Cannon v Aetna – LTD Insurer’s Internal Guidelines Do Not Impose Any Duty on Insurer or Provide Claimant Any Rights

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: Cannon v. Aetna Life Insurance Company

Court: United States District Court for the District of Massachusetts.

Type of Claim: Long Term Disability.

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

Claimant’s Employer: PharMerica Corp.

Claimant’s Occupation / Job Position: Pharmacist.

Disabilities: gastroparesis, syncope, and working diagnoses of paroxysmal atrial fibrillation, lyme disease, Parkinson’s disease and multiple sclerosis with symptoms of exhaustion, pain, occasional swelling in his knees, headaches, dizzy spells, sweats, chills, muscle cramps, occasional burning or itching on parts of his body and nonspecific rashes over his upper chest.

Note: Another one of the insurance company’s “independent medical” physicians dismissed Cannon’s “subjective complaints of nausea, vomiting, weight loss and episodes of dizziness leading to falls” because “the records have not documented persistently abnormal physical examination findings or laboratory studies that would support functional impairments from the claimant’s medium occupation other than his dates of hospitalization.” This physician concluded that Cannon’s self-reported symptoms of nausea, vomiting, weight loss and dizziness may have been the result of excessive alcohol use or alcohol withdrawal.

Benefits Paid? Short Term Disability benefits were paid for approximately five weeks. Based upon a non-examining doctor’s review and the underlying medical documentation, Aetna informed Cannon that “there [was] no evidence of a functional impairment which would substantiate an inability to perform [Cannon’s] occupation starting from October 4, 2010.”

Procedural history: The claim was remanded to allow the independent reviewing physicians to update their reports after the record was supplemented with additional medical records that were determined to be missing. After remand, Aetna did determine that Cannon was unable to perform his own occupation for two short periods of time in 2011 due to hospitalization for alcohol abuse and withdrawal symptoms. However, Aetna noted that those two time periods were after the expiration of the maximum STD benefits period, and that Cannon was also ineligible for benefits at those times because he had ceased active employment by each of these periods. The claimant then exhausted his administrative appeals.

Issues: (1) According to Cannon, Aetna unreasonably focused on the lack of definitive diagnosis rather than the disabling effects of his symptoms. (2) Cannon argued that it was arbitrary and capricious for Aetna to fail to consider the Social Security Administration’s (SSA’s) award of Social Security Disability Insurance (SSDI) benefits. (3) Aetna’s claim manual provides that if “the IME [independent medical examination]. . . disagrees with the level of the claimant’s functionality, the DMB or Clinical Consultant will provide a copy of the IME to the AP [attending physician], and ask the AP(s): [t]o review the IME . . . and advise which areas of the report the AP(s) agrees with[;] and which aspect of the report the AP(s) disagree with, and . . . to provide the clinical basis for their disagreement.” Aetna did not ask Dr. Chiang, Cannon’s attending physician, to review the IME reports and obtain his assessment of areas of agreement and disagreement. Cannon argues that Aetna did not follow its own internal guideline instructing its staff to relay the reviewing physicians’ contradictory determinations to Dr. Chiang and solicit his response, and that this was legal error.

Holdings: (1)The Court held that, taken as whole, Dr. Weinstein’s (the independent medical physician’s) report provided reasonably sufficient support for denying Cannon’s claimed benefits and that Aetna’s determination therefore was not arbitrary and capricious. The court later stated, “Moreover, Cannon failed to meet his obligation to produce objective evidence that he was unable to perform his own occupation.” (2) The Court held, “The Court cannot conclude that this is the “rare case” where an identical comparison of the statutory and plan criteria indicates that the SSA decision must be accorded controlling weight, … particularly where the fact of the SSDI award of benefits is contained in the record, but not any documentation of the claim made and the reasoning employed by the SSA. The Court concludes that it was not arbitrary and capricious for Aetna not to consider the SSDI benefits award.” (internal citations omitted). (3) The Court held Aetna’s guidelines do not provide any legal right to Cannon or impose any legal duty on Aetna. (citing, Martin v. Polaroid Corp. Long Term Disability Plan, No. Civ. A. 03-11507-RGS, 2004 WL 1305661, at *2 (citing Doe v. Travelers Ins. Co., 167 F.3d 53, 60 (1st Cir. 1999)). The Court added, “Moreover, the scope of the Court’s remand did not explicitly require a peer-to-peer consultation between Dr. Chiang and the independent reviewing physicians. The Court’s Order provided a ‘remand to allow the independent, reviewing physicians, including Dr. Weinstein, to update their reports after the record is supplemented with the additional medical records identified in Dr. Weinstein’s February 7, 2011 report, including records from Cannon’s primary care physician, Dr. Chiang.’ That was the extent of the action required by Aetna in this case; the Court did not require Aetna to reopen the administrative proceeding beyond the requested updated reports.”

Summary: In the Court’s own words, “In summary, the burden falls on Cannon to show he was entitled to STD benefits, a burden that he has not met here. Dr. Chiang’s APS and the SSA determination letter both provide some supporting evidence, but Aetna need not defer to Dr. Chiang as Cannon’s treating physician, Black & Decker, 538 U.S. at 834, and the SSA’s eligibility determination did not bind Aetna, Pari-Fasano, 230 F.3d at 420, and is devoid of the context and reasoning needed to inform Aetna’s determination. Cannon does not point to substantial evidence in the medical record that his symptoms impaired him to an extent that he was unable to perform his own occupation. Aetna’s determination, therefore, was not an abuse of discretion.”

Here is a PDF version of Cannon v. Aetna available for download:

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