997);
Griswold Properties, LLC v. Lexington Ins. Co., 275 Mich. App. 543, 740 N.W.2d 659 (2007), opinion reinstated in
part, superseded in part on other grounds, 276 Mich. App. 551, 741 N.W.2d 549 (2007)).
436

Connecticut Fire Ins. Co. v. Fox, 361 F.2d 1, 6 (10th Cir. 1966).

437

Nance v. Sun Life Assur. Co. of Canada, 294 F.3d 1263, 1268 (10th Cir. 2002).

438

Id.

439

Complaint ¶ 2, docket no. 2-2, filed Apr. 23, 2014 (citing 29 U.S.C. § 1003(b)(1)), Hartford’s Answer ¶ 2, docket
no. 5, filed Apr. 30, 2014
440

Complaint, docket no. 2-2, filed Apr. 23, 2014.

441

Fire Ins. Exch. v. Oltmanns, 2012 UT App 230, ¶ 6, 285 P.3d 802.

442

Id. (quoting United States Fidelity & Guar. Co. v. Sandt, 854 P.2d 519, 521-22 (Utah 1993)).
63

cases is contrary to the guiding policies that apply to the interpretation of the Plan and Group
Policy in this case.
Additionally, Hartford’s reading of the “Proof of Loss” definition attempts to shift the
analysis of Williams’s claim into principles of law governing a breach of the covenant of good
faith and fair dealing. 443 These principles are not relevant to Williams’s claim for a breach of the
Plan and Group Policy’s express terms. 444 If Hartford’s reading of the “Proof of Loss” definition
were correct, there would be no distinction between a claim for breach of the contract’s express
terms and a claim for beach of the covenant of good faith and fair dealing. This reading would
create an identity of issues under each type of claim. The issues for both claims would be
whether Hartford diligently investigated the claim and made a prompt and reasonable
determination as to coverage. Under Hartford’s analysis, it would not matter whether Hartford’s
decision ultimately violated the express terms of the Plan and Group Policy by incorrectly
denying LTD benefits despite the claimant having a covered Disability. This analysis and result
would defeat Williams’s contractual rights and be contrary to the recognition of two distinct
claims under contract: breach of the contract’s express terms, and breach of the covenant of good
faith and fair dealing. 445 Hartford’s reading may also conflict with Utah’s administrative rule
“prohibit[ing] the use of reservation of discretion clauses in forms that are not associated with
ERISA employee benefit plans.” 446

443

Hartford’s Motion at 24-31, docket no. 17, filed Mar. 31, 2015; Hartford’s Response at 4-6, 12, docket no. 19,
filed May 1, 2015.
444

Supra at 54-55.

445

Blakely, 633 F.3d at 947; Machan, 2005 UT 37, ¶¶ 17-21.

446

Utah Admin. Code R590-218.
64

Therefore, in accordance with the Plan and Group Policy’s plain language 447 and general
principles of insurance contract interpretation, 448 Williams’s requirement to provide Hartford
with timely and satisfactory Proof of Loss is one of form, as opposed to a grant of discretion and
deference to Hartford and its decision to approve or deny LTD benefits. Moreover, based on the
information and documentation Williams provided to Hartford and her participation with and
responses to Hartford’s requests for additional Proof of Loss, Williams complied with her duty to
provide Hartford with timely and satisfactory Proof of Loss.
Williams was and is under the Regular Care of a Physician
To receive LTD benefits under the Plan and Group Policy, Williams was required to be
under the Regular Care of a Physician. 449 The Plan defines “Regular Care of a Physician” as:
[The participant is] attended by a Physician, who is not related to [the participant]:
1. with medical training and clinical experience suitable to treat [the
participant’s] disabling condition; and
2. whose treatment is:
a) consistent with the diagnosis of the disabling condition;
b) according to guidelines established by medical, research and
rehabilitative organizations; and
c) administered as often as needed,
to achieve the maximum medical improvement. 450
The parties do not dispute that at all relevant times, Williams was under the Regular Care
of a Physician. There is no evidence in the record that Williams failed to be under the Regular
Care of a Physician. Rather, the record evidence reflects that Williams regularly visited multiple
physicians to receive treatment for her various medical conditions, and that Williams’s

447

Administrative Record at 24-25, docket no. 14-1.

448

Fire Ins. Exch. v. Oltmanns, 2012 UT App 230, ¶ 6, 285 P.3d 802.

449

Administrative Record at 10, 21, docket no. 14-1, filed Mar. 5, 2015.

450

Id. at 34, docket no. 14-1.
65

physicians prepared multiple APS that were provided to Hartford. 451 Therefore, Williams
complied with her duty to be under the Regular Care of a Physician.
Hartford breached its contractual duty to Williams by denying her claim for LTD benefits
Hartford owes Williams a contractual duty to pay LTD benefits to Williams if she has a
qualifying Disability that is not excluded from coverage; became Disabled while insured under
the Plan and Group Policy; remains Disabled; was and is under the Regular Care of a Physician;
and provided Hartford with satisfactory Proof of Loss. 452 It has already been determined that
Williams was and is under the Regular Care of a Physician, 453 and that she timely provided
Hartford with satisfactory Proof of Loss. 454 Therefore, whether Hartford breached its contractual
duty to pay LTD benefits to Williams turns on whether Williams has a qualifying Disability that
is not excluded from coverage; became Disabled while insured under the Plan and Group Policy;
and remains Disabled.
Williams has a qualifying Disability that is not excluded from coverage and became
Disabled while insured under the Plan and Group Policy
For purposes of an initial approval of LTD benefits payments, the Plan defines
“Disability” or “Disabled” as:
[D]uring the Elimination Period and for the next 24 months, [the participant is]
prevented by:
1. accidental bodily injury;
2. sickness;
3. Mental Illness;
4. Substance Abuse; or
5. pregnancy,

451

Id. at 999-1001, docket no. 14-10 and docket no. 14-11, 1202-10, 1238-39, docket no. 14-13.

452

Supra at 55-57.

453

Supra at 65-66.

454

Supra at 58-65.
66

from performing one or more of the Essential duties of [the participant’s own]
Occupation, and as a result [the participant’s] Current Monthly Earnings are no
more than 80% of [the participant’s] Indexed Pre-disability Earnings. 455
“Essential Duty” is defined under the Plan as:
[A] duty that:
1. is substantial, not incidental;
2. is fundamental or inherent to the occupation; and
3. can not be reasonably omitted or changed. 456
“To be at work for the number of hours in [the participant’s] regularly scheduled workweek is
also an Essential Duty.” 457
The Plan and Group Policy exclude coverage for “a Disability that is due to, contributed
to by, or results from a Pre-existing Condition[.]” 458 Coverage is also excluded if the participant
is receiving or eligible for benefits for a Disability under a prior disability plan, as well as for any
Disability:
1. unless [the participant is] under the Regular Care of a Physician;
2. that is caused or contributed to by act of war (declared or not);
3. caused by [the participant’s] commission of or attempt to commit a felony, or to
which a contributing cause was [the participant] being engaged in an illegal
occupation; or
4. caused or contributed to by an intentionally self inflicted injury. 459
LTD benefits terminate on the date the participant is “no longer Disabled as defined” by the
Plan. 460

455

Administrative Record at 29, docket no. 14-1, filed Mar. 5, 2015.

456

Id.

457

Id.

458

Id. at 19, docket no. 14-1.

459

Id. at 21, docket no. 14-1.

460

Id. at 11, docket no. 14-1.
67

Williams applied for LTD benefits alleging disability from “[p]ain and limited mobility in
[her] right hip & leg – lower back pain” beginning in March 2011. 461 Williams’s family doctor,
Dr. Inouye, made a primary diagnosis of osteoarthritis of the right hip with a secondary diagnosis
of hyperthyroidism. 462 Williams’s orthopedist, Dr. Colledge, made a primary diagnosis of
degenerative disk disease and osteoarthritis in the hip with a secondary diagnosis of
hypothyroidism. 463 Williams’s doctors indicated that she could not engage in prolonged sitting,
standing, and bending. 464
There is no dispute that Williams became Disabled, as defined by the Plan, while insured
under the Plan and Group Policy. There is also no dispute that Williams’s Disability, including
her diagnosis of fibromyalgia, does not fall within the exclusions to coverage identified in the
Plan and Group Policy. And there is no dispute that Williams’s Disability qualified her for LTD
benefit payments throughout the Elimination Period and the next 24 months due to the
restrictions and limitations caused by her Disability, which prevented her from performing one or
more of the Essential Duties of her Occupation. The record evidence undisputedly establishes
this by the fact that Hartford initially approved the payment of LTD benefits to Williams through
May 2012. 465 Moreover, based on the Proof of Loss Williams provided to Hartford, which
included her diagnosis of fibromyalgia, Hartford continued paying LTD benefits to Williams
through June 16, 2013. 466

461

Id. at 1197-98, docket no. 14-12.

462

Id. at 1203, docket no. 14-13.

463

Id. at 1209, docket no. 14-13.

464

Id. at 1205, 1210, docket no. 14-13.

465

Id. at 187 (July 15, 2011), docket no. 14-2, 345-47, docket no. 14-4.

466

Id. at 191, docket no. 14-2.
68

Indeed, Hartford’s basis for denying William’s claim for LTD benefits was not that
Williams did not become Disabled while insured under the Plan and Group Policy or that her
disability fell within an exclusion to coverage. 467 Rather, Hartford based its denial of Williams’s
claim for LTD benefits on its determination that “the medical information does not establish that
[she] remained Disabled from performing [A]ny [O]ccupation as defined by the [Plan and Group
P]olicy.” 468 Therefore, whether Hartford breached the express terms of the Plan and Group
Policy rests on whether Williams remained Disabled beyond of the effective date of the Plan and
Group Policy’s Any Occupation provision.
Williams remained Disabled beyond of the effective date of the Plan and Group Policy’s
Any Occupation provision
The Any Occupation provision of the Plan’s definition of “Disability” or Disabled” is
triggered after 24 months following the Elimination Period. 469 The Any Occupation provision
provides that to remain Disabled “[the participant] must be so prevented from performing one or
more of the Essential Duties of Any Occupation.” 470 “Any Occupation” is defined as:
[A]n occupation for which [the participant is] qualified by education, training or
experience, and that has an earnings potential greater than an amount equal to the
lesser of the product of [the participant’s] Indexed Pre-disability Earnings and the
Benefit Percentage and the Maximum Monthly Benefit shown in the Schedule of
Insurance. 471
Importantly, the Plan’s definition of “Essential Duty” includes “[t]o be at work for the number of
hours in [the participant’s] regularly scheduled workweek[.]” 472

467

Id. at 192, docket no. 14-2.

468

Id.

469

Id. at 29, docket no. 14-1.

470

Id.

471

Id. at 28, docket no. 14-1.

472

Id. at 29, docket no. 14-1.
69

Hartford initially denied William’s claim for LTD benefits on June 13, 2013. 473 Hartford
stated that it based its decision on “[a]ll the documents contained in [Williams’s] file … viewed
as a whole.” 474 However, in discussing the basis for its decision, Harford relied on the fact that:
[Dr. Ayyar’s] review of [Williams’s] claim indicates that restrictions and
limitations are not supported beyond [June 6, 2013]. This means that [Williams is]
not Disabled from [her own] Occupation effective [June 12, 2013] and will not be
Disabled from Any Occupation as of [June 17, 2013]. [Williams is] not precluded
from performing the Essential Duties of [her own] Occupation as an Elementary
School Teacher. 475
Hartford further discussed that “ [Ms. Shelton’s] Employability Analysis … showed that there
are a number of occupations for which [Williams is] qualified that are within [her] physical
capabilities.” 476 Ms. Shelton based this conclusion on the restrictions and limitations identified
by Dr. Ayyar:
Sit unlimited; stand/walk no more than 15 minutes continuously for total of 30
cumulative minutes per hour, maximum of 4 cumulative hours per day; lift up
to 25 [pounds] up to 3 cumulative [hours] per day, up to 26 [pounds] or more up
to 30 cumulative minutes per day; occasionally kneel, squat, bend or stoop
maximum of 2 [hours] per day; activity not formally limited above should be
considered unlimited. Ms. Williams is able to perform Sedentary demands 8 hours
per day, 40 hours per week. There is no evidence to support cognitive and/or
mental restrictions. 477
Ms. Shelton identified the following occupations as a “representative sample” of the occupations
that Williams could perform: Teacher, Elementary School; Teacher, Mentally Impaired; Teacher,
Vocational Training; Teacher, Learning Disabled; and Jacket Preparer. 478 Hartford concluded that
based on this information:

473

Id. at 199-205, docket no. 14-2 and docket no. 14-3.

474

Id. at 202, docket no. 14-3.

475

Id. at 204, docket no. 14-3.

476

Id.

477

Id. at 444, 465, docket no. 14-5.

478

Id. at 445-46, docket no. 14-5.
70

[Williams is] not prevented from performing the essential duties of Any
Occupation. Because of this, [Williams] will not meet the policy definition of
Disability as of [June 12, 2013], and [her] LTD benefits will terminate on that
date. 479
After Williams appealed the denial of her claim for LTD benefits, Hartford referred her
file to Dr. Rea to perform an independent peer review. 480 In his report, Dr. Rea stated:
While fibromyalgia does not stand as an objective clinical entity (upon which
impairment and resultant physical limitations can be based) and the degenerative
low back spinal condition is not objectively significant, there is a more solid,
objective underpinning for impairment stemming from advanced-level right hip
osteoarthritis. 481
Therefore, based solely on Williams’s “hip involvement,” Dr. Rea concluded that Williams was
capable of full-time work with the following limitations and restrictions:
•
•
•
•
•
•
•
•

Lifting/pulling/pushing/carrying to up to 10 pounds on an occasional basis.
Sitting for up to 30 minutes at a time for up to 6 hours of sitting over an 8-hour
day.
Walking/standing for up to 15 minutes at a time, for up to 2 hours of
walking/standing over an 8-hour day.
Kneeling on an occasional basis.
No squatting, crawling, crouching, and climbing.
Bending on a rare basis.
There would be no limitations on reaching.
There would be no limitations for hand usage, such as
fingering/handling/grasping/gripping. 482

Hartford denied Williams’s appeal on January 13, 2014. 483 Hartford again stated that it
“based [its] decision to deny benefits on policy language and all of the documents contained in
the claim file, viewed as a whole.” 484 Hartford indicated that “[i]n determining the claim, [it]

479

Id. at 204, docket no. 14-3.

480

Id. at 354-61, docket no. 14-4.

481

Id. at 358, docket no. 14-4.

482

Id.

483

Id. at 190-92, docket no. 14-2.

484

Id. at 190, docket no. 14-2.
71

carefully considered all relevant medical, vocational, and other evidence, including any SSA
determinations or materials provided to [Hartford].” 485 Nevertheless, in discussing the basis for
the denial, Hartford restated Dr. Rea’s assessment and conclusions of Williams’s restrictions and
limitations, as well as the assessment and conclusions of Dr. Ayyar. 486 Hartford recognized Dr.
Inouye’s conclusion that Williams [is unable in any way to continue to work as a teacher, [and] is
currently disabled[,]” and that Williams had “attended an functional capacit[y] evaluation which
concluded she is not capable of performing any level of work.” 487 However, despite the
conflicting assessments of Williams’s functionality, Hartford concluded that:
[T]he weight of the information in [Williams’s] file viewed as a whole supports
that [she] is medically capable of performing at least full time sedentary work
within the … limitations [identified by Dr. Rea,] and that she is vocationally
employable at that work level. 488
This was Hartford’s “final determination” on Williams’s claim for LTD benefits. 489
Ultimately, while Hartford may have viewed all of the information in Williams’s file as a
whole, its denial of her claim for LTD benefits was based its acceptance of the restrictions and
limitations identified by Dr. Ayyar and Dr. Rea, and the conclusions of Ms. Shelton’s
Employability Analysis. 490 But Dr. Ayyar, Dr. Rea, and Ms. Shelton never personally examined
Williams. 491 Moreover, none of them accounted for restrictions and limitations based on
Williams’s fibromyalgia diagnosis. 492

485

Id. at 191, docket no. 14-2.

486

Id.

487

Id.

488

Id. at 192, docket no. 14-2.

489

Id.

490

Id. at 190-92; 199-205, docket no. 14-2 and docket no. 14-3.

491

Id. at 66, docket no. 14-1, 354-61, docket no. 14-4, 462-66, docket no. 14-5.

492

Id.
72

The Tenth Circuit Court of Appeals has recognized that “‘fibromyalgia presents a
conundrum for insurers and courts evaluating disability claims.’” 493 This is because:
‘[fibromyalgia’s] cause or causes are unknown, there is no cure, and of greatest
importance to disability law, its symptoms are entirely subjective. There are no
laboratory tests for the presence or severity of fibromyalgia. The principal
symptoms are ‘pain all over,’ fatigue, disturbed sleep, stiffness, and—the only
symptom that discriminates between it and other diseases of a rheumatic
character—multiple tender spots, more precisely 18 fixed locations on the body
(and the rule of thumb is that the patient must have at least 11 of them to be
diagnosed as having fibromyalgia) that when pressed firmly cause the patient to
flinch.’ 494
Because fibromyalgia’s symptoms are subjective, it naturally follows that the best evidence of
whether an individual’s fibromyalgia is disabling comes from a personal examination of the
individual, including validity testing.
In this case, the best and most credible evidence of Williams’s actual restrictions and
limitations cause by fibromyalgia comes from Dr. Inouye and the Functional Capacity
Evaluation that Williams voluntarily attended. Dr. Inouye explained that he had been treating
Williams for 20 years, and that her health had declined over the past two years. 495 Dr. Inouye
mapped 17 of 18 positive trigger points on Williams consistent with a diagnosis of
fibromyalgia. 496 Throughout the relevant timeframe, Dr. Inouye consistently reported Williams
as having worsening pain and fatigue due to fibromyalgia. 497 Dr. Inouye stated that Williams’s
degree of functionality “depends on [the] day[.]” 498 Dr. Inouye further reported that Williams

493

Welch v. Unum Life Ins. Co. of America, 382 F.3d 1078, 1087 (10th Cir. 2004) (quoting Walker v. American Home
Shield Long Term Disability Plan, 180 F.3d 1065, 1067 (9th Cir. 1999)).
494

Gilbert v. Astrue, 231 Fed. Appx. 778, 783 (10th Cir. 2007) (quoting Sarchet v. Chater, 78 F.3d 305, 306 (7th
Cir. 1996).

495

Administrative Record at 550, docket no. 14-6, filed Mar. 5, 2015.

496

Id. at 680, docket no. 14-7.

497

See e.g. id. at 381, docket no. 14-4, 524, docket no. 14-6, 675, docket no. 14-7.

498

Id. at 1000, docket no. 14-10.
73

“has never been a malingerer in [his] extensive association with her[.]” 499 In his most recent
APS, Dr. Inouye opined that Williams could only sit for a total of 2-3 hours per workday, stand
for a total of 1 hour per workday, and walk for a total of 1 hour per workday. 500 These
restrictions and limitations would effectively allow Williams to work a maximum of
approximately 4-5 hours per day. 501 Therefore, Dr. Inouye’s assessment of Williams’s
functionality, including restrictions and limitations based on her fibromyalgia diagnosis, was that
she “is disabled currently[, and] cannot in any way continue to work as a [full-time] teacher.” 502
Dr. Inouye’s assessment of Williams’s functionality is supported by the results of
Williams’s Functional Capacity Evaluation, which took into account her fibromyalgia diagnosis
and included validity testing. 503 The evaluator, Mr. Rosello, reported that Williams “[a]ppeared
to give full volitional effort” during the testing, as objectified through validity testing. 504 Mr.
Rosello noted that “[a]fter 5 minutes rest, [Williams’s] ending heart rate was 123 beats per
minute and 96% O2 saturation[, with a p]ain level [of] 7/10 in her right hip, back, shoulders and
feet.” 505 Based on the testing results, Mr. Rosello concluded that “[Williams] does not appear
capable of performing work, even in the sedentary category, secondary to deconditioning,
increasing pain and muscle weakness.” 506

499

Id. at 550, docket no. 14-6 (emphasis omitted).

500

Id. at 709, docket no. 14-8.

501

Id.

502

Id. at 550, docket no. 14-6 (emphasis omitted).

503

Id. at 371-80, docket no. 14-4.

504

Id. at 380, docket no. 14-4.

505

Id.

506

Id.
74

The assessments of Dr. Inouye and Mr. Rosello, which come from in person examination
and account for Williams’s fibromyalgia diagnosis, 507 provide the most accurate and complete
picture of Williams’s functionality. Hartford’s decision to reject these assessments and, instead,
rely on the peer review assessments of Dr. Ayyar and Dr. Rea, and Ms. Shelton Employability
Analysis was improper given the nature of fibromyalgia and the record evidence.
The record evidence reveals that Hartford’s Ability Analysts and MCMs repeatedly stated
that additional medical information was necessary to accurately determine Williams’s restrictions
and limitations, and recommended that the most appropriate step to confirm Williams’s
functionality would be requiring her participation in an IME. 508 However, Hartford chose to
forgo an IME based on its belief that the IME providers were located too far away from
Williams’s home. 509 This rational makes little sense in light of Hartford’s denial of Williams’s
claim for LTD benefits—Hartford determined that Williams was not healthy enough to travel
approximately 100 miles to attend an IME, 510 but nevertheless concluded that she is capable of
full-time employment in her own occupation as a teacher, 511 or at least full-time sedentary
work. 512
Moreover, while Hartford received information from Williams’s other physicians,
specifically Dr. Richey and Dr. Jackson, which support its determination that Williams is capable

507

Id. at 380, docket no. 14-4, 550, docket no. 14-6, 680, docket no. 14-7, 709, docket no. 14-8, 1000, docket no. 1410.
508

See e.g. id. at 94, (Mar. 19, 2013 12:27:55 p.m.), 100 (Feb. 28, 2013 3:12:55 p.m.), docket no. 14-1, 108 (Feb. 21,
2013), 112 (Jan. 30, 2013), 119 (Jan. 4, 2013 2:03:31 p.m.), 130 (Oct. 10, 2012), 142 (Aug. 9, 2012 8:58:38 a.m.),
170 (Jan. 24, 2012 3:00:25 p.m.), 179 (Nov. 18, 2011 12:50:26 p.m.; Nov. 21, 2011), docket no. 14-2.
509

Id. at 129 (Oct. 11, 2012 10:14:08 p.m.), 130 (Oct. 11, 2012 9:54:03 p.m.), docket no. 14-2.

510

Id.

511

Id. at 204, docket no. 14-3.

512

Id. at 192, docket no. 14-2.
75

of at least full-time sedentary work, 513 these opinions did not account for restrictions and
limitations caused by fibromyalgia. 514 The restrictions and limitations identified by Dr. Richey
related only to Williams’s lumbar spine impairment. 515 And Dr. Jackson’s opinions related only
to Williams’s hip issues. 516 Therefore, these assessments do not provide an accurate and
complete picture of Williams’s functionality.
Hartford’s decision to deny Williams’s claim for LTD benefits also gave no credence to
the peer review of Dr. Green, which concluded that fibromyalgia was “a limiting factor[.]” 517 Dr.
Green explained that he “did not feel that there was any symptom magnification here[,]” and
noted that Williams’s “physicians feel that she is not exaggerating her symptoms.” 518
Because Hartford did not go to the source—Williams—for personal examination to
determine her functionality, but rather, simply relied on peer review assessments that did not
account for restrictions and limitations based on Williams’s fibromyalgia diagnosis, Hartford’s
determination of Williams’s functionality was incomplete and inaccurate. Given the record
evidence and the nature of fibromyalgia, Hartford’s decision to reject the conclusions of Dr.
Inouye and the Functional Capacity Evaluation is unreasonable.
There is no dispute that Williams has fibromyalgia and the undisputed evidence supports
a finding that fibromyalgia is a limiting factor to Williams’s functionality. 519 Therefore,

513

Id. at 406, 408, docket no. 14-5, 576, docket no. 14-6, 866, docket no. 14-9.

514

Id. at 406, 408, docket no. 14-5, 866, docket no. 14-9.

515

Id. at 406, 408, docket no. 14-5.

516

Id. at 866, docket no. 14-9.

517

Id. at 867, docket no. 14-9.

518

Id. at 868, docket no. 14-9.

519

Id. at 380, docket no. 14-4, 550, docket no. 14-6, 680, docket no. 14-7, 709, docket no. 14-8, 1000, docket no. 1410.
76

accepting the conclusions of Dr. Inouye and the Functional Capacity Evaluation, 520 which are the
most credible and complete assessments of Williams’s functionality, Williams is incapable of
performing full-time employment. As a result, Williams is “prevented from performing one or
more of the Essential Duties of Any Occupation.” 521 The Plan’s definition of “Essential Duty”
includes that the participant “be at work for the number of hours in [the participant’s] regularly
scheduled workweek[.]” 522 Therefore, Williams remained Disabled beyond of the effective date
of the Group Policy’s Any Occupation provision, and Hartford breached its contractual duty to
Williams by denying her claim for LTD benefits. 523 Even if this were an appropriate case to
afford deference to Hartford’s determination, which it is not, 524 the result would not change
because Hartford’s determination of Williams’s functionality would remain incomplete,
inaccurate, and unreasonable in light of the clear record evidence.
Williams suffered damages as a result of Hartford’s breach
Under the Plan and Group Policy, benefits are paid equal to 662/3% of a claimant’s PreDisability Earnings, reduced by Other Income Benefits as defined by the Plan and Group
Policy. 525 The maximum period of LTD benefit payments is based on the participant’s normal
retirement age. 526

520

Id.

521

Id. at 29, docket no. 14-1.

522

Id.

523

Id. at 10, docket no. 14-1.

524

Supra at 54-55, 58-65.

525

Administrative Record at 6, 13, docket no. 14-1, filed Mar. 5, 2015.

526

Id. at 7-8, docket no. 14-1.
77

Because of Hartford’s breach of the Plan and Group Policy in denying Williams’s claim
for LTD benefits, 527 Williams has not received the LTD benefit payments which she is entitled to
since June 16, 2013. 528 Therefore, Williams has suffered damages as a result of Hartford’s breach
of the Plan and Group Policy. The amount of Williams’s damages is not determined in this
Memorandum Decision and Order.
CONCLUSION
Because the record evidence undisputedly demonstrates that Williams has established
each of the elements of her breach of contract claim against Hartford, 529 Williams is entitled to
summary judgment on her claim.
ORDER
IT IS HEREBY ORDERED that:
(1)

Williams’s Motion for Summary Judgment 530 is GRANTED; and

(2)

Hartford’s Motion for Summary Judgment 531 is DENIED.

The parties are directed to meet, confer, and jointly file by February 28, 2017, a report
stating the status of this case moving forward.
Signed February 8, 2017.
BY THE COURT:

____________________________
District Judge David Nuffer

527

Supra at 66-77.

528

Administrative Record at 191, docket no. 14-2, filed Mar. 5, 2015.

529

Bair, 2001 UT 20, ¶ 14.

530

Docket no. 18, filed Mar. 31, 2015.

531

Docket no. 17, filed Mar. 31, 2015.
78