Cannon v. Aetna – Aetna Not Bound By SSA Disability Determination

A pharmacist with multiple serious and unresolved diagnoses lost his long-term disability (LTD) case after the court found he failed to produce objective evidence that his symptoms prevented him from performing his job. The court also ruled that Aetna was not bound by the SSA’s award of Social Security disability benefits, particularly since no documentation of the SSA’s reasoning was included in the record.

Gregory Cannon, a pharmacist at PharMerica Corp, filed a claim for disability benefits under an Aetna policy after developing a complex set of conditions including gastroparesis, syncope, and working diagnoses of paroxysmal atrial fibrillation, Lyme disease, Parkinson’s disease, and multiple sclerosis. His symptoms included exhaustion, pain, dizziness, headaches, muscle cramps, and nonspecific rashes, among others.

Aetna paid approximately five weeks of short-term disability benefits before concluding — based on a non-examining physician’s review — that there was no evidence of functional impairment preventing Cannon from performing his job. After a court-ordered remand to supplement the medical record, Aetna did find Cannon unable to work during two brief hospitalization periods in 2011, but determined he was ineligible for benefits at those times because he had already exhausted his STD benefits period and was no longer actively employed. 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 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. 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 copy of the decision: Cannon v. Aetna