Murphy v. Aetna

Case Name: Marjorie Murphy v. Aetna Insurance Company

Court: U.S. District Court for the District Court of Rhode Island.

Date of Decision: January 24, 2017.

Type of Claim: Long Term Disability.

Insurance Company: Aetna Insurance Company.

Claimant’s Employer: FM Global.

Claimant’s Occupation / Job Position: Claim Technical Assistant.

Disabilities: Acute liver failure related to alcoholic hepatitis. Although Murphy’s liver disease stabilized after hospitalization and abstinence from alcohol, she still suffers from cirrhosis, renal insufficiency, pancreatitis, and liver disease.

Definition of Disability in the Plan/Policy: After the first two-year ”own occupation” period, Murphy’s eligibility for receiving LTD benefits depended on a determination that she was unable to work at “any reasonable occupation.”

Other Key Definitions in the Plan/Policy: “Reasonable Occupation” was defined in the Policy as “any gainful activity for which you are, or may reasonably become, fitted by education, training, or experience. It does not include work under an Approved Rehabilitation Program.”

Benefits Paid? Yes. Under the Policy, Murphy received LTD benefits for the first two years after a “waiting period”, because she was unable to work at her own job at FM Global.

Basis For Denial / Termination of Benefits: Aetna terminated Murphy’s disability claim by letter dated July 2, 2014, based on the medical records provided by Dr. Mis and his advice regarding Murphy’s current level of functional capacity and in consideration of the result of the TSA analysis. Aetna advised Murphy that if she wished to appeal the decision, Aetna would review additional materials, including a narrative report detailing her specific physical and/or mental limitations placed on her by her doctor, diagnostic studies, and any other information specific to her condition or that would assist in the review of her claim.

Procedural history: Murphy appealed Aetna’s decision to terminate her LTD benefits by letter dated July 14, 2014, enclosing a July 3, 2014 letter from Dr. Mis, in which he opined that it “would be hard” for Murphy to “perform repetitive tasks and sustain [a] part-time or even full-time employment schedule.”

Subsequently, Aetna Senior Appeal Specialist Susan Dorman concluded that Murphy’s disability claim was not supported, noting that “[t]here was a lack of medical evidence to support impairment from any reasonable (sedentary) occupation. File lack [sic] abnormal examination findings, or diagnostics to substantiate a specific functional deficit.”

Murphy thereafter filed a complaint in Federal Court against Aetna. The parties submitted cross-motions for summary judgment on August 15, 2016 (ECF Nos. 14, 16). After Magistrate Judge Sullivan issued an R&R on November 22, 2016, Murphy filed an objection on December 9, 2016, to which Aetna responded with a reply on December 22, 2016.

Key Physician/Medical Provider Opinions: The Administrative Record reflects that Murphy was regularly seen by Dr. Mis and that he reported his findings and conclusions to Dr. Callahan. In a March 10, 2011 letter, Dr. Mis noted, inter alia, that Murphy’s cirrhosis and renal insufficiency were “stable;” that she suffered from fatigue; and that she “remained quite active going swimming on a daily basis.” Subsequent letters by Dr. Mis reflect that Murphy, who had undergone surgery for a complete hip replacement in 2011, continued to complain of fatigue, but that she continued to swim daily and tried to get motivated to do aerobic exercise at the gym.

Murphy’s case was reviewed by Aetna staff clinical consultant Kimberly Harris, R.N. (“Nurse Harris”) on January 25, 2013, after which she recommended that Aetna Senior LTD Claims Analyst Richard Collins (“Collins”) obtain additional records from Dr. Mis to evaluate Murphy’s functional capacity. After receiving additional information from Dr. Mis, Nurse Harris noted that Dr. Mis opined that Murphy was unable to work but that “[m]edical information does not support that [Murphy] would be precluded from frequent sitting, occasionally standing/walking and lifting up to 10 lbs. And her activities appear to be beyond these activities.” The record also reflects that Harris attempted to call Dr. Mis’s office twice and that, although Dr. Mis subsequently left a message that he would call back, he did not do so.

Aetna Senior LTD Claims Analyst Richard Collins requested by letter to Murphy that she have Dr. Mis provide a response to Aetna’s “narrative request regarding your functional capacity” for “continued review of your [LTD] claim.” In response to Collin’s request, Dr. Mis returned the provided form and under “level of capacity she has on a full time basis,” he checked the option for “S-Sedentary work.” That category was further described as involving “sitting most of the time, but may involve walking or standing for brief periods of time,” as well as exerting up to 10 pounds of force occasionally and/or a negligible amount of force frequently to lift, carry, push, pull, or otherwise move objects. Dr. Mis noted that Murphy had “[n]o specific restrictions except for what she can tolerate” and that she suffered from “chronic fatigue and often needs to rest after periods of activity.”

After the benefits were terminated and after Murphy’s appeal, an “independent peer review” of Murphy’s records by Manoj K. Mehta, M.D. – which included a teleconference with Dr. Mis – resulted in the same conclusion: that Murphy was not “impaired” in order to qualify for LTD benefits. Aetna next obtained a Functional Capacity Evaluation (“FCE”), which concluded that Murphy “demonstrated physical abilities at the SEDENTARY physical demand level.”

Vocational Analysis by Aetna: Murphy’s file was then referred for a Transferable Skills analysis (“TSA”), evaluating, inter alia, Murphy’s work experience, education and training, functional capacities/restrictions, and her transferable skills. Based on that information, Senior Vocational Field Case Manager Donna Kisslinger Abram concluded that Murphy’s background was compatible with four identified jobs in the open labor market at her reasonable wage level in the local market.

Issues: The matter before the Court is Murphy’s objection to the November 22, 2016 Report and Recommendation (“R&R”), in which Magistrate Judge Sullivan recommended that Murphy’s motion be denied and Aetna’s motion be granted.

Murphy raises four specific objections to the R&R.
(1) First, she suggests that Aetna’s denial of the continuation of LTD benefits was “largely based upon a Functional Capacity Evaluation (‘FCE’) performed at the behest of Aetna.”
(2) Further, Murphy argues that the R&R “overlooked manifest deficiencies with that FCE that destroyed its evidentiary value.”
(3) Murphy argues that the R&R failed to apply established case law requiring the reviewer to examine the record as a whole and to refrain from mischaracterizing the record.
(4) Finally, Murphy maintains that she was denied the opportunity for a full and fair review at the internal administrative level “in that Aetna failed to adequately inform her of the type of evidence necessary to perfect her appeal.”

Holdings: (1), (2) and (3) Murphy’s suggestion that Aetna’s denial of her internal administrative appeal was largely based on the Functional Capacity Evaluation (“FCA”) requested by Aetna finds no substantiation in the record, nor does the FCA contain manifest deficiencies that “destroyed its evidentiary value.” Rather, the FCA was only one element in a rather extensive record and, as such, it was generally consistent with prior observations by Murphy’s physician, which reflected, inter alia, an improvement in her overall health and in Murphy’s reported activities, while acknowledging consistent self-reporting of fatigue.

(4) As to Murphy’s argument that Aetna failed to adequately inform her of the type of evidence necessary to perfect her appeal, this plaint cannot carry the day. Aetna’s July 2, 2014 cancellation notice informed Murphy that Aetna would review “any additional information you care to submit, such as medical information from all physicians who have treated you for the condition(s).” This invitation was followed by a four-point descriptive list of items, including (1) a detailed narrative report, (2) diagnostic studies, (3) information specific to the condition(s) related to Murphy’s disability, and (4) any other information or documentation that might assist Aetna in reviewing the case. It is undisputed, and the record reflects, that in response to this notification, Murphy submitted no new physical examinations or diagnostic test results; rather, her appeal was supported primarily by a letter describing, inter alia, aspects of her health and her disagreement with Dr. Mis’s evaluation that she could return to a sedentary occupation on a full time basis. Dr. Mis’s July 3, 2014 follow-up letter, written in connection with Murphy’s appeal, offers no specific, fact-based support for her disability claims. Dr. Mis’s general suggestion that Murphy “cannot sustain a steady work environment” appears to be inconsistent with some of his earlier reports, as well as his assessment of Murphy’s capacity for carrying out a sedentary occupation. At the same time, Dr. Mis advises Murphy to exercise and volunteer to “improve her quality of life.”

Noteworthy court comments: The record, when viewed in its entirety, reveals that Murphy has made a remarkable, almost unexpected recovery after initially being hospitalized for acute liver failure and being considered for a liver transplant. Murphy still suffers from what appear to be related ailments, such as cirrhosis, renal insufficiency, pancreatitis and liver disease; she also underwent hip and shoulder replacement surgeries due to her osteoarthritis. Notwithstanding these serious health issues, Murphy’s condition appears to have stabilized sufficiently for her to engage in a number of normal activities, such as parenting and engaging in regular exercise. At some point during her recovery, Murphy reported that she was quite active and that, although she still felt fatigued, she was bored and considered going back to work.

Summary: When considering the record as a whole, the Court is of the opinion that Aetna’s denial of LTD benefits to Murphy was supported by substantial evidence therein and that Murphy has not met her burden to establish that such denial was arbitrary and capricious. Accordingly, Murphy’s objections to Aetna’s denial cannot withstand Aetna’s motion for summary judgment.

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.
Be the first to comment!
Post a Comment