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Toro v. Hartford Life And Accident Insurance Co.

United States District Court, E.D. Michigan, Southern Division

August 21, 2017

Angela Toro, Plaintiff,
v.
Hartford Life and Accident Insurance Company, Defendant.

          Mona K. Majzoub U.S. Magistrate Judge.

          ORDER DENYING PLAINTIFF'S CROSS MOTION TO REVERSE DEFENDANT'S ERISA DETERMINATION AND MOTION FOR SUMMARY JUDGMENT [19] AND GRANTING DEFENDANT'S MOTION FOR JUDGMENT ON THE ADMINISTRATIVE RECORD [20]

          Arthur J. Tarnow, Senior United States District Judge.

         Plaintiff Angela Toro is 45-years old and suffers from degenerative cervical disc disease, lumbar spondyloses, and rheumatoid arthritis. She challenges the decision by Defendant Hartford Life and Accident Insurance Company to deny her claim for Long Term Disability (“LTD”) benefits issued under an ERISA-governed employee benefit plan (“the Plan”) to her employer, ZF North America, Inc. Plaintiff's claim falls under 502(a)(1)(B) of ERISA, 29 U.S.C. § 1132(a)(1)(B).

         For the reasons stated below, Plaintiff's Cross Motion to Reverse Defendant's ERISA Determination and Motion for Summary Judgment [19] is DENIED. Defendant's Motion for Judgment on the Administrative Record [20] is GRANTED.

         Factual Background

         45-year old Angela Toro worked as a machinist from August 2011 to October 2012 at ZF Lemforder. Through her employment, she participated in the Plan, which was sponsored and administered by ZF Group North America, Inc. Defendant Hartford Life and Accident Insurance Company is the Plan's insurer.

         Plaintiff has a long history of neck and back ailments. She had an MRI of her thoracic spine and an MRI of her lumbar spine in January 2010. HA 685-86. Plaintiff had a second MRI of her lumbar spine in September 2012. HA 345-48. She stopped working on October 23, 2012 because she needed a procedure to alleviate her back pain. HA 694. Dr. Salwa Mohamedahmed, [1] Plaintiff's treating physician, indicated that Plaintiff was excused from work from October 29, 2012 to January 2, 2013. HA 681. Plaintiff applied for and received Short Term Disability (“STD”) Benefits from approximately October 30, 2012 through April 22, 2013. HA 166.

         On December 26, 2012, Dr. Mohamedahmed extended Plaintiff's leave to April 29, 2013. HA 679. On April 23, 2013, Dr. Rudram Muppuri extended Plaintiff's leave time again, to May 22, 2013, due to uncontrolled chronic lower back pain. HA 678. Plaintiff had another MRI of her thoracic spine on April 25, 2013 and an MRI of her lumbar spine in August 2014. HA 339-40, 343-44, 393-94.

         I. The Terms of the Insurance Policy

         ZF Group North America, Inc. sponsored and administered the Insurance Policy at issue for the benefit of its employees. The Policy provides disability benefits if a participant becomes disabled while insured under the policy, remains disabled during and after the elimination period, and submits proof of loss. HA 725. To receive coverage, an individual's disability must result from accidental bodily injury, sickness, mental illness, substance abuse, or pregnancy. HA 734. An individual is considered disabled under the Policy if she is prevented from performing one or more of the essential duties of:

1) Your occupation during the elimination period;
2) Your occupation for the 24 month(s) following the elimination period, and as a result your current monthly earnings are less than 80% of your indexed pre-disability earnings; and
3) After that, any occupation.

HA 734.

         “Your occupation” refers to “your occupation as it is recognized in the general workplace, ” rather than “the specific job you are performing for a specific employer or at a specific location.” HA 737. “Any occupation” means:

Any occupation for which you are qualified by education, training or experience, and that has an earnings potential greater than the lesser of:
1) The product of your Indexed Pre-Disability Earnings and the Benefit Percentage; or
2) The maximum monthly benefit.

HA 733.

         An “Essential Duty” is one that “is substantial, not incidental; is fundamental or inherent to the occupation; and cannot be reasonably omitted or changed.” HA 734. A participant's ability to work the number of hours in a regularly scheduled work week qualifies as an Essential Duty. HA 734. Benefit payments will stop when the participant is no longer disabled. HA 726.

         II. Plaintiff's claim for Long Term ...


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