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Ortiz v. The Hartford

United States District Court, D. New Mexico

November 4, 2019

THE HARTFORD, Defendant.



         After making long-term disability (LTD) payments for two years, Defendant Hartford Life and Accident Insurance Co. (Hartford) began a formal assessment into whether it should continue disbursing benefits to Plaintiff Jessica Ortiz (Ortiz). Hartford evaluated her medical record and determined that Ortiz was not disabled under the terms of her employer plan, and therefore, it would no longer pay LTD benefits. As a result of Hartford terminating these benefits, Oritz seeks to recover under the Employee Retirement Income Security Act of 1974 (ERISA). In this Memorandum Opinion and Order, the Court takes up Hartford's Motion for Summary Judgment against Ortiz's claims. (Doc. 19.) Given that employers have flexibility to define the terms of their benefits programs and independent doctors corroborated Hartford's findings on appeal, the Court will grant Hartford's Motion for Summary Judgment.

         I. Background and Administrative Record

         Ortiz worked at T-Mobile USA, Inc. (T-Mobile) for years prior to her disability, which began in November 2013. (Doc. 1 (Compl.) ¶ 2.) T-Mobile established a plan to pay LTD benefits to employees under ERISA. (Administrative Record[1] (AR) at 31, 32.) T-Mobile named Hartford “as the claims fiduciary for benefits provided under the Policy” and granted it “full discretion and authority to determine eligibility for benefits and to construe and interpret all terms and provisions of the Policy.” (AR at 31.) Under the plan, disability was defined as an inability to perform duties of the specific role for 24-months. (AR at 21.) After that period, to continue receiving disability payments, the individual needed to show an inability to perform “Any Occupation.” (Id.) This means “any occupation for which [an individual is] qualified by education, training or experience” and has a greater earnings potential than the indexed amount.[2] (Id.)

         Ortiz stopped working after November 24, 2013, due to pregnancy and hyperemesis. (Compl. ¶¶ 2, 7.) In addition, Ortiz suffered from “major depressive disorder, degenerative joint disease, fibromyalgia, cervical radiculopathy, lumbar radiculopathy, and disabling physical effects.” (Id. ¶ 2.) As a result, she began receiving LTD payments from Hartford starting February 22, 2014. (Compl. ¶¶ 2-3.) In May 2016, Ortiz saw Dr. Eximena Patricia Galarza-Rios. (AR at 188.) While Dr. Galarza-Rios found that she suffered from “weight loss” and “pain due to fibromyalgia, ” she “observed to appear healthy and in no acute distress.” (Id.)

         At all times prior to the disability, “Plaintiff obtained and continued her employment in reliance upon . . . disability income insurance benefits in the event she became disabled and became insured under this LTD policy effective [June 1, 2013].” (Compl. ¶ 6.) Ortiz contends that she “provided sufficient proof of loss, medical evidence, health history, and other relevant, necessary, and material evidence in support of the said claim, including releases for the Defendant to obtain information from medical and other sources . . . .” (Id. ¶ 3.) Yet Hartford started an investigation into Ortiz's collection of LTD benefits under the any occupation definition because after 24 months, beneficiaries must be “totally disabled” to continue the program. (AR at 244-45.) After evaluating evidence compiled from Ortiz's personal physician and a behavioral case manager's independent psychiatric evaluation, Hartford determined on January 20, 2016, that Ortiz was “not [d]isabled from [a]ny [occupation] under the terms of the policy.” (AR at 77-79.)

         Ortiz appealed Hartford's determination. (AR at 1163-65.) Hartford referred the case to the University Disability Consortium (UDC) for independent evaluation. (AR at 420-21.) Three doctors separately reviewed the record, which included Dr. Galarza-Rios's review. (AR at 387- 412.) After thorough assessment, Dr. Jennifer Wisdom-Schepers (AR at 397), Dr. Sara Kramer (AR at 403), and Dr. Desmond Ebanks (AR at 411) each concluded that Ortiz was not disabled under the plan definition. Given the three independent medical reports, Hartford denied Ortiz's appeal for LTD benefits on September 6, 2016. (Compl. ¶ 10.) In an unrelated proceeding, Ortiz applied for and received a favorable administrative decision for Social Security Disability Insurance Benefits on July 6, 2017. (Id. ¶ 8.)

         Nevertheless, Ortiz filed this lawsuit on July 5, 2018. She claims that because of the “arbitrary and capricious . . . refusal of the Defendant to pay [her] disability benefits pursuant to the subject plan, [she] has suffered financial loss and hardship . . . .” (Id. ¶ 11.)

         II. Legal Standard

         Under the summary judgment standard, “the movant [must] show[] that there is no genuine dispute as to any material fact and the movant is entitled to judgment as a matter of law.” Fed.R.Civ.P. 56(a); see also Garrison v. Gambro, Inc., 428 F.3d 933, 935 (10th Cir. 2005) (reiterating the standard). A “genuine” issue arises when “a rational trier of fact could resolve the issue either way.” Adler v. Wal-Mart Stores, Inc., 144 F.3d 664, 670 (10th Cir. 1998) (citation omitted). And a material fact “is essential to the proper disposition of the claim.” Id. (citation omitted). In assessing motions for summary judgment, the Court takes all reasonable inferences in favor of the nonmoving party. See Matsushita Elec. Indus. Co. v. Zenith Radio Corp., 475 U.S. 574, 587 (1986). The moving party bears the initial responsibility of “show[ing] that there is an absence of evidence to support the nonmoving party's case.” Bacchus Indus., Inc. v. Arvin Indus., Inc., 939 F.2d 887, 891 (10th Cir. 1991) (quoting Celotex Corp. v. Catrett, 477 U.S. 317, 325 (1986)). Once the moving party passes this initial hurdle, “the burden shifts to the nonmoving party to set forth specific facts showing that there is a genuine triable issue.” Johnson v. City of Roswell, 752 Fed.Appx. 646, 649 (10th Cir. 2018) (citing Schneider v. City of Grand Junction Police Dep't, 717 F.3d 760, 767 (10th Cir. 2013)).

         Typically, the moving party may employ “depositions, documents, electronically stored information, affidavits or declarations, stipulations, . . . admissions, interrogatory answers, or other materials.” Fed.R.Civ.P. 56(c)(1)(A). But in ERISA cases, “summary judgment is merely a vehicle for deciding the case . . . .” Cardoza v. United of Omaha Life Ins. Co., 708 F.3d 1196, 1201 (10th Cir. 2013) (quoting LaAsmar v. Phelps Dodge Corp. Life, Accident Death & Dismemberment & Dependent Life Ins. Plan, 605 F.3d 789, 796 (10th Cir. 2010)). Determining whether an employee is eligible for benefits “is decided solely on the administrative record, and the non-moving party is not entitled to the usual inferences in its favor.” Id. (internal quotation marks and citation omitted).

         III. Analysis

         Ortiz's ERISA claim seeks to recover benefits and to enforce the terms of the T-Mobile employer plan. See 29 U.S.C. § 1132(a)(1)(B). When a benefits plan grants discretion to the administrator, courts will review its eligibility determinations under the “arbitrary and capricious” standard. Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 109 (1989) (citations omitted). As long as the decision to end benefit payments “was reasonable and made in good faith, ” the Court will defer to the administrator. Eugene S. v. Horizon Blue Cross Blue Shield of N.J., 663 F.3d 1124, 1133-34 (10th Cir. 2011) (internal quotation marks and citations omitted). A reasonable decision is based on substantial evidence, which is “more than a scintilla but less than a preponderance.” Sandoval v. Aetna Life & Cas. Ins. Co., 967 F.3d 377, 382 (10th Cir. 1992) (quotation omitted). In reviewing the case, administrators “cannot shut their eyes to readily available information when the evidence in the record suggests that the information might confirm the beneficiary's theory of entitlement and when they have little or no evidence in the record to refute the theory.” Gaither v. Aetna Life Ins. Co., 394 F.3d 792, 807 (10th Cir. 2004) (citation omitted). And when a court looks at this determination, it “cannot go beyond the administrative record.” Id. at 381.

         a. The administrative record shows that Ortiz is not disabled under the any occupation ...

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