Neno v. Aetna – Court Finds There Was No Abuse Of Discretion

Aetna Life Insurance Company (“Aetna”) paid Neno’s long-term disability (LTD) benefits through the “own occupation” period but terminated them once the “any occupation” standard took effect, finding insufficient medical evidence to support ongoing work restrictions despite his neck and hip pain. The court upheld the denial, finding Aetna’s decision was based on substantial evidence — including a functional capacity evaluation and three independent physician reviews — and reflected reasoned, principled decision-making rather than an abuse of discretion.

Definition of Disability: For the first twenty-four months of disability, a “disabled” employee is one who “cannot perform the material duties of [his] own occupation solely because of an illness [or] injury [and] his earnings are 80% or less of [his] adjusted predisability earnings.” The plan defines “own occupation” as “[t]he 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 . . . [f]or your specific employer . . . .”

The plan identifies Aetna as the “claims fiduciary for benefits provided under the Policy” and confers Aetna with “discretion and authority to determine eligibility for benefits and to construe and interpret all terms and provisions of the Policy.”

Benefits Paid? Aetna denied the claim for long-term disability benefits.

Procedural History: The claimant received LTD benefits during the “own occupation” period, but benefits were terminated after 24 months at the beginning of the “any occupation” period. Aetna terminated the Plaintiff’s benefits, claiming insufficient medical evidence in the administrative file to support a part-time work restriction.

The Plaintiff appealed his long-term disability denial and submitted additional medical documents. Among them was a June 27, 2014, MRI of Neno’s cervical spine. It showed a posterior disc bulge at C3-C4 with mild AP stenosis of 9.8 mm and mild to moderate left foraminal encroachment, and a posterior disc bulge at C5-C6 “with borderline AP diameter 1 cm and mild bilateral foraminal encroachment.”

On July 24, 2014, Dr. Mark Mendelssohn, an independent board-certified orthopedic surgeon, reviewed Neno’s file. After a “detailed review” of the Plaintiff’s medical history, he concluded:

“Although [Neno] has multiple problems, including repeated surgery for Morton’s neuroma, neck pain, and back pain for which he has had multiple neurosurgical and orthopedic consultations and was deemed not to be a surgical candidate, he has had extensive pharmacological management, but continues to have subjective complaints. Most recently, he has had bilateral carpal tunnel release without evidence of any functional deficits. Medical documentation does not substantiate a functional impairment, if any, from 1/14/13 through 7/18/14.”

After reviewing Neno’s file, Aetna informed Neno that his denial of long-term disability benefits had been upheld on appeal. The Plaintiff then filed his lawsuit.

Issues: Whether Aetna’s denial of the Plaintiff’s LTD claim was reasonable.

Holdings: (1) The Court held that Aetna reasonably defined the material duties of the Plaintiff’s “own occupation”. The Court further held that Aetna reasonably determined that the Plaintiff could perform his material duties:

“To qualify for long-term disability benefits, Neno was required to submit satisfactory proof that he was unable to perform the “material duties” of his “own occupation.” See Elliott v. Sara Lee Corp., 190 F.3d 601, 603 (4th Cir. 1999) (noting that the burden of proving a disability is placed on the employee). As Neno’s “own occupation” was determined to be sedentary as found in the general economy, Neno was required to present medical evidence indicating that he was unable to perform the requirements of a sedentary occupation.

In conducting its review of Neno’s claim for long-term disability benefits, Aetna reviewed the results of Neno’s functional capacity evaluation, the assessment of his treating physician, Dr. Tham, and reviews of Neno’s medical records by three independent board-certified doctors.6 Following its review, Aetna determined that Neno was not disabled. The evidence in the record demonstrates that this decision was reasonable, based on substantial evidence, and was therefore not an abuse of discretion.”

Summary: “In sum, the medical evidence available does not suggest that Aetna abused its discretion by determining that Neno is able to perform the “material duties” of his “own occupation” as defined under the employee welfare benefit plan. Aetna’s decision was supported by substantial evidence and was made with deliberate and principled reasoning, as it reviewed Neno’s medical records and sought opinions from independent sources. Therefore, based on the undisputed facts in the record, Aetna did not abuse its discretion in denying Plaintiff’s claim for long-term disability benefits.”

Here is a PDF copy of the decision: Neno v. Aetna