Colon Carter (“Carter”) worked as an estimating analyst for Bath Iron Works (“BIW”), a subsidiary of General Dynamics. His job duties included “developing cost proposals for new Navy and commercial work; developing and maintaining proposal support documents and checklists; creating financial models; maintaining company baselines for all Programs; assisting management with department staffing plans; and Earned Value Management System (EVMS) Analysis.” The job duties also indicated that Carter would have to perform a sedentary work level. Through his employment with BIW, Carter was covered by a long term disability plan which Aetna Life Insurance Company (“Aetna”) provided.
The Plan states that “Regular full-time employees of Bath Iron Works who are non-represented salaried employees are [eligible] for benefits under the Plan.” The definition of disability under the Plan is cited as:
“From the date you first become disabled and until Monthly Benefits are payable for 18 months, you will be deemed disabled on any day if: you are not able to perform the material duties of your own occupation solely because of: disease or injury; and your work earnings are 80% or less of your adjusted predisability earnings. After the first 18 months that any Monthly Benefit is payable during any period of disability, you will be deemed to be disabled on any day if you are not able to work at any reasonable occupation solely because of: disease or injury. If your own occupation requires a professional or occupational license or certification of any kind, you will not be deemed to be disabled solely because of the loss of that license or certification.”
“Own Occupation” is further defined as:
“The occupation that you are routinely performing when your period of disability begins. Your occupation will be viewed as it is normally performed in the national economy instead of how it is performed: for your specific employer; or at your location or work site; and without regard to your specific reporting relationship.”
In addition to these definitions, the Plan’s language limits its coverage to twenty-four months for certain conditions, including that of chronic pain syndrome.
On May 4, 2016, Carter applied for long term disability benefits for chronic pain syndrome, chronic spinal disorder, and chronic neuropathic pain. On August 2, Aetna denied this claim. A senior long term disability benefits manager at Aetna, William Diaz, noted a lack of “tests or objective records supporting” Carter’s claim and that there were no records with “findings of range of motion in degrees of upper extremities or spine, strength, tone, [or] reflexes of lower extremities.” Carter appealed this denial and submitted additional information.
In January of 2017, Aetna asked Carter’s Dr. Totta if he would be able to return to full-time employment. Dr. Totta stated that Carter’s symptoms would “occasionally to frequently” interfere with his work and “his ability to maintain his attention and concentration needed to perform his normal work duties.” At this point, William Diaz stated that “the information submitted and the attorney’s summary is not sufficient to overturn denial” of the claim, so he forwarded the file to Aetna’s appeals department.
Aetna then had an independent review done on Carter’s file. Dr. Howard Grattan reviewed the information and noted that Carter had “the ability to lift, carry, push, and pull 20 pounds occasionally and 10 pounds frequently.” He also found a suggestion by Dr. Totta that Carter have “breaks 10 minutes per every hour . . . [was] not well supported, as he does not have any ongoing neurological deficits.” Lastly, Dr. Totta also stated that “he could not provide objective physical changes to explain what changed” regarding “the time that [Mr. Carter] worked vs when he went out of work.” As a result, Aetna chose to uphold its denial, leading to the instant suit.
Carter’s main argument is that Aetna was arbitrary and capricious when it denied his claim because Dr. Grattan made a flawed review of his disability claim and Aetna then relied on that review. Alternatively, Aetna argues that “in the presence of conflicting evidence, it is entirely appropriate for a reviewing court to uphold the decision of the entity entitled to exercise its discretion.” Aetna further states that the record provides all the support it needed to make its decision. And more specifically, Carter “did not meet his burden of proof as he failed [to] produce any medical evidence that he was functionally impaired from working at his own occupation, but instead provided evidence that he was in fact able to perform his sedentary occupation.”
In response to this, Carter argued that while Aetna “can give conflicting opinions [different] weight, it cannot reinvent the evidence before it.” He also claims that Dr. Grattan’s decisions were not based on the record. Aetna then claimed that Carter uses “false assumptions; . . . red herrings in the record; and cherry-picks facts and quotes while conveniently omitting others from the same doctors.” It also redirected the Court to the issue at hand, stating that “the issue here is not whether Plaintiff suffers from any maladies . . .[But] whether Plaintiff is able to perform the material duties of his own occupation as it is performed in the national economy.” Further, it again argued that Carter “did not meet his burden of proof as he failed to produce any medical evidence that he was functionally impaired from working at his own occupation, but instead provided evidence that he was in fact able to perform his sedentary occupation.”
Overall, the Court found that Dr. Grattan based his decisions on conflicting opinions from different medical providers who treated Carter. Further, the Court explained that its role was not to weigh the evidence but to decide if Aetna’s decisions were reasonable and not arbitrary and capricious. Here, the Court believed that Aetna had made a reasonable decision based on sufficient evidence in order to make an informed decision denying Carter’s claim. As such, the Court decided to rule in favor of Aetna and against Carter.[Note: this claim was not handled by the Ortiz Law Firm. It is merely summarized here for a better understanding of how Federal Courts are handling long term disability insurance claims.]
Here is a copy of the decision in PDF: Carter v. Aetna