Court: District Court, D. Delaware; March 30, 2012; Federal District Court
Linette Fisher filed a lawsuit against Aetna Life Insurance Company under ERISA, alleging unlawful denial of short-term disability (STD) benefits related to her employment with Bank of America. Fisher claims the denial was arbitrary and seeks declaratory relief for benefits, interest, attorney fees, and costs, or alternatively, a requirement for Aetna to consider all evidence regarding her claim. Aetna moved to dismiss a breach of fiduciary duty claim, which was later stipulated to be dismissed without prejudice by both parties. The court has jurisdiction to hear the case and is currently reviewing cross motions for summary judgment on Fisher’s claim for STD benefits.
The court granted Fisher’s motion, denied Aetna’s, and remanded the decision for further consideration by the claims administrator. Aetna acts as a third-party claim administrator for Bank of America’s STD plan, which requires an employee to be deemed "disabled" for more than seven consecutive days due to specific conditions. To qualify for benefits, employees must have continuous medical care and provide satisfactory medical evidence of their disability. Benefits end under certain conditions, including the determination by a medical provider that the employee is no longer disabled. If coverage is denied, claimants have the right to appeal, and the plan allows for a second opinion, with a third opinion required if there is a conflict between the original and second opinions, which is jointly selected and paid for by the company.
Fisher worked as a Credit Card Analyst at Bank of America for fourteen years, primarily in a sedentary role. On April 17, 2009, she filed for Short-Term Disability (STD) benefits, Family Medical Leave Act (FMLA), and Bank of America Medical Leave (BACMED) after failing to report to work. Aetna acknowledged her STD claim on the same day and requested a medical information release form, which Fisher returned on April 24, 2009. Aetna denied her STD benefits on May 1, 2009, citing a lack of specific clinical information from her provider, Dr. Townsend, despite multiple attempts to obtain it.
Fisher appealed the denial on May 7, 2009, indicating her physician would send the necessary documentation shortly. On the same day, she underwent an MRI, which showed no intracranial abnormalities. On May 12, 2009, Nurse Susan Townsend faxed an Attending Physician Statement (APS) to Aetna, diagnosing Fisher with migraine headaches and stating she was unable to work but could perform daily activities. Nurse Townsend noted that Fisher's restrictions were indefinite and listed her medications.
By June 1, 2009, Aetna approved Fisher for BACMED and FMLA leave. A follow-up appointment on June 2, 2009, indicated that Fisher's headaches were stress-related and improved during her vacation, though she still suffered from sensitivity and mild nausea. Nurse Townsend requested an extension of Fisher’s FMLA leave through July 16, 2009, citing the necessity of absence during migraine flare-ups, which occurred bi-monthly. Further testing on June 2, 2009, again revealed no neurological explanations for her symptoms. On June 6, 2009, Nurse Townsend issued a second APS, reiterating that Fisher had no ability to work with an undetermined return date.
Nurse Townsend documented various objective evidence types, including MRI and MRA results, physical and mental exams, as well as the Patient Health Questionnaire 9 (PHQ 9) and Mood Disorder Questionnaire (MDQ), although no results from the latter two were present in the records. On June 8, 2009, Fisher contacted Aetna regarding the denial of benefits dated May 1, 2009, explaining that she had sent an appeal letter, which Aetna could not locate. Adrienne Bowman from Aetna indicated that the initial denial was due to “insufficient objective documentation” regarding Fisher's inability to work due to headaches. On June 25, 2009, Aetna acknowledged receipt of Fisher's appeal request letter, stating she would receive a response within 45 days.
Fisher’s medical visit on July 2, 2009, revealed ongoing headaches, with medications including HCTZ, Celexa, and Topamax. Subjective notes suggested some improvement but ongoing symptoms like nausea and sensitivity to light and sound. Dr. Townsend adjusted Fisher’s medications to better manage her condition. On July 10, 2009, Fisher authorized the release of her medical records to Aetna. By July 22, Aetna determined Fisher had complied with documentation requests, overturning the initial denial of her STD benefits effective April 17, 2009, and sending the claim for further review.
Fisher's follow-up on August 11, 2009, indicated minor improvements with the medication, yet she reported visual disturbances and sleep issues. Dr. Townsend noted normal objective findings and reduced Fisher's Topamax dosage. A note faxed to Aetna on September 1 confirmed Fisher's disability extended through at least August 11, 2009. However, Aetna denied her appeal on September 2, citing insufficient information regarding her job performance capabilities and normal test results. Fisher was informed of her right to appeal within 180 days. Fisher returned to work on September 21, 2009. Her attorney notified Aetna of the intention to appeal on November 13, 2009, and Aetna confirmed receipt of the appeal on November 25, stating a decision would be communicated within 45 days, which later extended due to the need for further medical review.
Dr. Steve Swersie, an internal medicine specialist, reviewed Fisher’s claim on December 22, 2009, finding insufficient evidence to support a claim of functional impairment throughout the relevant period. Although Fisher exhibited some symptoms, Dr. Swersie concluded that these were not severe enough to hinder her daily activities or work. He deemed the restrictions imposed after April 17, 2009, inappropriate. Dr. Vaughn Cohan, a neurologist, reviewed the claim on December 24, 2009, and similarly noted a lack of documentation indicating that Fisher's headaches were severe enough to prevent her from performing daily activities, including work. Despite Dr. and Nurse Townsend's support for Fisher’s absence from work, Dr. Cohan determined that the provided documentation did not substantiate a level of impairment warranting her continued absence. He attempted to reach Dr. Townsend for further information on January 4-6, 2010, and Aetna faxed Dr. Townsend the reports from Drs. Swersie and Cohan, requesting a response by January 21, 2010, but received none. On February 12, 2010, Cenatus informed Fisher, through her attorney, that her short-term disability (STD) benefits were denied due to insufficient medical evidence of her inability to perform essential job functions. Aetna also indicated Fisher’s right to pursue civil action within one year if she disagreed with this decision.
The document further outlines the summary judgment standard, stating that a court may grant summary judgment if there are no genuine issues of material fact, with the moving party bearing the burden of proof. If the moving party meets this burden, the nonmoving party must then present specific facts demonstrating a genuine issue for trial. The court must view facts and inferences in favor of the nonmoving party, but mere existence of evidence is insufficient; there must be enough for a jury to reasonably find in favor of the nonmoving party on the disputed issue. If the nonmoving party fails to show sufficient evidence on an essential element of its case, the moving party is entitled to judgment as a matter of law.
ERISA permits beneficiaries to sue administrators or fiduciaries for benefits owed under a plan. Courts typically review benefit denials de novo unless the plan grants discretionary authority, in which case an arbitrary and capricious standard is applied. Under this standard, the burden is on the plaintiff to demonstrate that the administrator's benefits denial was unreasonable, unsupported by substantial evidence, or legally erroneous. The review is confined to the record before the plan administrator, and a decision meets the substantial evidence threshold if reasonable people might agree with it. In this case, the court must assess Aetna's denial of benefits under the arbitrary and capricious standard because Aetna has discretionary authority. Fisher outlines four reasons justifying summary judgment under this standard: (1) Aetna's acknowledgment of Fisher's disability for FMLA and BACMED benefits, (2) Aetna's failure to consider all of Fisher's conditions affecting her work capability, (3) the imposition of an unattainable objective disability requirement, and (4) Aetna's preference for a consultant's medical opinion over Fisher's treating physician's opinion. The discussion also highlights the relevance of inconsistent benefit awards, referencing the Glenn case where a participant was found disabled by the SSA but deemed capable by the plan administrator. Fisher was granted both FMLA and BACMED benefits, with FMLA benefits requiring specific information from a healthcare provider's certification. Aetna approved Fisher's FMLA leave based on her physician's certification, which documented her incapacity due to migraines and anxiety. The ability to reconcile the granting of FMLA leave with the denial of short-term disability (STD) benefits is noted, as BACMED serves associates who do not qualify for STD benefits.
The court determines that denying short-term disability (STD) benefits while awarding benefits under the Family and Medical Leave Act (FMLA) and BACMED is consistent and not arbitrary. STD benefits require proof of disability, defined as the inability to perform essential job functions for over seven consecutive days due to various medical conditions, which necessitates physical examinations or objective medical evidence—requirements not present under FMLA or BACMED.
Regarding the evaluation of relevant diagnoses, the court references a precedent where failure to address all pertinent medical conditions raised concerns of arbitrariness. In this case, Fisher was diagnosed with both migraine and muscle tension headaches. Fisher claims that Aetna did not adequately consider the impact of muscle tension headaches on her work capacity, citing that Aetna's neurologist focused only on migraine evidence. However, the court finds that Aetna's review included both diagnoses, as reflected in the opinions of Drs. Swersie and Cohan, who acknowledged the separate conditions and their effects on Fisher's symptoms.
Additionally, the court addresses the requirement for objective medical evidence. It notes that demanding objective tests for conditions lacking such evidence can be deemed arbitrary. Fisher argues that chronic muscle tension headaches, like fibromyalgia, often cannot be substantiated by objective evidence. Aetna contends that the plan's stipulation for objective evidence justifies the denial of Fisher's claim, asserting that Dr. Townsend's findings provided objective support for her disability. The court concludes that Aetna's assessments, including normal results from various objective tests, served to rule out other diagnoses rather than solely to substantiate Fisher's claims.
Notes from Dr. and Nurse Townsend indicate the presence of objective evidence; however, the information related to Fisher’s headaches is primarily subjective. The court must evaluate whether the requirement for objective evidence regarding Fisher's headaches is arbitrary and capricious, particularly in cases like fibromyalgia and migraines where objective evidence may not be available. Aetna denied Fisher's claim, citing insufficient medical evidence to support her inability to perform her job functions. This denial is deemed arbitrary and capricious if based solely on the lack of objective evidence for Fisher's subjective headache complaints.
In ERISA claim denials, plan administrators are not required to defer to treating physicians, particularly when conflicting medical opinions exist. The plan allows administrators discretion to weigh evidence, and favoring certain medical opinions over others is not necessarily an abuse of discretion. However, administrators cannot arbitrarily disregard reliable evidence, including treating physician opinions. Fisher argues that Aetna's reviewing physicians ignored her treating physician’s observations, making Aetna's reliance on their reports arbitrary and capricious. Aetna contends that its physicians considered Dr. Townsend’s opinion and that favoring their opinions over Fisher's treating physicians was not arbitrary.
Dr. Cohan, Aetna's reviewing neurologist, acknowledged Dr. Townsend's support for Fisher’s absences but concluded that the documentation did not demonstrate sufficient impairment to justify continued absences. He noted a lack of evidence for a functional impairment affecting Fisher's ability to perform her specific job duties. Dr. Cohan also attempted to contact Dr. Townsend multiple times to discuss Fisher's case but received no response.
Dr. Swersie referenced the medical notes of Dr. and Nurse Townsend regarding diagnoses and recommendations. The court determined that Aetna was not required to favor Dr. Townsend's opinion over those of Drs. Cohan and Swersie. Contrary to Fisher's claims, the administrative record showed that Drs. Cohan and Swersie considered all information from Dr. Townsend in relation to Fisher's job requirements. Aetna is not obligated to meet claimants in person before denying claims unless specifically stated in the Associate Handbook. Fisher criticized Aetna for not suggesting a jointly selected healthcare provider as per the handbook, which allows for a third provider's opinion to resolve conflicts. Aetna argued that this process pertains only to FMLA disputes, and while the court disagreed, it found Aetna's choice not to use a third provider was not arbitrary or capricious, as the plan permits, rather than requires, such action. The court affirmed that obtaining a second independent evaluation prior to claim determination is appropriate.
Regarding remedies, the court can either remand the case to the administrator for reevaluation or grant/deny benefits directly. Following the precedent set in Saffle v. Sierra Pacific Power Co., the court noted that remand is appropriate when an ERISA plan administrator misinterprets the plan. The court found Aetna’s denial of STD benefits to be arbitrary and capricious for requiring objective medical evidence for a condition (headaches) that is typically not measurable by standard tests. The court emphasized that administrators should thoroughly review medical records to establish a rational link between a claimant's subjective complaints and their ability to work. Consequently, the court remands the case for Aetna to reassess the claim in accordance with the opinion.
The court identified that the record contained mostly conclusory statements regarding Fisher's claims of headache-related disability, purportedly communicated through Nurse Townsend, indicating that her headaches were stress-related and severely impacted her ability to work. Aetna's decision to deny benefits must be accompanied by an explanation that specifically addresses Fisher's subjective complaints. The court granted the plaintiff's motion for summary judgment and denied the defendant's motion, remanding the benefits decision to the claim administrator for reevaluation in line with the court's opinion.
An order was issued on March 30, 2012, to enter judgment for the plaintiff and against the defendant, along with directives for further proceedings. The document referenced various medical tools like the APS for disability documentation, the PHQ-9 for depression diagnosis, and the MDQ for bipolar disorder diagnosis. It cited the legal framework allowing participants to seek recovery of benefits and clarified that non-FMLA-related plans may require additional information from employees. Additionally, it noted that if an employee does not provide required evidence under such plans, an employer cannot terminate unpaid FMLA leave. The court indicated that it can consider precedent from social security decisions and highlighted that Aetna could utilize non-medical evidence, like daily activities, in its benefit denial process. The discussion included the appropriateness of selecting a third physician for short-term disability claims.
