Street v. Aetna Life Insurance Co.

Citations: 188 F. Supp. 3d 1279; 2016 U.S. Dist. LEXIS 67226; 2016 WL 2961556Docket: Case No: 8:15-cv-388-T-24 MAP

Court: District Court, M.D. Florida; May 23, 2016; Federal District Court

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Summary judgment has been granted in favor of Defendants Aetna Life Insurance Company, Aetna, and Federal Express Corporation (FedEx) in a case involving Plaintiff Patricia Street. The court applied the standard for summary judgment, determining that there was no genuine dispute over material facts, thus allowing the defendants to prevail as a matter of law. In this context, the court noted that it must view evidence favorably toward the non-movant and that the burden initially lies with the moving party to demonstrate the absence of genuine issues for trial. In cases involving denials of benefits under the Employee Retirement Income Security Act (ERISA), the court functions more like an appellate body, reviewing the reasonableness of administrative decisions based on existing records rather than taking new evidence.

The background of the case involves the Federal Express Corporation Long Term Disability Plan, administered by FedEx and claims managed by Aetna. The Plan grants Aetna exclusive discretion over eligibility determinations for benefits, with its decisions being final unless proven arbitrary and capricious by a competent court. The Plan stipulates that eligible employees who are deemed "Disabled" according to specific criteria are entitled to long-term disability benefits, calculated as 60% of their monthly income. The definition of "Disabled" includes both Occupational and Total Disability but requires that the individual is under continuous care from a practitioner and that their condition is supported by significant objective medical findings.

Absence of significant objective findings, workplace conflicts, or shifts do not support a disability claim under the Plan. An 'Eligible Employee' must be in Permanent Full-Time Employment; casual, temporary, or part-time employees, as well as those on certain types of leave, are excluded. To establish a qualifying disability, documentation from the employee or their healthcare professional must include significant objective findings such as medical examinations, test results, or observable abnormalities; pain alone is insufficient for proof. For Occupational Disability, the Plan offers long-term benefits of 60% of monthly income for up to two years, defined as the inability to perform regular job duties due to a medically-determined impairment. Beyond two years, a Covered Employee must demonstrate Total Disability, defined as the inability to engage in any compensable employment for at least 25 hours per week. Coverage terminates if an employee no longer meets the definition of an Eligible Employee.

The Plaintiff, a Senior Business Systems Advisor at FedEx, received Short-Term Disability benefits from March to September 2011 due to an intrailac thromboembolism. She subsequently claimed other health issues, including emphysema and COPD, and received LTD benefits from September 2011 to September 2013. After two years, she needed to prove Total Disability to continue receiving benefits. Her claim was denied on September 26, 2013, due to insufficient objective findings. Defendants cited Dr. Leonard Cosmo’s examination and report, wherein he acknowledged multiple chronic conditions but concluded the Plaintiff was fit for sedentary work. Dr. Cosmo indicated she could sit for eight hours daily but should avoid heavy machinery and heights due to her medical condition.

Dr. Wendy Weinstein's peer review of the Plaintiff's medical records concluded that several medical conditions did not prevent the Plaintiff from working twenty-five hours per week. These conditions included: chronic obstructive pulmonary disease (COPD) and emphysema, a stable hypercoagulable state treated with Coumadin, stable depression managed with Zoloft, controlled hypertension, and mild obstructive sleep apnea, among others. Although the Plaintiff reported numbness and weakness in her legs, her medical records noted normal balance and gait. A specific assessment indicated that while the Plaintiff experienced claudication after walking approximately 100 yards, it was not deemed lifestyle limiting, as there was no indication of rest pain or tissue loss.

The Plaintiff appealed the denial of her long-term disability (LTD) benefits, which was ultimately upheld on June 23, 2014. Aetna's final denial letter outlined that the Plaintiff's medical records did not provide sufficient evidence to support her claim for LTD benefits. Despite her complaints of limited mobility, Aetna found no objective medical evidence confirming her inability to walk, stand, or sit. The letter emphasized that, although the Plaintiff had a history of serious medical issues, there were no recent indications of complications that would impair her ability to perform sedentary work. Additionally, Aetna noted that the disability criteria used by the Social Security Administration (SSA) differed from the Plan's definition of Total Disability. The review committee concluded that there were no significant objective findings to support the existence of a functional impairment that would prevent the Plaintiff from engaging in compensable employment for the required hours. Consequently, the Plaintiff did not meet the Plan's requirement for Total Disability benefits.

The denial letter indicated that the committee acknowledged Plaintiff's medical condition as causing functional impairment from April 1, 2014, due to a medical device placement. However, Federal Express confirmed that the Plaintiff was not on approved Family Medical Leave for her illness during this period, categorizing her as not an 'Eligible Employee' under the Plan, leading to the denial of benefits for April 1 to April 5, 2014. Subsequently, the Plaintiff filed a lawsuit on February 24, 2015, contesting Aetna's denial of long-term disability (LTD) benefits. 

The legal standard for reviewing ERISA claims, as established by the Supreme Court in Firestone Tire & Rubber Co. v. Bruch, dictates a de novo standard of review unless the plan grants discretionary authority to the administrator. The Eleventh Circuit has outlined three standards of review based on the level of discretion: de novo, arbitrary and capricious, and heightened arbitrary and capricious in cases of conflict of interest. Recent rulings have expanded this framework into a six-step analysis for district courts, beginning with determining if the administrator's decision is 'wrong' under de novo review. If found 'wrong', the court assesses whether discretion was granted to the administrator, and if so, whether reasonable grounds supported the decision. If reasonable grounds exist, the court examines for conflicts of interest before applying the appropriate level of review. The court must first assess if the Defendant's decision is 'wrong' based on the administrative record; if not, the inquiry concludes and summary judgment favors the Defendant.

The Court evaluates whether the denial of the Plaintiff’s long-term disability (LTD) benefits claim was 'wrong' under a de novo standard, which examines if the Court disagrees with the administrator's decision. The review is confined to the evidence available to the administrator at the time of the decision. The LTD Plan defines 'Total Disability' as an inability to engage in any compensable work for at least twenty-five hours per week due to medically-determinable impairments.

Defendants seek summary judgment, arguing that the denial of benefits was not incorrect. Although Plaintiff has multiple diagnosed medical conditions, such as COPD and hypertension, a diagnosis alone does not establish disability under the LTD plan. Subjective complaints do not gain objectivity merely through documentation by a physician. The independent medical examination and peer review concluded that Plaintiff was not totally disabled and could work twenty-five hours weekly. 

While Plaintiff references other medical notes, they do not contradict the expert findings that supported Aetna’s decision. The administrator is entitled to consider expert opinions when determining disability and is not required to give special deference to treating physicians’ assessments. The administrator may rely on conflicting reliable evidence without needing to justify its decision against the treating physician's evaluation. Ultimately, the Court finds Aetna's decision to deny benefits was not erroneous, leading to the granting of Defendants’ motion for summary judgment.

Independent consulting physicians determined that the Plaintiff could work twenty-five hours per week. Under ERISA policies, individuals capable of sedentary-to-light work are not considered totally disabled. The Plaintiff carries the burden of proving her disability, which the Court finds she has not met. Although the Plaintiff claims the need for rest breaks prevents her from part-time work, this argument is dismissed. Relevant case law supports that inability to stand or walk for extended periods does not equate to an inability to perform part-time sedentary work. The administrator's assessment that the Plaintiff could work while engaging in swimming activities is deemed reasonable.

The Plan requires proof of disability through "significant objective findings," defined as observable anatomical, physiological, or psychological abnormalities noted in tests or medical exams. The Court finds that this requirement is not ambiguous, as established in previous cases within the Circuit. The Plaintiff has failed to provide the necessary proof of total disability, as her claims of pain lack substantiation by significant objective findings. Additionally, the Plaintiff's assertion that the Plan's requirement for significant findings is arbitrary and capricious is also rejected, as the Plan's definition is clear and consistent with established standards.

Defendants reference Brucks v. Coca-Cola Co. to highlight the importance of requiring objective evidence for claims related to diagnosed conditions, asserting that such a requirement ensures fairness and integrity in the legal process by preventing subjective claims from influencing coverage decisions. The court supports this view, emphasizing that claimants must demonstrate actual disabilities rather than perceived ones, and that objective evidence helps deter fraudulent claims.

Plaintiff's challenge to the denial of Long-Term Disability (LTD) benefits for April 1-5, 2014, is rejected. The court finds that Plaintiff was not an Eligible Employee during this period due to being on unapproved leave, and thus Aetna was not obligated to provide benefits. The court concludes that Aetna's denial was not de novo wrong, aligning with the Eleventh Circuit's analysis framework, which favors the claim administrator's decision.

Regarding the alleged conflict of interest, the court notes that it is unnecessary to address this issue since the administrator's decision was upheld. However, it clarifies that Aetna, as the Claims Paying Administrator, acted without a conflict because it does not fund or administer the LTD plan, and its decisions are based on the exclusive discretion granted by the Plan. The burden is on the Plaintiff to prove any wrongdoing, which was not demonstrated in this case.

Defendants' Motion for Summary Judgment has been granted, resulting in the cancellation of the pretrial conference set for June 8, 2016. The Clerk is instructed to enter judgment in favor of the Defendants, terminate all pending motions, and close the case. The Plaintiff did not file a timely response to the summary judgment motion, prompting the Court to issue an order to show cause regarding the motion being treated as unopposed. The Plaintiff attributed the delay to a misunderstanding of the Local Rules. Additionally, the Plaintiff failed to respond timely to the Defendants' motion for a protective order, and her initial response did not comply with the Local Rules; this response was struck, leading to a subsequent submission that she claimed adhered to the rules. The Court advises the Plaintiff’s counsel to review the Local and Federal Rules of Civil Procedure before future practice. The term "claudation," not defined by the parties, refers to pain or cramping in the lower leg due to inadequate blood flow. Aetna's denial letter specified that "significant objective findings" are observable abnormalities noted during medical examinations, separate from the Plaintiff's symptoms. Aetna also clarified that the relevant standard for disability under the Plan is the ability to perform any occupation for at least 25 hours per week, rather than the ability to perform the Plaintiff’s previous job.