Gaines v. Aetna

Case Name: Ronda Gaines v. Aetna Inc.

Court: U.S. District Court for the Northern District of Georgia.

Date of Decision: March 31, 2015.

Type of Claim: Long Term Disability under ERISA.

Insurance Company: Aetna Life Insurance Company.

Claimant’s Employer: Aetna Inc.

Claimant’s Occupation / Job Position: Care Manager Consultant.

Disabilities: The Plaintiff suffered from multiple medical issues, including lupus, fibromyalgia, asthma, and mild degenerative joint changes.

Definition of Disability in the Plan/Policy:

Other Key Definitions in the Plan/Policy:

Benefits Paid?

Basis For Denial / Termination of Benefits: On August 2, 2010, the Plaintiff’s application for long-term disability benefits was denied when the plan administrator determined that the medical records did not support an inability to work. Specifically, the records indicated that the Plaintiff had improved after her thyroidectomy.

On November 2, 2010, ALIC upheld the initial denial of benefits to the Plaintiff. That denial was based on Dr. Borigini’s determination that the medical records did not show a physical basis for any limitations based on the Plaintiff’s lupus.

On June 21, 2011, the Plaintiff requested a third review of her file. With the request for the third review, the Plaintiff’s attorney submitted additional medical records, a physician questionnaire from Dr. Fowler, and the FCE, all attempting to document the Plaintiff’s inability to work.

ALIC based its final decision on September 12, 2011, on the independent clinical reviews as well as all information in the Plaintiff’s file. Specifically, ALIC noted the lack of serological evidence of active lupus, Dr. Alghafeer’s conclusion that the Plaintiff had no trouble driving, balancing, standing, or walking, and Dr. Ayyar’s conclusion that the Plaintiff’s pain was a result of personal tolerance not any disease.

Procedural history: Plaintiff appealed the initial denial of benefits under the Plan, stating that her request for disability was not based solely on her thyroid surgery, but rather on symptoms associated with lupus and chronic pain. On September 12, 2011, ALIC again upheld the denial of benefits to the Plaintiff.

As allowed under ERISA, the Plaintiff filed a lawsuit to challenge that decision. Both parties moved for judgment on the administrative record.

Other important factors: As a part of applying for long-term disability benefits, the Plaintiff underwent a Functional Capacity Evaluation (“FCE”). This evaluation was performed on May 20 and 23, 2011. Because the Plaintiff arrived 70 minutes late on the first day of the evaluation, a second day of evaluation was required. The evaluator noted, therefore, that the Plaintiff’s “functional abilities on a day-to-day basis could not be validated.” The evaluator additionally noted that in hand coordination activities performed at desk height, the Plaintiff displayed effort inconsistent with her ability to lift her purse. In all other activities, the Plaintiff used maximal effort. Specifically, the evaluator noted the level of effort using patterns of movement, heart rate, and blood pressure. The effort displayed in activities outside of finger flexion and hand coordination was consistent with the Plaintiff’s diagnoses, past medical and surgical history, and objective physical findings. The evaluator found that the Plaintiff was limited in her ability to tolerate seated work, which she could only do for up to 33% of the workday. Additionally, the evaluator found that the Plaintiff did not meet the Department of Labor qualifications for a sedentary position because she could tolerate up to ten pounds of force only occasionally and seated work activities for less than half of the workday.

Key Physician Opinions: On June 30, 2010, Dr. Fowler’s office notes stated that the Plaintiff’s lupus occurred randomly, was improved, and had no associated symptoms. Dr. Fowler also completed an Attending Physician’s Statement on June 30, 2010. In that statement, Dr. Fowler stated that the Plaintiff was unable to work and noted several times her difficulty sitting for long periods of time. At a visit to Dr. Fowler on August 2, 2010, the Plaintiff’s medical records reflect that her chronic pain issues were still prevalent and that “standing or walking for prolonged periods” was difficult.

The physician questionnaire, completed by Dr. Fowler, indicated the diagnoses of lupus, fibromyalgia, hypoparathyroidism, hypocalcemia, renal disease, and depression. Dr. Fowler stated that the Plaintiff presented with multiple trigger points consistent with fibromyalgia, ankle tenderness and edema, chronic low back and lower extremity pain, and chronic fatigue. He also noted the Plaintiff’s list of medications, including 20 milligrams of Oxycontin every 12 hours. Dr. Fowler further stated that the medications contributed to the Plaintiff’s fatigue, that her pain affected her ability to maintain attention and concentration in
daily work activities, and that she was not able to sustain a 40-hour work week.

On September 28, 2010, the Plaintiff’s file was referred to Dr. Mark Borigini for review. Dr. Borigini is an independent physician who is board certified in internal medicine with a specialty certificate in rheumatology and added expertise in fibromyalgia. Upon review of the Plaintiff’s medical records, Dr. Borigini noted diagnoses of chronic pain, lupus, fatigue, hypothyroidism, and mild degenerative joint disease. He further explained that aside from one note mentioning PIP swelling, the medical records contained no documentation that the Plaintiff’s lupus was persistently active or of any major organ involvement related to lupus. Dr. Borigini’s opinion was that the Plaintiff could continue work, at least on light duty, given that there was no documentation of inability to work and that one of Dr. Fowler’s notes in June 2010 stated that the Plaintiff could work light duty.

On August 12, 2011, the Plaintiff’s claim was submitted to a rheumatology specialist for further independent review. That specialist, Ibrahim Alghafeer, reviewed the Plaintiff’s records from a rheumatology perspective. After review of the Plaintiff’s records, Dr. Alghafeer noted diagnoses of lupus, fibromyalgia, and arthritis. He noted the FCE results indicating that the Plaintiff did not meet the demands of sedentary work due to her inability to handle up to ten pounds of force and inability to tolerate sitting for most of the time.

On August 12, 2011, a third independent physician, Dr. Siva Ayyar, who is board certified in occupational medicine, reviewed the Plaintiff’s file. Dr. Ayyar disregarded the results of the FCE, stating that based on his review, the evaluator stated that the Plaintiff gave inconsistent effort throughout the evaluation. He stated that the Plaintiff’s constraints were the result of deconditioning, absence from the workplace, poor tolerance to pain, and individual motivation and desire. After noting that the Plaintiff’s principal issues were fibromyalgia, lupus, and chronic pain, Dr. Ayyar stated that “[p]ain, however, in and of itself, should not be a debilitating or disabling issue.” He then continued by stating his opinion that the Plaintiff could work in excess of the limits set by the FCE and Dr. Fowler, but for her lack of personal tolerance. Dr. Ayyar’s opinion was that the Plaintiff’s inability to work was not due to her medical diagnoses, but rather to her desire and motivation to work. He believed that a sit/stand accommodation would assist the Plaintiff in returning to work.

Issues: After it found the insurance company’s decision to deny benefits de novo wrong, the Court turned its attention to determining whether the plan administrator’s decision was reasonable.

Holdings: (1) “While courts may not require a plan administrator to give special deference to a treating physician’s opinion, “plan administrators may not arbitrarily refuse to credit a claimant’s reliable evidence, including the opinions of a treating physician.” Plan administrators may rely on independent medical opinions and credit those opinions over the opinions of treating physicians. Inconsistencies in a treating physician’s records cast doubt on the reliability of that physician’s assessment. Specifically with regard to chronic pain syndrome and fibromyalgia, however, the Eleventh Circuit has found that plan administrators acted arbitrarily and capriciously when they ignored physical examinations, medical reports, and self-reported symptoms related to those conditions. Additionally, it is arbitrary and capricious for plan administrators to rely on flawed peer reviews that mischaracterize evidence, ignore evidence, or come to findings contradicted by the evidence.

Here, the Defendant refused to credit reliable evidence from the Plaintiff’s medical records and relied on flawed peer reviews.”

“While it is certainly reasonable for plan administrators to rely on independent physicians, and even to credit those physicians’ opinions over the opinions of treating physicians, it is not reasonable for plan administrators to rely on opinions like those of Drs. Alghafeer and Ayyar that ignore and mischaracterize evidence. The plan administrator’s decision here was therefore unreasonable.”

Noteworthy court comments: “Here, the Defendant refused to credit reliable evidence from the Plaintiff’s medical records and relied on flawed peer reviews. Specifically, Dr. Alghafeer, the rheumatology specialist, ignored evidence that the Plaintiff was unable to walk and had excessive fatigue. In coming to his conclusion, he stated that the Plaintiff’s medical records indicated no “sleepiness or fatigue that affected her ability to drive, balance, stand or walk.” This ignores evidence that the Plaintiff came to at least one doctor’s appointment in a wheelchair, came to one using a cane, and numerous references by Dr. Fowler to chronic pain and fatigue that affected movement. It also ignores Dr. Hanna’s note stating that the Plaintiff had muscle weakness that prevented her from engaging in day-to-day activities.

Dr. Ayyar, the occupational medicine specialist, ignored the diagnosis of chronic pain syndrome and attributed all of the Plaintiff’s complaints to personal tolerance. In coming to this conclusion, Dr. Ayyar ignored statements from both the Plaintiff herself and Dr. Fowler that she was motivated and wanted to return to work. Dr. Ayyar actually stated that chronic pain cannot be disabling in and of itself. This is directly contrary to the Eleventh Circuit’s decision in Lee. Dr. Ayyar also stated that Dr. Fowler failed to document the frequency or amount of opiate medications taken by the Plaintiff, relying on this failure to determine that the Plaintiff’s inability to concentrate due to her medications was unfounded based on the records. Contrary to Dr. Ayyar’s statement, however, Dr. Fowler did document at least once that the Plaintiff was taking 20 milligrams of Oxycontin every 12 hours.

Furthermore, the Plaintiff’s subjective complaints, when uncontradicted, and in fact supported by evidence, namely the FCE, do constitute medical evidence. This is not a situation like that in Ray, where the employee’s subjective complaints were directly contradicted by video surveillance evidence. Both independent physicians who reviewed the Plaintiff’s file after the FCE was performed mentioned it in their reviews. Dr. Alghafeer gives no indication, however, that the FCE factored into his decision. Dr. Ayyar references the FCE at length, but discredits it, stating “[a]s noted by the evaluator, Ms. Gaines gave inconsistent effort throughout the evaluation.” Dr. Ayyar’s statement mischaracterizes the evidence – the evaluator stated only that the Plaintiff displayed inconsistent effort with regards to grip strength and hand coordination, not throughout the evaluation. In fact, the evaluator provided objective pulse and blood pressure evidence that the Plaintiff was using maximal effort in other activities. While it is certainly reasonable for plan administrators to rely on independent physicians, and even to credit those physicians’ opinions over the opinions of treating physicians, it is not reasonable for plan administrators to rely on opinions like those of Drs. Alghafeer and Ayyar that ignore and mischaracterize evidence. The plan administrator’s decision here was therefore unreasonable.”

Summary: “For the reasons stated above, the Plaintiff’s Motion for Judgment/Trial on the Papers is GRANTED. The Defendant’s Motion for Judgment on the Administrative Record is DENIED. The Plaintiff is entitled to a judgment awarding her 18 months of Long-Term Disability benefits and the matter is remanded to Aetna to determine whether she is disabled from any occupation.”

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.
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