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Holzman v. The Hartford Life and Accident Insurance Co.

United States District Court, D. Massachusetts

January 14, 2019

William Holzman, Plaintiff,
The Hartford Life and Accident Insurance Co., Defendant.


          Nathaniel M. Gorton United States District Judge.

         This case arises out of a dispute over the decision by the Hartford Life and Accident Insurance Company (“the Hartford” or “defendant”) to deny William Holzman (“Holzman” or “plaintiff”) long-term disability (“LTD”) benefits under the Employee Retirement Income Security Act (“ERISA”).

         I. Background

         Holzman was employed at Anderson Corporation (“Anderson”) and the Hartford issued a group disability insurance policy (“the Group Policy”) to Anderson that is governed by ERISA. Under the Group Policy, a participant is entitled to LTD benefits when the Hartford determines that the employee is disabled and eligible to receive benefits.

         The term “disabled” is defined as when the employee cannot perform one or more of his essential duties and the employee's monthly earnings are less than 80% of his indexed pre-disability earnings. LTD benefits are also limited by the Pre-Existing Condition provision which provides that

[N]o benefit will be payable under The [Group] Policy for any Disability that is due to, contributed to by, or results from a Pre-Existing Condition.

         A pre-existing condition is defined as

any accidental bodily injury, sickness, mental illness, pregnancy, or episode of substance abuse

         for which the individual receives “Medical Care” during the 90-day period that ends the day before the effective date of coverage (“the Look-Back Period”). Medical Care is received by a patient when a physician or health care provider is consulted or gives medical advice, or recommends, prescribes or provides treatment. Treatment includes, but is not limited to, medical examinations, tests, attendance or observation by a physician, and use of drugs, medicines, services, supplies or equipment by the patient. The Pre-Existing Condition provision does not apply if the disability occurs after the last day of the Look-Back Period or after the last day of 365 consecutive days during which the employee has been continuously insured under the Group Policy.

         Holzman became insured under the Group Policy on June 10, 2016, with a Look-Back Period of March 12, 2016, to June 9, 2016. Prior to the Look-Back Period, on March 7, 2016, Dr. Eric Weber (“Dr. Weber”) determined that Holzman had a facial nerve disorder or perhaps Bell's palsy. He prescribed medicine for Holzman's condition but noted the cause of his symptoms were unknown at the time.

         On May 19, 2016, Dr. Weber examined Holzman again and observed that the facial paralysis had increased. He recommended additional laboratory tests and assured the plaintiff that his symptoms would improve. At that point, Dr. Weber informed the plaintiff that his Lyme disease test was negative and concluded, again, that Holzman had Bell's palsy. On June 29, 2016, a few weeks after the end of the Look-Back Period, Dr. Weber observed that Holzman had a small growth on his jaw and referred him to another doctor. A few weeks later, Dr. Richard Wein (“Dr. Wein”) counseled Holzman on his likely prognosis of salivary duct cancer.

         Holzman stopped working on July 29, 2016, when he had surgery to remove the mass in his jaw. At his post-surgery appointment, Dr. Wein confirmed plaintiff's cancer diagnosis and Holzman sought further cancer treatment thereafter. He filed his claim for LTD benefits under the Group policy in January, 2017.

         In April, 2017, the Hartford informed Holzman that his LTD claim was subject to the Pre-Existing Condition provision and that he was exempt from coverage because he received Medical Care during the Look-Back Period. Holzman appealed that decision in May, 2017. The Hartford Appeals Specialist referred the appeal to an independent, board-certified oncologist, Dr. Brian Samuels (“Dr. Samuels”), who performed a review of Mr. Holzman's medical records and treatment history.

         Dr. Samuels concluded that Holzman had symptoms related to his salivary duct cancer before June 10, 2016, but that 1) the symptoms did not result in the cancer and 2) because no diagnosis of cancer was made prior to June 29, 2016, there was no Medical Care or treatment prior to June 10, 2016, related to or resulting in the cancer. He also determined that Dr. Weber's treatment notes during the Look-Back Period showed that the symptoms were related to the later diagnosis of cancer, although it was not known to be cancer at the time. In June, 2017, the Hartford notified Holzman that ...

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