Case Name: Granville v. Aetna Life Insurance Company
Court: United States District Court for the Middle District of Pennsylvania
Type of Claim: Long Term Disability
Insurance Company: Aetna Life Insurance Company (hereinafter “Aetna”)
Claimant’s Employer: Penn Foster, Inc.
Claimant’s Occupation / Job Position: Enrollment Advisor
Definition of Disability: The Test for disability under the Plan provides in relevant part:
From the date that you first become disabled and until Monthly Benefits are
payable for 24 months, you will be deemed to be 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 24 months that any Monthly Benefit is payable during a 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
“Material Duties” is defined by the Plan as duties that “are normally required for performance of your own occupation; and cannot be reasonably: omitted or modified. However to be at work in excess of 40 hours is not a material duty.”
“Own occupation” is defined by the Plan as:
the occupation 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.
Benefits Paid? Long Term Disability benefits were denied from the beginning of the LTD claim process.
Procedural history: The Plaintiff exhausted her administrative appeals and filed an ERISA lawsuit.
Key Physician Opinions: By the time Aetna denied the LTD claim, it had been provided with numerous medical records and physician opinions:
“on March 20, 2012 Plaintiff provided Aetna with an Attending Physician Statement (“APS”) from Joseph Stella, M.D. dated March 14, 2012, a Capabilities and Limitations Worksheet (“CLW”) from Shahroon Choudhry, M.D. dated March 14, 2012, a Work History and Education Questionnaire, and other forms and releases authorizing Aetna to obtain relevant medical and income information. … Dr. Stella’s APS diagnosed Plaintiff with cervicalgia, herniated disc, and spinal stenosis. … Dr. Stella noted that Plaintiff was awaiting a neurosurgical evaluation but no subsequent office visits were noted. Plaintiffs symptoms were identified as “neck pain, right shoulder pain with numbness tingling and weakness of the right hand.” … Dr. Stella identified MRI findings which he described as showing “severe stenosis” with “C6/C7 disk herniation” and, based on those findings, opined that Plaintiff had no ability to work and restricted her from pulling, pushing, and lifting weights greater than fifteen pounds. … In the CLW, Dr. Choudhry found Plaintiff could occasionally climb, crawl, kneel, bend, and twist and was capable of lifting one to five pounds. … He did not limit or comment on whether Plaintiffs head and neck movements were restricted despite the noted diagnosis of herniated disc in the neck, but he did restrict her right hand grasping and motor manipulation. Dr. Holla, a neurosurgeon, wrote a letter to Dr. Choudhry, dated June 5, 2012, stating that Plaintiff had cervical radiculopathy of the C6 and C7 vertebrae on the right and that he offered surgery; this letter is contained in the administrative record. In an August 8, 2012 letter from Dr. Stella to Aetna, Dr. Stella stated that the Plaintiff “remains totally disabled due to her cervical disc disease and stenosis associated with a cervical radiculopathy.” … Dr. Stella further stated that “this has resulted in significant pain, numbness and weakness in her right upper extremity.”
After an appeal submitted by the Plaintiff’s attorney in the administrative review process, Aetna referred the claim out for review by one of its doctors:
“The independent reviewer for Aetna was Robert Swotinsky, M.D., Board-Certified in Occupational Medicine. … Dr. Swotinsky found that Plaintiff was capable of full-time sedentary work and that there were no records of medication-related impairments. … Dr. Swotinsky characterized the MRI results relied upon by Dr. Stella to support a finding of disability, supra at 7, as showing a pinched nerve and further stated that a pinched nerve ‘does not by itself establish an inability to do sedentary work, i.e. does not establish complete disability.’ … Dr. Swotinsky further characterized exam findings in the record as ‘suggest[ing] some weakness and/or loss of sensation in the right arm,’ but concluded that “this also does not equate with complete disability.”
Issues: (1) Whether Aetna’s reliance on Dr. Swotinsky’s IME was sufficient to support its denial. (2) Whether Aetna should have conducted an in-person independent medical examination. (3) Whether Aetna adequately considered the claimant’s specific job requirements.
Holdings: “Based on the Court’s review, the administrative record before Aetna during the pendency of Plaintiffs administrative LTO claim and her administrative appeal supported her claim for benefits; Aetna’s denial is arbitrary and capricious because it is “without reason” and unsupported by substantial evidence under Fleischer. Fleisher, 679 F.3d at 121. The Court finds that there is objective medical evidence of Plaintiffs disability under the Plan’s applicable “own occupation” standard and that Aetna has failed to point to any record evidence to the contrary, let alone substantial evidence.”
(1) “Aetna appears to place great stock in Dr. Swotinsky’s paper review and relies on it to undermine the office notes and opinions coming from Drs. Choudhry and Stella. However, the Court finds his review to have little application to the question before Aetna: was Plaintiff disabled from her own occupation? Dr. Swotinsky concludes that there is insufficient evidence to support the treating physician’s conclusions of “complete disability.” … But Dr. Swotinsky’s task was to evaluate Plaintiff’s disability status as of January 2012, when the test for disability was measured by her own occupation. … Finding her capable of sedentary work and not completely disabled does not speak to this less stringent standard, even where Plaintiff’s own occupation was classified as a sedentary demand level.”
(2) “Relatedly, the Court is wary of Aetna’s failure to conduct an independent medical examination in this case, an examination which it had aright to require under the terms of the Plan. … While it is true that Defendant was not required by the terms of the Plan to conduct an independent medical examination of Plaintiff, the Court will consider the failure to pursue such an examination in evaluating Dr. Swotinsky’s paper review as compared to the contrary disability findings of Drs. Choudhry and Dr. Stella. … To the extent that Aetna argues that there is insufficient clinical evidence to support Plaintiffs claim for disability, the Court again emphasizes that Plaintiff has come forward with some objective evidence of her disability, as well as professional medical opinions as to her disability based on a treating relationship and that Aetna made little effort to further investigate. Denying benefits based on inadequate information and lax investigatory procedures is a procedural factor relevant to the arbitrary and capricious standard.”
(3) “The Court is also wary of Dr. Swotinsky and Aetna’s apparent failure to “consider the claimant’s specific job requirements under an ‘own occupation’ policy, another procedural factor which ‘call[s] into question the fairness of the process and suggest[s] arbitrariness.’”
Summary: “‘Procedural irregularities in the review process cast doubt on the administrator’s impartiality.’ Harper v. Aetna Life Ins. Co., No. 10-1459,2011 WL 1196860, at *2 (E.D. Pa. March 31,2011) (citing Miller, 632 F.3d at 845). Here, Aetna has engaged in multiple procedural irregularities, including conducting a self-serving paper review of the medical files based on the incorrect disability standard, relatedly relying on the opinion of a non-treating, non-examining physician without reason, and denying benefits based on inadequate information and lax investigatory procedures, as evidenced by Aetna’s decision not to pursue an independent medical examination and its failure to analyze the specific requirements of Plaintiffs own occupation. These irregularities compounded each other throughout the review and appeal of Plaintiffs administrative claim and lead this Court to find that Aetna acted arbitrarily and capriciously in denying Plaintiffs LTO benefits.”
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.
Here is a copy of the decision in PDF: