Charles v. UPS, Aetna, et al – Aetna Abused Discretion by Requiring Clinical Proof of Fatigue from Medication

Disclaimer: This was not a case handled by disability attorney Nick A. Ortiz. The court case is summarized here to give readers a better understanding of how Federal Courts decide long term disability ERISA claims.

Case Name: Charles v. UPS National Long Term Disability Plan, Aetna Life Insurance Company, et al.

Court: United States District Court for the Eastern District of Pennsylvania.

Type of Claim: As part of his employment with UPS, the Plaintiff participated in the UPS National Long-term Disability Benefits Plan.

Insurance Company: Aetna Life Insurance Company (hereinafter “Aetna”).

Claimant’s Employer: UPS.

Claimant’s Occupation / Job Position: Plaintiff started with UPS as a Pre-loader / Porter, and was promoted to a package car driver.

Disabilities: partial complex seizure disorder with grand mal seizures. His neurologist prescribed a medication called lamotrigine, also known as Lamictal, to control his seizures. Because he was taking anti-seizure medication, the plaintiff could no longer drive a truck for UPS because Department of Transportation regulations prevented him from doing so.

Definition of Disability:
The terms of the LTD plan dictate that the test for determining whether a participant is disabled changes after two years. A participant’s initial determination of disability is based on whether he is disabled from his “own occupation.” After receiving benefits for two years, a participant will only continue to receive benefits if he is unable to perform any “reasonable occupation.” The plan defines a “reasonable occupation” as “any gainful activity” for which a participant is “or may reasonably become, fitted by education, training, or experience; and [w]hich results in, or can be expected to result in, an income of more than 60% of your adjusted predisability earnings.”

Benefits Paid? Aetna authorized the plaintiff to receive LTD benefits for two years, then terminated benefits.

Procedural history: The claimant received LTD benefits during the “own occupation” period, but benefits were terminated after 24 months at the beginning of the “any occupation” period. Aetna terminated the plaintiff’s benefits, claiming that there was insufficient medical evidence in the administrative file to support a part-time work restriction

Key Physician Opinions: In support of his appeal, the plaintiff submitted a letter from his primary care physician dated March 20, 2012 stating that he was restricted to working part-time because the Lacmital used to treat his seizures caused him significant sedation. His physician stated “we must continue to limit his hours worked on a daily basis to 5 per day, for his health and safety, as working longer hours would put him at risk of making mistakes due to fatigue and somnolence, including potentially falling asleep at the wheel on the way home.”
After the claimant’s appeal of the termination of benefits, Aetna referred the plaintiff’s case for another peer review. Ultimately, the peer review doctor – Dr. Root – found that “there [was] a lack of documented evidence of objective neurological functional impairment in the claimant from 2/18/12 to 5/31/12 which would preclude him from working any occupation.

Issues: (1) Aetna argues that there was insufficient medical evidence to support a finding of impairment. Specifically, Aetna argues that there was no clinical evidence to show that the plaintiff’s seizure medication adversely affected him, requiring a restriction to part-time work. This was Aetna’s rationale for denying the plaintiff’s claim on appeal. (2) Whether Aetna had an inherent conflict of interest which tainted its decision. (3) Whether Aetna’s use of the plaintiff’s vocational analysis was an abuse of discretion. (4) Whether Aetna’s review of the plaintiff’s administrative appeal was an abuse of discretion.

Holdings: (1) Aetna’s denial of the plaintiff’s claim based on a lack of clinical evidence was an abuse of discretion. “Though it’s not clear what type of clinical evidence Aetna thought was missing, Aetna implicitly argues that the plaintiff’s self-reported feelings of fatigue and his doctor’s diagnosis that Lacmital caused this sedation were not enough to show disability. Aetna’s expectation that the plaintiff should undergo some additional “clinical” test to prove that he is, in fact, experiencing fatigue from his medication is arbitrary and capricious.” (2) “Aetna is an insurance company that both evaluates and pays for LTD benefits under the Plan. This situation presents a conflict of interest. This conflict does appear to have influenced Aetna’s decision. From the beginning of the “reasonable occupation” review, Aetna’s notes indicate that its biggest concern was with the bottom line. After determining that the plaintiff would need to be making over $30 hour under his current restrictions, Aetna then referred his case for a peer-to-peer review to determine if the part-time restriction only (not any of the other restrictions) was necessary. This sequence of events raises questions about the propriety of Aetna’s ultimate decision.” (3) The Court held that the vocational analysis offered jobs that were not “reasonable” under the terms of the plan, given the plaintiff’s noted work restrictions. (4) The Court stated, “From the record provided, Aetna did not seem to consider the additional information offered by the plaintiff in rendering its appeal decision.” There was no indication in the record that Aetna did anything to resolve the conflicting medical opinions or to include the additional opinion evidence provided by the plaintiff’s treating physician into its analysis. “For example, Aetna did not order an independent medical examination.” The Court further stated, “Overall, Aetna’s determination appears to have given great weight to their own experts while giving little, if any, consideration to the plaintiff’s own treating physicians. Without further explanation, this is an abuse of discretion.”

Summary: Aetna’s denial of LTD benefits was an abuse of discretion. “An administrator’s decision is arbitrary and capricious “if it is ‘without reason, unsupported by substantial evidence or erroneous as a matter of law.’” [citations omitted]. Aetna’s decision to deny the plaintiff benefits was unsupported by substantial evidence and was, thereby arbitrary and capricious. Aetna gave great weight to the opinions of its own experts and afforded little, to no, weight to the plaintiff’s own physicians. Under the circumstances, the plaintiff’s physicians—who had been treating him for several years—would be better able to recommend health and safety conditions than doctors who simply reviewed his medical files. From reading the record, it is clear that Aetna’s goal was to deny the plaintiff’s claim.” (emphasis added).

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