Executive Summary: Lisa Jones submitted a claim for long term disability benefits under an LTD Plan provided to her by Boeing. Aetna was the plan administrator; Aetna denied the LTD claim. Ms. Jones sued under the Employee Retirement Income Security Act (ERISA) for denial of benefits and breach of fiduciary duty. The district court (lower court) dismissed the fiduciary claim as “duplicative” of the denial-of-benefits claim. The District Court then ruled against Jones and granted summary judgment against Jones on the denial-of-benefits claim. The Court of Appeals affirmed the District Court in part, reversed in part, and remanded for further consideration of the breach of fiduciary duty claim.
The Details: Lisa Jones (“Jones”) was employed by The Boeing Company (“Boeing”) and her job title was business and planning analyst. Through her employment with Boeing, she was covered under an employee welfare benefit plan that allowed for both short-term and long-term disability benefits which were administered by Aetna Life Insurance Company (“Aetna”). In October of 2013, Jones filed for short-term benefits and ceased work. By October 21, Jones’ rheumatologist Dr. Francisco J. Garriga provided an “Attending Physician Statement” which indicated a primary diagnosis of “ankylosing spondylitis” and a secondary diagnosis of “migraines.”
At that time, Dr. Garriga explained that Jones would be unable to work until November 4th. Aetna approved Jones’ short-term benefits claim on October 23, with an effective date of October 24. Following this, Dr. Garriga extended Jones’ return-to-work dates a number of times. Aetna responded by extending Jones’ benefits but also requiring periodic updates from Dr. Garriga. By January 30, 2014, Aetna extended Jones’ benefits through its final date of February 17.
On the 26th of February, Dr. Garriga provided an extension date of April 28. Aetna then sought a “Capabilities and Limitations” worksheet from him on March 17th. Dr. Garriga left most of the form blank as “no formal testing had been done – would need PT appointment to accurately assess.” Soon after, Dr. Brian Dent, chiropractor, provided an additional “Capabilities and Limitations” form explaining that Jones could only work between two and four hours a day, depending on her flare-ups.
As of April 16, Aetna stated that Jones had not provided sufficient information to demonstrate that she was unable to work. It then requested additional information and submitted her file for review to a Dr. Kia Swan-Moore. Dr. Swan-Moore reviewed the file and contacted Dr. Garriga, who indicated that “there is no physical clinical reason [Jones] cannot work however [Jones] continues to tell him that the pain is so intense she could not concentrate.” Dr. Swan-Moore also attempted to contact Dr. Mahendra Gunapooti, Jones’ pain management specialist, but was unable to reach him.
By April 24, Dr. Swan-Moore opined that – according to her review of the medical records in the file – Jones was able to work for a full eight hours daily from February 17 to May 30. Her ability to work eight hours during that period also included unlimited walking, sitting, and standing, along with minor limits on carrying, pushing, and pulling. On April 28, Aetna terminated Jones’ benefits effective on February 17. On the date of termination, Dr. Gunapooti submitted records indicating chronic pain, a number of medications, and a record of epidurals. Dr. Swan-Moore reviewed this additional information and tried to reach out to Dr. Gunapooti. She was unable to reach him again. Dr. Swan-Moore reaffirmed her original determination, which led to Aetna confirming its denial of Jones’ benefits.
Later, on July 8, Jones underwent a functional capacity evaluation by Kevin J. Wilhite, a physical therapist. Wilhite explained that Jones “demonstrated lifting performance that would place her in the Sedentary Physical Demand Category” but that he was “ultimately Unable to Classify her ability of work over an 8 hour work day due to her inability to complete the aerobic capacity testing.” He further indicated that as a result of her alleged pain, he “would not expect her to tolerate any activity over 2 hours,” and explained that “Productive Sedentary work for an 8 hour work day would not be expected based on this date’s performance.” Wilhite also suggested that she “demonstrated inconsistent performance” such as “movement and muscle recruitment patterns that were inconsistent when aware and unaware of observation.” Aetna determined that Jones’ inconsistent performances did not support a finding of disability.
Jones appealed on July 17th, submitting Wilhite’s report and another “Attending Physician Statement” from Dr. Garriga. Aetna asked a Dr. Daniel Gerstenblitt to review whether Jones was disabled during the February 18 and April 16 time period. Dr. Gerstenblitt attempted to reach out to Dr. Garriga seven times, but could not contact him. He then stated that Jones “appears to have chronic neck and back pain,” noting that her “functional capacity evaluation was an invalid study and self-limited,” and that “there is absolutely no reason that she is incapable of performing in at least a sedentary position.” On October 8, Aetna denied Jones’ appeal. Later, in January of 2015, Jones submitted a letter from the Social Security Administration and asked Aetna to place it in her file.
In February, Jones filed a lawsuit in District Court against Aetna. The court denied Jones’ first claim for breach of contract in the disability claim, explaining that Aetna had not abused its discretion when denying Jones’ claim. Jones’ second argument was that Aetna breached a fiduciary duty to her by not obtaining her medical records, by not informing her of the proper place to send her proof of disability, and by working with claims examiners who each had conflicts of interest. The lower court dismissed this breach of fiduciary claim, however, concluding that it was “duplicative” of Jones’ first claim. However, Jones argued to the court of appeal that the District Court was in error by dismissing her argument.
The court of appeal held that the denial of benefits and breach of fiduciary duty claims were not duplicative, because they are based on two different theories of liability. Count I asserts a wrongful denial of benefits, while Count II alleges that Aetna breached a fiduciary duty. As such, the court of appeal held that the second claim should not have been dismissed by the lower court and reversed that decision.
Additionally, Jones argued that the lower court should not have ruled in favor of Aetna for its denial of her benefits. The court of appeal held that Jones did not prove that Aetna was unreasonable in its decision-making. In fact, the court of appeal found that Aetna was reasonable in relying on Dr. Swan-Moore’s review because it “accurately represent[ed] [Jones’s] medical record and adequately address[ed] the evidence supporting her claim for disability.” Therefore, overall, the court of appeal affirmed the lower court’s decision to deny Jones’ first claim and reversed and remanded the decision to dismiss the second claim.[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: