• Menu
  • Skip to right header navigation
  • Skip to main content
  • Skip to primary sidebar
  • Skip to footer

Before Header

Has your disability claim been wrongfully denied or terminated? Call us today for help!  (888) 321-8131

  • Facebook
  • LinkedIn
  • YouTube

OLF Ortiz Law Firm National Disability Attorneys

Ortiz Law Firm is dedicated to helping people recover the disability benefits they deserve. We handle group Long Term Disability (LTD) claims, individual disability insurance policy claims, ERISA disability claims, and Social Security Disability claims.

  • ABOUT US
    • Nick Ortiz
    • Our Team
    • Case Results
    • Testimonials
  • PRACTICE AREAS
    • Long Term Disability
      • Long Term Disability Appeals
      • Long Term Disability Lawsuits
      • Lump Sum Buyouts/Settlements
    • ERISA Disability Claims
    • Individual Disability Insurance
    • Social Security Disability Claims
      • Initial Applications for Social Security Disability
      • Request for Reconsideration
      • Hearing Before an Administrative Law Judge
    • Long Term Care Insurance Claims
    • Personal Injury Claims
  • DISABLING CONDITIONS
    • Long Term Disability
    • Social Security Disability
  • INSURANCE CARRIERS
    • View All
    • Insurance Company Tricks And Tactics
  • RESOURCES
    • Blog
    • eBooks, Guides, and More
    • Lump Sum Disability Buyout Calculator
    • Long Term Disability FAQs
    • Social Security Disability FAQs
    • Long Term Disability Glossary
    • Individual Disability Insurance Policy Analysis
    • Long Term Disability Federal Court Case Summaries
    • Abbreviations in Social Security Disability Claims
  • Search
  • CONTACT

Mobile Menu

Call us today for help!

(888) 321-8131
  • ABOUT US
    • Nick Ortiz
    • Our Team
    • Case Results
    • Testimonials
  • PRACTICE AREAS
    • Long Term Disability
      • Long Term Disability Appeals
      • Long Term Disability Lawsuits
      • Lump Sum Buyouts/Settlements
    • ERISA Disability Claims
    • Individual Disability Insurance
    • Social Security Disability Claims
      • Initial Applications for Social Security Disability
      • Request for Reconsideration
      • Hearing Before an Administrative Law Judge
    • Long Term Care Insurance Claims
    • Personal Injury Claims
  • DISABLING CONDITIONS
    • Long Term Disability
    • Social Security Disability
  • INSURANCE CARRIERS
    • View All
    • Insurance Company Tricks And Tactics
  • RESOURCES
    • Blog
    • eBooks, Guides, and More
    • Lump Sum Disability Buyout Calculator
    • Long Term Disability FAQs
    • Social Security Disability FAQs
    • Long Term Disability Glossary
    • Individual Disability Insurance Policy Analysis
    • Long Term Disability Federal Court Case Summaries
    • Abbreviations in Social Security Disability Claims
  • Search
  • CONTACT
You are here: Home / Case Summary Blog / Granville v. Aetna – Aetna’s Denial Is Arbitrary and Capricious

Granville v. Aetna – Aetna’s Denial Is Arbitrary and Capricious

April 7, 2020 //  by Ortiz Law Firm//  Leave a Comment

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

Disabilities: Cervicalgia, herniated disc, and spinal stenosis. Plaintiff’s symptoms were identified as “neck pain, right shoulder pain with numbness tingling and weakness of the right hand.”

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
  • injury.

“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 LTD 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: Granville v. Aetna

FacebookTweetPinLinkedInPrintEmail

Category: Case Summary Blog, Long Term DisabilityTag: Aetna

Recent Posts

  • How to Win a Long Term Disability Appeal: Do’s and Don’ts
  • 3 Steps You Must Take Right Now If Your LTD Benefits Are Terminated!
  • Leveraging the Grid Rules to Secure SSDI Benefits After Age 50
  • What Is an On-The-Record Decision in a Social Security Disability Claim?
  • Understanding the Difference Between Diagnosis and Functional Impairment in Long Term Disability Claims
Previous Post: « Graham v. LINA – Court Rules LINA Must Review Claim Under “Medium-Occupation” Standard
Next Post: Griffin v. Hartford – Plaintiff Failed to Furnish Proof of Loss »

Reader Interactions

Leave a Reply Cancel reply

Your email address will not be published. Required fields are marked *

Primary Sidebar

Top Ten Mistakes That Will Destroy Your Long Term Disability Claim

View All Resources

"I highly recommend Ortiz Law Firm. Very friendly staff. They helped me win my appeal against Liberty Mutual. Thank you all for being the best!!"

Lavanda T.

View All Testimonials

Learn More About Long Term Disability

  • Areas We Serve
  • Frequently Asked Questions
  • Denials and Appeals
  • Your Chances of Getting Approved
  • Medical Eligibility
  • Additional Parts That Do Not Happen in Every Case
  • Medical Conditions That May Qualify
  • Long Term Disability Insurance Carriers
  • Occupations That May Qualify
  • LTD Federal Court Case Summaries

Footer

Contact Us

Our experienced disability law firm is ready to fight for you. Contact us today for a free case evaluation.

(888) 321-8131
316 S Baylen St., Ste 590
Pensacola, FL 32502

  • Email
  • Facebook
  • LinkedIn
  • YouTube

Claims We Handle

  • Group Long Term Disability
  • ERISA Disability Claims
  • Individual Disability Insurance
  • Social Security Disability Claims
  • Long Term Care Insurance
  • Florida Personal Injury

Quick Links

  • About Us
  • Free Resources
  • Client Testimonials
  • Case Results
  • Nationwide Representation
  • Refer a Case

Site Footer

© 2023 Ortiz Law Firm

Sitemap | Disclaimer | Privacy Policy

Share this ArticleLike this article? Email it to a friend!

Email sent!