Cassidy v. Aetna – Court Holds That There Is a Difference Between Diagnosis and Limitation

In Cassidy v. Aetna Life Insurance Company, the U.S. District Court for the Eastern District of Kentucky ruled in favor of Aetna in a Long Term Disability Insurance Claim. The decision was issued on May 21, 2021. The Long Term Disability Insurance claim was governed by the Employee Retirement Income Security Act of 1974 (ERISA). Ms. Cassidy was a senior analyst with General Dynamics Corporation. In June 2018, Ms. Cassidy was diagnosed with chronic tonsillitis, chronic pharyngitis, and pain in her throat.” Prior to receiving these diagnoses, she had also been diagnosed with chronic fatigue syndrome, which required intermittent leaves of absence from October 2017 until June 2018. She also suffered from fibromyalgia, pain in her joints, depression with anxiety, Serratia marcescens infection, and a thyroid nodule. Following these diagnoses, Ms. Cassidy applied for short term disability (STD) from Sedgwick Management Services and was approved. As her STD benefits were coming to an end, Ms. Cassidy applied for Long Term Disability insurance benefits. In support of her application, Ms. Cassidy supplied documentation from her APRN, who had diagnosed Ms. Cassidy with chronic fatigue syndrome and fibromyalgia and indicated that she was to be “off work indefinitely.” After reviewing Ms. Cassidy’s documentation of her claim, Aetna’s own clinic consultant nurse indicated that support had not been provided to indicate that Ms. Cassidy qualified for long term disability, other than requiring a tonsillectomy that would require around two weeks of recovery. On December 27, 2018, Aetna reviewed Ms. Cassidy’s supplementation and denied her long term disability claim due to a “lack of evidence to support neurological, physical and psychological impairment from seated activities” and due to the purported insufficiency of the documentation provided by Ms. Cassidy’s ARNP. Ms. Cassidy appealed the denial letter. To assist with the appeal, Aetna contracted with a third-party vendor to have Ms. Cassidy’s documentation reviewed by an “independent” physician. The “independent” physician, a physician board certified in Internal Medicine, did not examine Ms. Cassidy in person. Instead, the physician conducted only a file review of her records. The reviewing physician concluded that there was no “objective basis” to prove that Ms. Cassidy had any sort of functional limitation that would prevent her from conducting the material duties of her sedentary work. Although the reviewing physician agreed that Ms. Cassidy presented subjective evidence of limitation, he concluded that she had provided no objective evidence in support. Moreover, none of Ms. Cassidy’s medical providers could provide objective proof of her limitations. Instead, her treating providers indicated that their diagnoses and reported limitations were based solely on Ms. Cassidy’s subjective complaints. In response to the reviewing physician’s findings, Ms. Cassidy reiterated her earlier arguments and added a letter from the Social Security Administration which stated that she had been found disabled under its rules as of January 2019. Upon review of the reviewing physician’s findings and Ms. Cassidy’s response, Aetna denied the appeal due to a lack of objective evidence that Ms. Cassidy could not perform the material duties of her job. Ms. Cassidy then filed her lawsuit. Ms. Cassidy had four primary arguments:

• That Dr. Nudell improperly conducted a file review instead of examining her in person;
• that Aetna had a conflict of interest,
• that Aetna did not adequately explain why its decision differed from the SSA’s finding and Sedgwick’s earlier approval of short term disability, and
• that Aetna’s objective evidence requirement was improper.

Ms. Cassidy first argued that Aetna’s reliance on the opinion of Dr. Nudell rendered its denial of long term disability arbitrary and capricious. The Court quoted Miller v. Aetna Life Insurance Company: “While there is ‘nothing inherently objectionable about a file review by a qualified physician in the context of a benefits determination,’ the Sixth Circuit has noted that it is a ‘factor to be considered in reviewing the propriety of an administrator’s decision regarding benefits.” The following comment is also noteworthy: “Although Dr. Nudell did not physically examine Ms. Cassidy, his review did not question the existence or severity of her conditions. Instead, his review simply concluded that Ms. Cassidy had not proven that she could not perform her job.” The Court also reminds us, “Because a plaintiff bears the burden of proof in an ERISA benefits case, Aetna was not required to seek out evidence on its own that Ms. Cassidy could not perform the material duties of her occupation.” The court then said, “Instead, Ms. Cassidy’s failure to provide that evidence led to the denial of her claim.” Ouch. Second, Ms. Cassidy argued that Aetna’s decision was “arbitrary and capricious” because, as the entity which both decides whether a person is eligible for benefits and pays out the benefits, it has a “financial incentive to deny the claim.” The Court acknowledged that it must take into consideration the conflict as a factor in determining whether the administrator’s decision was arbitrary and capricious. However, in evaluating such a conflict of interest, the court further clarified that it must look to see if there is evidence that the conflict in any way influenced the plan administrator’s decision. In this case, the Court determined that Ms. Cassidy provided no evidence, aside from a conclusory statement, that Aetna’s decision was motivated by an alleged conflict. Third, Ms. Cassidy argued that Aetna did not adequately explain why its decision to deny her long term disability benefits differed from the decisions of different entities, including the Social Security Administration. While the Court agreed that the administrative record did not include any analysis of the SSA decision or why Aetna’s decision differed, it declined to give this third argument significant weight because Ms. Cassidy raised this argument for the first time in her reply and Aetna was unable to respond to the claim. Finally, Ms. Cassidy argued that Aetna improperly required that she provide objective evidence that her medical condition prevents her from performing the material duties of her occupation. Ms. Cassidy argued that, because Aetna’s plan did not explicitly require objective evidence of impairment, Aetna’s subsequent requirement of such evidence renders its denial arbitrary and capricious. However, the Court pointed out that Sixth Circuit precedent clearly indicates that an administrator can require a claimant to provide objective medical evidence of the functional limitations resulting from a medical condition, “even when such a requirement does not appear among the plan.” Ms. Cassidy argued that her debilitating conditions, chronic fatigue syndrome and fibromyalgia, are not easily proven by objective evidence because the symptoms of those conditions present primarily through subjective reports of pain. The court acknowledged that these symptoms arguably prove the existence of her conditions, However, the Court clarified that Aetna did not require objective proof that Ms. Cassidy suffered from chronic fatigue syndrome or fibromyalgia. Instead, Aetna required objective evidence that her medical conditions prevented her from performing the material duties of her occupation. There is a difference between proving the existence of a medical condition and proving the existence of limitations resulting from the medical condition. The Court found that the evidence provided by Ms. Cassidy was insufficient to prove functional limitation. Accordingly, the Court ruled in favor of Aetna. [Note: this case 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: Cassidy v Aetna