Court: District Court, M.D. Florida; March 3, 2014; Federal District Court
The Court, presided over by District Judge Elizabeth A. Kovachevich, is addressing cross-motions for summary judgment in an ERISA case involving Plaintiff Doris Hopp and Defendants Aetna Life Insurance Company and Bank of America Corporation. Hopp claims entitlement to Short Term Disability benefits from November 23, 2010, to May 24, 2011, totaling $18,172.68, along with pre-judgment interest, attorney's fees, and other relief. Defendants seek summary judgment, asserting that Aetna’s denial of benefits was not erroneous and, even if it were, had a reasonable basis and was not arbitrary or capricious.
Hopp's motion raises critical issues: the correctness of Aetna’s denial of benefits, the proper delegation of discretionary authority by Bank of America to Aetna, and whether the Court should grant judgment to Hopp based on Aetna’s alleged lack of discretionary authority in its claims decisions.
The Court outlines the standard for summary judgment under Rule 56, stating that it is warranted when there is no genuine issue of material fact, and the moving party is entitled to judgment as a matter of law. It emphasizes that unresolved factual issues in the administrative record do not prevent summary judgment unless the administrator's decision is deemed wrong or arbitrary. Furthermore, conflicting evidence regarding disability alone does not create a factual dispute that would preclude summary judgment, as it is reasonable for an administrator to reject certain evidence in favor of conflicting proof.
In reviewing an ERISA plan administrator's benefits decision, the Court follows a specific analysis:
1. It first applies a de novo standard to assess if the administrator's denial of benefits is "wrong." If not, the decision is affirmed.
2. If the decision is found to be "de novo wrong," the Court checks if the administrator had discretion in claims review. If not, the decision is reversed.
3. If the administrator had discretion and the decision is "de novo wrong," the Court examines whether there were "reasonable" grounds for the decision, applying the arbitrary and capricious standard.
4. If no reasonable grounds exist, the decision is reversed; if reasonable grounds are found, the Court investigates any conflict of interest.
5. In the absence of a conflict, the decision is affirmed.
6. If a conflict exists, it is considered as a factor in evaluating whether the decision was arbitrary and capricious.
The Court's review is limited to the material available to the administrator at the time of the decision.
Regarding the facts of the case, Doris Hopp, a Home Services Specialist II at Bank of America, held a sedentary position with significant underwriting authority. She sought treatment from various healthcare professionals between November 2010 and May 2011. Bank of America provides a Group Benefits Program, which includes multiple ERISA-regulated component plans. The 2010 Associate Handbook outlines employee rights and details about the STD Plan, emphasizing that the official plan documents govern any discrepancies in the summary plan descriptions.
The Bank of America Associate Handbook 2010 outlines the administration of the Group Benefits Program, with the Corporate Benefits Committee serving as the plan administrator. This committee, appointed by the Compensation and Benefits Committee of the Board of Directors, oversees the Group Benefits Program's administration and provides contact information in the handbook.
The handbook specifies that the chapters on Leaves of Absence, Disability, and Workers’ Compensation, along with the Leaving Bank of America chapter, form the summary plan description for the Short-term Disability (STD) Plan, part of the Group Benefits Program.
For Short-term Disability, Bank of America offers benefits that replace a portion of income for up to 26 weeks for associates who cannot perform essential job functions due to disability, which is defined as being unable to work for over seven consecutive calendar days due to pregnancy, illness, injury, non-elective surgery, or hospitalization. Eligibility requires ongoing treatment from a qualifying healthcare provider, which includes licensed Medical Doctors, APRNs, NPs, or PAs. The treatment must be appropriate, necessary, consistent with national guidelines, focused on maximizing medical improvement, and validated by the provider's qualifications.
Bank of America reserves the right to request a second opinion for continued benefits. After a seven-day elimination period, benefits are payable for up to 26 weeks, with the potential to apply for Long-term Disability (LTD) benefits thereafter.
To apply for STD benefits, associates must first notify their manager and adhere to specific reporting requirements, then contact the STD Claims Administrator, Aetna, within 16 days of the disability onset. Required medical documentation must be submitted within 15 days. Failure to provide timely medical information may lead to claim denial and benefit lapses. Access to Bank of America systems is revoked from the leave's effective date.
To extend Short-term Disability (STD) benefits within the 26-week maximum period, employees must inform their manager of an updated expected return date and contact the STD Claims Administrator for an extension request. Benefit payments are processed through payroll, with all deductions continuing, and employer-paid benefits are taxable. The Bank of America Corporate Benefits Committee has delegated authority to various teams and service providers to determine eligibility for benefits and resolve claims questions. Appeals for denied claims must be submitted to the appropriate insurance company or the Bank of America Benefits Appeals Committee, depending on the plan. The STD Plan does not cover cases where an employee fails to provide satisfactory medical evidence or comply with examination requests. The STD plan is funded by Bank of America, with Aetna as the claims administrator. For associates not eligible for STD benefits, Bank of America offers Medical Leave, which is unpaid after using available sick days. Aetna also administers leaves. In the case of the plaintiff, FMLA leave was initially denied due to incomplete documentation but was later approved, along with Medical Leave. The plaintiff returned to work without restrictions on June 1, 2011. Aetna denied the plaintiff's STD claim on December 17, 2010, citing insufficient medical evidence and lack of response from healthcare providers regarding the symptoms that would prevent the plaintiff from performing their job duties.
The provider's report indicated anxiety and stress but failed to specify how the symptoms' frequency, duration, or intensity would hinder the ability to perform job duties as a Home Services Specialist II. The submitted information lacked necessary clinical details to demonstrate an inability to fulfill occupational responsibilities. For the claim to be substantiated from a psychological standpoint, the provider must present examination findings documenting impairments, such as behavioral observations, results of a formal mental status examination, or performance-based psychological tests with standardized scores. Additional information required includes a narrative report detailing physical and mental limitations since November 23, 2010; the treating provider's prognosis and treatment course; diagnostic studies from the same period; and any other relevant documents that could aid in evaluating the disability claim.
On January 4, 2011, Plaintiff Hopp appealed Aetna's denial of short-term disability (STD) benefits, which was again denied on May 27, 2011. Aetna's policy, GP-721040, is part of Bank of America’s Group Benefits Program, which also includes the Employee Assistance Program (EAP) that offers counseling services. The disagreement between the parties centers on the standard of review for Aetna’s decision to deny benefits. Plaintiff Hopp contends that the language in the Summary Plan Description (SPD) does not sufficiently grant discretionary authority to Aetna, referencing CIGNA Corp. v. Amara. Hopp argues that the defendants have not proven their entitlement to deferential review due to the absence of a plan document properly delegating such discretion.
Defendants assert that Plaintiff Hopp's lawsuit is based on the Summary Plan Document (SPD) attached to the Complaint, which grants Aetna discretionary authority to determine benefit eligibility. They argue that, based on prior cases involving them, Aetna's authority was not contested. Defendants provided the relevant Group Life and Accident Health Insurance Policy, confirming Aetna's discretion over employee benefits.
The excerpt also references *CIGNA Corp. v. Amara*, where CIGNA transitioned its pension plan and faced challenges regarding proper notice of benefit changes. The District Court found CIGNA's disclosures violated ERISA, prompting a reformation of the plan and a directive for CIGNA to pay benefits accordingly. The Supreme Court reviewed whether the District Court employed the correct standard, specifically if Section 502(a)(1)(B) allowed for the relief granted, and concluded it did not. The Court recognized that Section 502(a)(3) permits equitable relief, contingent on the principles applied.
The Supreme Court rejected the argument that plan disclosures are part of the plan itself, indicating that Section 102(a) requires plan administrators to provide summary descriptions that do not constitute plan terms. It emphasized the importance of clarity in summary disclosures, cautioning that binding them could compromise their simplicity. Ultimately, the Court determined that summary documents communicate plan information to beneficiaries but do not define the plan's terms under Section 502(a)(1)(B), thus limiting the District Court's authority to reform CIGNA's plan.
Additionally, the Bank of America Associate Handbook 2010 clarifies the treatment of the Group Benefits Program under ERISA, stating it is regarded as a single welfare benefits plan solely for specific reporting purposes, while each component plan is treated separately for all other legal requirements.
Key provisions of the Group Benefits Plan include the Introduction, First Amendment, and Second Amendment. The Summary Plan Description (SPD) is designed to meet statutory requirements by providing beneficiaries with a clear explanation of their rights and obligations as outlined in 29 U.S.C. Sec. 1022(a). The SPD indicates that the Group Benefits Program and its components are based on official plan documents, which take precedence over any conflicting descriptions in the SPD. It clarifies that the SPD does not create enforceable rights or an employment relationship.
The Court found no disputed issues regarding the SPD's adequacy, its potential harm to the Plaintiff, or misrepresentations of the plan's provisions. The SPD serves both as a summary for participants and as part of the Group Benefits Plan. The Group Benefits Program's Article VII details the Plan Administrator's powers, while Article VIII outlines the Claims Administrator's authority and claims procedures. The Plan Administrator can delegate its discretionary powers to the Claims Administrator, including eligibility determinations for plan coverage.
The SPD indicates that the Bank of America Corporation Corporate Benefits Committee has entrusted Aetna with discretionary authority to determine eligibility, interpret the STD plan's terms, and manage benefit claims. Consequently, the Court has determined that a deferential review of Aetna's decisions is appropriate, applying the arbitrary and capricious standard for review of the administrator's actions.
The Court evaluates whether the Defendants' determination that the Plaintiff was not disabled is supported by rational evidence. Under ERISA, the Plaintiff must demonstrate entitlement to Short Term Disability (STD) benefits according to the Plan's terms. The Summary Plan Description (SPD) defines "disabled" as the inability to perform essential job functions for over seven consecutive days due to various medical conditions. Evidence of arbitrary and capricious decision-making can include lack of substantial evidence, procedural irregularities, legal errors, bad faith, or conflicts of interest. In this case, there is no structural conflict of interest as Bank of America funds the STD Plan while Aetna administers it.
Substantial evidence is required, as outlined in the SPD, which necessitates satisfactory objective medical evidence of disability. The Plaintiff's STD claim commenced on November 23, 2010, following her last workday on November 22, 2010. The Plaintiff cited stress from a demanding job, her husband's illness, and her mother’s recent death as reasons for her inability to work. Although Dr. Timmons, her physician, noted her distress and prescribed medication, medical records indicated she was alert and oriented during a visit on November 18, 2010. Despite acknowledging her emotional state would hinder her job performance, Aetna found that the clinical information from Dr. Timmons did not sufficiently demonstrate how her symptoms would prevent her from fulfilling her job duties as a Home Services Specialist II.
Aetna asserts that the submitted information lacks sufficient clinical evidence to demonstrate that Plaintiff Hopp cannot perform her duties as a Home Services Specialist II. To substantiate her claim, Hopp's provider must provide examination findings that document impairments, such as behavioral observations, formal mental status examinations, or performance-based tests with standardized scores. Aetna requested additional documentation, including a detailed report of limitations related to Hopp's disability claim, her provider’s prognosis, diagnostic study results, and any pertinent information to aid the claim evaluation.
Aetna's request implies a need for clinical evidence to assess the severity of Hopp's impairments affecting her workplace functionality. Although some documentation indicates a severe condition, Dr. Timmons only identified "stress related to Husband’s condition and mother’s death" and noted "anxiety with normal grief reaction," without establishing an anxiety disorder. The diagnosis alone does not confirm Hopp's inability to perform essential job functions; Dr. Timmons did not provide evidence that Hopp was incapable of working outside a leave of absence suggested by her employer. Additionally, while Aetna must consider Hopp's subjective reports of fatigue, it may evaluate them against objective medical evidence. Aetna's requirement for objective evidence does not exceed reasonable standards, and Dr. Timmons’ conclusion regarding Hopp's inability to perform her job was not grounded in observed symptoms or behaviors.
Aetna, acting as the Leaves Administrator, had the authority to approve FMLA leave and BACMED, rather than Bank of America. The Plaintiff's applications for both were granted based on FMLA Certification forms from her healthcare providers. On January 4, 2011, the Plaintiff appealed the denial of short-term disability (STD) benefits, prompting Aetna to review additional documentation from Alice Savage, LHMC, CAP, and Dr. Gustavo Cuadra.
Documentation from Ms. Savage indicated that cognitive testing on December 8, 2010, and January 5, 2011, yielded normal results, although the Plaintiff struggled with specific memory functions. On December 15, 2010, it was noted that the Plaintiff was advised by her employer to pursue short-term disability. Ms. Savage documented the Plaintiff's emotional state as distressed, with symptoms of crying, anxiety, and panic attacks. Despite experiencing significant weight loss and sleep disturbances, the Plaintiff was able to perform activities of daily living (ADLs) and did not exhibit suicidal ideation.
Ms. Savage diagnosed the Plaintiff with an adjustment disorder with mixed anxiety and depressed mood, assigning GAF scores of 63 and 60, indicating mild to moderate symptoms. Dr. Cuadra's mental status exam on February 2, 2011, showed intact memory and good cognitive functions, although he diagnosed the Plaintiff with mild major depression and prescribed medications, increasing the dosage of Prozac over time. Initially, Dr. Cuadra assigned a GAF of 50, reflecting serious symptoms. Subsequent exams indicated the Plaintiff's mental status was generally stable, with no signs of suicidal ideation or psychosis. The Court's review of the Administrative Record revealed mixed indications regarding the severity of the Plaintiff's impairment throughout her treatment.
Plaintiff experienced significant anxiety and panic attacks at work due to constant phone calls, leading to a claim for short-term disability (STD) benefits from Aetna. Aetna initially denied this claim, citing a lack of objective medical evidence to support that Plaintiff was unable to perform essential job functions from November 23, 2010, to June 1, 2011. Aetna provided detailed explanations for both the initial denial and the decision made after the appeal.
The Plaintiff contends that Aetna's inconsistent decisions—granting Family and Medical Leave Act (FMLA) and BACMED benefits while denying STD benefits—constitute an arbitrary and capricious decision-making process, as established in *Metropolitan Life Ins. Co. v. Glenn*. FMLA benefits are granted based solely on a health care provider's certification form, which requires specific information about the medical condition, while BACMED provides unpaid leave for those ineligible for STD benefits. Unlike STD benefits, which require objective medical evidence of disability, FMLA and BACMED can be awarded based solely on the provider's certification.
To qualify for BACMED, the applicant must submit specific information, including the nature of the medical condition and expected return-to-work date, within 15 days of the condition's onset. FMLA leave ends when the qualifying condition no longer exists, as determined by the Leaves Administrator. Additionally, BACMED ends when the claimant is deemed able to work by both their health care provider and the Leaves Administrator or fails to provide requested medical documentation.
The Plaintiff also argues that Aetna selectively reviewed medical records, disregarding the opinion of an Employee Assistance Program (EAP) provider recommended by Bank of America.
An Employee Assistance Program (EAP) aims to assess problems early, provide short-term counseling affecting work performance, and offer referral services. Aetna acknowledged information from Alice Savage, who holds a Master of Science, is a Licensed Mental Health Counselor, and a Certified Addiction Professional. However, her qualifications do not meet the treating health care provider criteria outlined in the Short-Term Disability (STD) Plan, which includes licensed Medical Doctors, Advanced Practice Registered Nurses, or Physician Assistants. Ms. Savage provided three one-hour counseling sessions without an established patient relationship and assisted the Plaintiff until they could see a psychiatrist.
The Court noted that a clinical psychologist qualifies as a health care provider for Family and Medical Leave Act (FMLA) leave. Since FMLA and BACMED leaves run concurrently, Ms. Savage's certification sufficed for both leaves. The Plaintiff's FMLA leave was approved until February 28, 2011, and BACMED until June 7, 2011, based on Ms. Savage's certification. The Plaintiff had been referred to the EAP by their supervisor, and there was confusion regarding the delay in obtaining medical treatment for the Plaintiff's serious health condition.
The sessions with Ms. Savage fell under a separate benefit plan from the Plaintiff's medical insurance, and the Plaintiff had already applied for STD benefits before meeting with Ms. Savage. The last workday was November 22, 2010, and the first counseling session was on December 8, 2010. Although Ms. Savage's Provider Certification forms were deemed adequate for FMLA and BACMED leaves, the STD Plan requires objective medical evidence of functional impairment. Ms. Savage’s records indicated normal cognitive functioning but suggested the Plaintiff not work due to emotional distress and the need for further treatment. Aetna accepted Ms. Savage's opinion for FMLA and BACMED but sought additional evidence for STD benefits due to conflicting observations of distress and normal mental status exams during the relevant period.
Aetna's reliance on the opinions of non-examining physicians regarding the Plaintiff's disability is contested. The Plaintiff argues that Aetna overlooked substantial evidence indicating disability, particularly in cases of chronic pain syndrome where objective evidence can arise from consistent diagnoses and physical manifestations. The medical records from Dr. Timmons, Ms. Savage, and Dr. Cuadra consistently document the Plaintiff's high stress, anxiety, and depressed mood. However, Dr. Timmons only noted that the Plaintiff's emotional state hindered her job performance due to an employer's directive, without behavioral observations or standardized assessments to substantiate this claim. Dr. Timmons primarily recorded discussions about the Plaintiff's stressors and her aspirations rather than specific job-related limitations.
Ms. Savage's records indicate normal cognitive function despite severe emotional distress. Dr. Cuadra, who did not submit Provider Certifications for periods prior to February 2, 2011, assessed the Plaintiff with a GAF score of 50, suggesting severe impairment, but failed to specify which job functions were affected. While Dr. Cuadra's mental status exams were mostly normal apart from depressed mood, reviews by Dr. Antoinette Acenas and Dr. Randy Rummler in March and May 2011, respectively, concluded that the Plaintiff had no psychiatric impairment preventing her from performing her usual job as a Home Service Specialist II. Dr. Acenas noted that all mental status examinations were within normal limits and deemed the treating provider's imposed restrictions as inappropriate.
On May 12, 2011, Ms. Savage contacted Aetna expressing her willingness to participate in a peer-to-peer consultation following the submission of a completed report. After Dr. Cuadra provided additional information on May 18, 2011, Aetna conducted a second review, but despite multiple attempts, Ms. Savage could not be reached for further input. Dr. Rummler, the reviewer, determined that the medical records did not support the existence of severe psychiatric impairment, deemed the imposed restrictions inappropriate, and found no evidence of adverse medication side effects.
Legal precedents establish that an ERISA administrator is not obligated to give special weight to a treating physician's opinion and can rely on the assessments of qualified consultants who review medical records without direct examination. Aetna considered all evidence but placed greater weight on the opinions of Drs. Acenas and Rummler, who concluded that the severity of the Plaintiff's impairments did not prevent her from working.
The Plaintiff argued that Aetna failed to assess how her documented limitations affected her ability to perform the duties of her job as a “Home Service Specialist II,” which involved high-volume mortgage refinancing tasks classified as sedentary work. Although the Plaintiff reported difficulties with concentration, Ms. Savage's testing indicated that she could maintain focus. Savage estimated a continuous incapacity period from November 2010 to June 2011 and noted that the Plaintiff would require weekly follow-up treatment, with flare-ups occurring daily.
Dr. Cuadra informed the Plaintiff she could not return to work prior to May 3, 2011, but later cleared her for full-capacity work on June 1, 2011. The Provider Certification form did not specify any job functions the Plaintiff was unable to perform. Following a request from Defendant Aetna for additional medical documentation to clarify the severity of the Plaintiff’s impairment, a conflict arose regarding the evidence of her functional limitations. The plan mandated objective medical evidence for claims, making Aetna's denial of benefits reasonable due to the Plaintiff's failure to provide such evidence. The absence of an Independent Medical Examination (IME) was scrutinized, but it was noted that courts have found that opting for a file review instead of an IME is not inherently an abuse of discretion. The Eleventh Circuit has affirmed that reliance on qualified physician file reviews is acceptable, especially when no significant procedural irregularities exist. Consequently, the absence of an IME did not render Aetna's decision arbitrary or capricious. Under ERISA, claimants are entitled to a "full and fair review" of adverse benefit determinations, which includes the right to at least one administrative appeal and the necessity to exhaust administrative remedies before initiating a lawsuit.
Plaintiff was granted extra time to submit records and had her claim reviewed by a different individual than the one involved in the initial adverse decision. The appeal process was paused to allow her healthcare providers to submit additional documentation. The Court determined that Aetna provided a full and fair review of the denial of short-term disability (STD) benefits.
Defendant Bank of America had delegated discretion to Aetna regarding eligibility and claims decisions. The Court found that Aetna's decision to deny Plaintiff Hopp's STD benefits was not incorrect; even if deemed wrong, the decision was reasonable. Consequently, the Court granted Defendants’ Motion for Summary Judgment and denied Plaintiff’s Motion for Summary Judgment. Final judgment was ordered in favor of Aetna Life Insurance Company and Bank of America Corporation against Plaintiff Doris Hopp.
