Carol H. Stewart v. Harford Life and Accident Insurance Company

Birmingham, Alabama insurance law lawyers represented Plaintiff, who sued Defendant on a breach of contract theory.



Carol Stewart sued to obtain two insurance benefits that she

believes Hartford Insurance Company owes her: (1) long-term dis-

ability payments and (2) a waiver of life-insurance premiums. Alt-

hough it concedes that Stewart was covered by its policy, Hartford

contends that she was ineligible for those benefits. Hartford's pol-

icy indisputably granted it discretion to make benefits determina-

tions, and we conclude that its determinations were permissible.

Accordingly, we must defer to Hartford's determinations and af-

firm the district court's order granting it summary judgment.

I

In 2007, prominent Birmingham attorney Carol Stewart's

physician diagnosed her with Parkinson's disease.1 At the time,

Burr Forman LLP, Stewart's employer, provided her with disability

insurance through its ERISA health plan. Sun Life Assurance Com-

pany of Canada, which serviced that plan, began paying Stewart

partial, and later total, disability benefits. In 2010, Burr Forman

cancelled its policy with Sun Life and switched the administration

of its ERISA health plan over to Hartford Insurance.

The new Hartford policy contained an exclusion clause spec-

ifying that a member of the firm was ineligible for disability-insur-

ance payments if she was receiving "benefits for a Disability under

a prior disability plan that: 1) was sponsored by [her] Employer;

and 2) was terminated before the Effective Date of The Policy.”

Because Sun Life was still paying Stewart disability benefits, Hart-

ford found that Stewart was "receiving benefits for [a] Disability

under a prior disability plan” that had been "terminated” before its

own policy went into effect and, consequently, that she wasn't eli-

gible for Hartford disability benefits.

Hartford also provided life insurance. Its life-insurance pol-

icy specified that one who was "Disabled” needn't pay premiums

for coverage, and it defined "Disabled,” in relevant part, as being

unable to perform "any work for which [one is] qualified by: 1) ed-

ucation; 2) training; or 3) experience.” Following a multi-step ap-

peals process, Hartford determined that Stewart wasn't "Disabled”

within the meaning of its policy and that she therefore had to pay

life-insurance premiums.

Stewart filed suit to obtain relief under 29 U.S.C. § 1132(a),

which allows an insurance-plan participant to bring a civil action to

"recover benefits due to [her] under the terms of [her] plan.” The

district court granted Hartford summary judgment. Stewart ap-

peals, arguing (1) that she is entitled to disability insurance from

Hartford because she doesn't fall into its policy's exclusion clause

and (2) that she is disabled and should not have been required to

pay premiums for life-insurance coverage.



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4 Opinion of the Court 21-11919

and (2) that she is disabled and should not have been required to

pay premiums for life-insurance coverage.2

II

When "reviewing a plan administrator's benefits decision”

this Court conducts the following six-step analysis:

(1) Apply the

de novo standard to determine whether

the claim administrator's benefits-denial decision is

"wrong” (i.e., the court disagrees with the administra-

tor's decision); if it is not, then end the inquiry and

affirm the decision.

(2) If the administrator's decision in fact is "de novo

wrong,” then determine whether he was vested with

discretion in reviewing claims; if not, end judicial in-

quiry and reverse the decision.

(3) If the administrator's decision is "de novo wrong”

and he was vested with discretion in reviewing

claims, then determine whether "reasonable”

grounds supported it (hence, review his decision un-

der the more deferential arbitrary and capricious

standard).

(4) If no reasonable grounds exist, then end the in-

quiry and reverse the administrator's decision; if rea-

sonable grounds do exist, then determine if he oper-

ated under a conflict of interest.

(5) If there is no conflict, then end the inquiry and af-

firm the decision.

(6) If there is a conflict, the conflict should merely be

a factor for the court to take into account when deter-

mining whether an administrator's decision was arbi-

trary and capricious.

Blankenship v. Metro. Life Ins. Co., 644 F.3d 1350, 1355 (11th Cir.

2011) (per curiam).

To summarize, Stewart was not entitled to disability pay-

ments because Hartford’s interpretation of the disability exclusion

was reasonable, and its conflict of interest didn’t lead it to make an

arbitrary or capricious decision. Likewise, Stewart was not entitled

to a waiver of life-insurance premiums because she wasn’t disabled

within the meaning of Hartford’s life-insurance policy.4



AFFIRMED.