Young v. Aetna – Aetna Committed Abuse Of Discretion In Denying LTD Claim

Young sought long-term disability (LTD) benefits from Aetna for chronic pain spanning her neck, back, shoulder, and hip, but Aetna terminated her claim after roughly five weeks, relying on a non-examining doctor’s file review. The court granted summary judgment in Young’s favor, finding Aetna abused its discretion by dismissing reliable medical and vocational findings, ignoring the impact of her medications, and disregarding physician worksheets that documented her inability to sustain full-time sedentary work — and declined to remand, since the record already established she was wrongly denied benefits she was entitled to.

Young’s treatment required daily neuropathic and opioid medications — including Gabapentin, Tramadol, and Vicodin — to manage pain in her pelvis, lower back, hip, and leg. Her treating physician, Dr. Marciello, explained that a full eight-hour workday would likely increase her pain and require even higher doses, further impairing her judgment and function. Despite extensive testing, her lower back pain remained “incompletely explained,” and her doctor ultimately recommended she pursue a modified nursing role without significant physical demands. This medication-related impact on her ability to work later became one of the court’s central reasons for ruling in her favor.

Definition of Disability: The Plan provides the following “Test of Disability”:

“From the date that you first become disabled and until Monthly Benefits are payable for 36 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 36 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.

If your own occupation requires a professional or occupational license or certification of any kind, you will not be deemed to be disabled solely because of the loss of that license or certification.”

In short, after thirty-six months of receiving disability benefits, the Plan’s definition of disability changed from the “own occupation” standard to the “any reasonable occupation” standard.

Benefits Paid? Long-term disability benefits were paid for approximately five weeks. Based upon a non-examining doctor’s review and the underlying medical documentation, Aetna informed Young that “there [was] no evidence of a functional impairment which would substantiate an inability to perform [Young’s] occupation starting from October 4, 2010.”

Procedural History: The claimant received LTD benefits during the “own occupation” period, but benefits were terminated towards the beginning of the “any occupation” period.

Key Physician Opinions: One of Plaintiff’s treating physicians, Dr. Marciello, addressed the impact of Plaintiff’s medications on her ability to work:

“In order to accommodate the daily and persistent pain of her pelvis, lower back, right hip and groin, and right leg, [Plaintiff] requires daily medications including neuropathic medicines such as Gabapentin which is likely to result in decreased concentration, decreased memory, and sedation. Furthermore, the pain results in her frequently requiring opioid pain medications including Tramadol and Vicodin which again may impair her judgment and functional tasks. Therefore, in my opinion, if she had to carry out full-time work, implying an 8-hour work day, it is more likely than not that her pain levels will increase, causing her to use more medications and possibly impairing her function and mental status capacity even further.”

Dr. Marciello further noted that the nature of Plaintiff’s musculoskeletal pain and weakness resulted in frequent flares of pain, which would cause her attendance in a workplace to be unreliable. (AR at 623.) In conclusion, Dr. Marciello explained:

“[Plaintiff] is at a medical end point. She has been treated by a number of medical providers. She has undergone numerous procedures, trials of medications, physical therapy, an extensive period of relative rest, all of which have been unsuccessful in managing her pain or improving her function. It is, therefore, in my opinion, that [Plaintiff] remains totally disabled from all gainful employment including sedentary work.”

As part of her appeal, Plaintiff also submitted a vocational assessment conducted by a vocational expert. The expert opined that Plaintiff could not perform any work, part-time or full-time, at any exertion level. He noted the Plaintiff’s documented inability to stand or sit for long periods. He found that the record established that Plaintiff could not stand for two hours in an eight-hour workday, the minimum amount required for sedentary work. He also noted that because she needed the assistance of a cane, she could not perform tasks with both of her hands while in a standing or walking position, a skill necessary to conduct sedentary work at an acceptable pace. He further noted that the record showed that sitting was the most challenging position for Plaintiff to maintain, and sedentary work requires the ability to sit for six hours in an eight-hour workday.

The expert, Parker, also noted Plaintiff’s use of pain medications, with their side effects of sedation and decreased ability to concentrate. He mentioned the treating doctor’s opinion that if Plaintiff were to return to work, she would need to increase her usage of these medications, which would, in turn, decrease her mental capacity. The vocational expert noted Plaintiff’s substantial impairments in performing activities of daily living, which required her to self-pace and limit the tasks performed due to early fatigue and pain. He stated that “the inability to sustain routine nondemanding household tasks is a strong indicator of the inability to sustain any work on a regular and consistent basis.” He concluded, “based on the limitations established by [Plaintiff’s] physicians, she is totally disabled from all employment,” and she would remain so for the foreseeable future.

As part of its internal appeal review process, Aetna obtained an independent medical file review from Dr. Frank Polanco, an Occupational Medicine and Pain Medicine specialist. After reviewing Plaintiff’s medical records, Dr. Polanco concluded that Plaintiff could perform work at a sedentary level. Based on Dr. Polanco’s report, Aetna upheld its decision to terminate Plaintiff’s benefits.

Issues: Plaintiff makes several related arguments in support of her motion for summary judgment.

(1) First, she argues that Aetna’s vocational review was flawed and insufficient. She asserts that the initial TSA relied solely on the restrictions imposed by an independent medical examiner while ignoring the medical records from the Plaintiff’s treatment providers. The Plaintiff argues that Aetna failed to evaluate whether she could perform the material duties of the sedentary occupations it identified. Plaintiff further notes that Aetna did not conduct a comprehensive vocational analysis after the submission of Plaintiff’s appeal and that Aetna ignored the vocational review conducted by her vocational expert.

(2) Next, Plaintiff argues that Aetna was unfairly selective in its review of the medical evidence and ignored evidence of her chronic pain.

(3) Plaintiff also argues that Aetna unreasonably evaluated her medical conditions in isolation from one another and failed to consider the constellation of symptoms from all of her various ailments. The Plaintiff claims that her disability stems from the intersection of the symptoms of her back condition, hip injuries, upper body injuries, gynecological issues, and the respective treatments for each of those conditions. Aetna, she contends, relied on Dr. Polanco’s assessment, which focused solely on Plaintiff’s lower-back problems and ignored the opinions from her treating physicians regarding her other conditions.

(4) Finally, Plaintiff argues that Aetna had a structural conflict of interest in reviewing Plaintiff’s claim and that this conflict should be factored into this Court’s review of Aetna’s decision.

Holdings: (1) The Court held that each independent medical exam report does not constitute “substantial evidentiary grounds for a reasonable decision” to deny Plaintiff’s LTD benefits. Aetna’s final termination letter mentions the vocational counselor’s report but does not explain why the counselor’s findings were rejected. Dr. Polanco’s report, however, addressed the vocational counselor’s assessment and dismissed it because the vocational counselor had allegedly based his opinions primarily on the treating doctor’s findings, which, according to Dr. Polanco, were not supported by clinical evidence.

However, the Court held that the treating physician’s report was based on his clinical findings, especially concerning the reports of the extent of Plaintiff’s chronic pain. Additionally, in producing his report (the only vocational assessment conducted based on medical records) the vocational counselor reviewed all of Plaintiff’s records, particularly emphasizing those from Plaintiff’s treating physicians. The Court held, “It was not reasonable, on these grounds, for Aetna to rely on Dr. Polanco’s summary dismissal of all findings of one of Plaintiff’s primary treating physicians, as well as the findings of the only independent vocational assessment conducted in this case. This reliance constitutes an abuse of discretion.”

(2) The Court held, “Additionally, Aetna abused its discretion by failing to address the impact of Plaintiff’s chronic medication usage on her ability to perform a full-time sedentary occupation at the requisite wage rate. … The medication issue is a critical component to the determination of whether Plaintiff is capable of performing ‘any reasonable occupation’ at the target wage rate.”

(3) The Court held, “Aetna also abused its discretion by dismissing without explanation four [Attending Physician Statement] APS and Capabilities and Limitations Worksheets, which showed that, from February of 2009 until at least February of 2012, Plaintiff could not perform full-time sedentary work.”

(4) The Court did not decide on this issue: “Having already found—without considering this additional factor—that Aetna abused its discretion, I need not delve into an examination of Aetna’s conflict. I shall simply add that the structural nature of the claims process adds fodder to my conclusion that Aetna failed to provide a principled, substantiated review as mandated by ERISA.”

Summary: The Court granted Plaintiff’s Motion for Summary Judgment: “As explained above, I have identified three primary reasons for determining that Aetna abused its discretion in denying Plaintiff’s benefits: Inappropriate reliance on unreliable findings by Drs. Topper, McPhee, and Polanco; failure to address Plaintiff’s qualifications and ability to engage in sedentary occupations in light of her medication requirements; and failure to address the findings in the APS and Capabilities and Limitations Worksheets showing that Plaintiff could not perform full-time sedentary work. These findings represent my opinion that Aetna erred in both the manner in which it conducted its review and in the substantive outcome of its decision. After thoroughly reviewing the record, I am convinced that Plaintiff was denied benefits to which she was clearly entitled; therefore, I do not see the benefit, under these circumstances, of remanding this case to the claims administrator for further evaluation.”

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