In Claire Refaey v. Aetna Life Insurance Company, in late September 2015, Plaintiff suffered from a viral disease causing quite a few medical symptoms including nausea, abdominal pain, diarrhea, weakness in her extremities, hypotension, and inability to walk. She was hospitalized and treated symptomatically. She was released from the hospital on October 2, 2015 and referred for outpatient psychiatric care.
On October 7, 2015, she was seen in an emergency room and admitted to the hospital due to weakness in her legs during a walk. She was released from the hospital two days later, on October 9, 2015.
Over the next few months, Plaintiff was seen by several physicians in different specialties including a cardiologist, neurologist, and primary care physician. She often complained about her legs being so weak she was unable to walk. Neuro-diagnostic testing was normal and the doctor who performed the test noted that she “exhibited significantly poor effort” during the examination.
During this time, her claim for short-term disability (STD) benefits was approved. Her treating physicians often recommended she get psychiatric care.
Finally, on April 26, 2016, a doctor at the Mayo Clinic diagnosed Plaintiff with chronic fatigue syndrome (CFS). From May 25, 2016 through June 17, 2016, she participated in a treatment regimen at Mayo. She did well with the exercise, group therapy, and occupational therapy sessions, but consistently complained about her job and said she did not want to return to it.
Plaintiff’s final diagnosis from Mayo Clinic included CFS and central sensitization syndrome (CSS) which includes the overlapping conditions of CFS, fibromyalgia, and myofascial pain. During the following months, she was treated by several physicians and participated in a study at the National Institutes of Health for her diagnosed conditions of CFS and CSS.
Plaintiff received STD benefits from September 28, 2015 until January 5, 2016 when Aetna terminated them. Litigation ensued and the case was settled and dismissed on January 15, 2018. On January 23, 2018, video surveillance showed Plaintiff outside of her home continuously for six hours. She drove, shopped, gassed up her car, talked on her cell phone, walked 0.2 miles with her young son, stood on the sidewalk for 13 minutes engaged in conversation, and used her computer while sitting upright after she returned home.
On February 8, 2018, Plaintiff’s disability insurance attorney filed a claim for long-term disability (LTD) benefits. She submitted her medical records and a personal statement about why she was incapable of working at any job.
Aetna found her personal statement was not supported by her medical records nor by its own video surveillance resulting in a disability insurance claim denial for LTD benefits on March 27, 2018. Plaintiff filed an administrative appeal which was denied on July 6, 2018. Plaintiff then filed this ERISA lawsuit in the U.S. District Court for the Western District of North Carolina.
On June 18, 2020, the District Court determined that Aetna did not abuse its discretion when it denied her LTD benefits. The Court made its ruling by analyzing eight factors presented in Booth v. Wal-Mart Stores, Inc. Assocs. Health & Welfare Plan, 201 F.3d 335, 342–43 (4th Cir. 2000), the Fourth Circuit case which laid out the following eight nonexclusive factors to be considered in reviewing the reasonableness of an administrator’s decision:
(1) the language of the plan; (2) the purposes and goals of the plan; (3) the adequacy of the materials considered to make the decision and the degree to which they support it; (4) whether the fiduciary’s interpretation was consistent with other provisions in the plan and with earlier interpretations of the plan; (5) whether the decision making process was reasoned and principled; (6) whether the decision was consistent with the procedural and substantive requirements of ERISA; (7) any external standard relevant to the exercise of discretion; and (8) the fiduciary’s motives and any conflict of interest it may have.
Application of the Booth Factors to Plaintiff’s Case
Factors 1 and 2: The language and purpose of the plan.
The language of the Plan makes it clear that a person is disabled if they are unable to perform the duties of their own occupation for the first 18 months. After that, the person must be unable to perform the duties of any reasonable occupation. The goal is to provide benefits to those who meet the disability definitions.
Aetna’s decision denying Plaintiff’s claim for LTD benefits and in denying her appeal of the denial was consistent with the Plan’s language and its purpose.
Booth Factor 3: Adequacy of materials considered to make the decision and the degree to which they support it.
Aetna fully considered the medical records and other materials submitted by Plaintiff in support of her claim. Aetna provided these materials to two peer reviewing physicians, both of whom confirmed they considered all the material and found the medical evidence did not support a functional impairment.
Plaintiff’s medical record includes information contrary to her claims. Those records, along with the contents of the video surveillance, provided sufficient evidence to refute her subjective reports. Plaintiff complained that the peer review physicians did not address some information in her medical records, but the Court said there is no requirement for a peer review physician to address every piece of medical information in a plaintiff’s record.
The Court concluded that analysis of this third Booth factor supported the finding that Aetna did not abuse its discretion in denying Plaintiff LTD benefits.
Booth Factor 4: Whether the fiduciary’s interpretation of the Plan is consistent with other provisions of the Plan and earlier interpretations of it.
The Court looked at this factor in detail and weighed this factor in favor of finding Aetna’s decision was reasonable.
Booth Factor 5: Whether the decision-making process was reasoned and principled.
Despite the medical records encompassing two years of numerous physicians in various specialties providing treatment and analysis, only one doctor ultimately supported her claim for LTD benefits based on the diagnosis of CFS. In fact, many physicians expressed skepticism of her claim to be disabled.
One treating physician specifically noted that “long term disability is not recommended.” Aetna had peer review of the medical records which supported its decision to deny LTD benefits.
The Court found that “Plaintiff’s own medical record and submissions, alone, constitute a reasonable basis for Aetna’s decision to deny her request for long-term disability benefits.”
Booth Factor 6: Whether the decision was consistent with the procedural and substantive requirements of ERISA.
ERISA requires the Plan to provide participants a full and fair hearing and to provide the participant, in writing, the reasons for the denial of benefits. Aetna did this and its actions were consistent with ERISA requirements.
Booth Factor 7: Was any external standard relevant to the exercise of discretion.
The Court said there was no additional external standard. The Plan language provided the administrator discretionary authority.
Booth Factor 8: The fiduciary’s motives and any conflict of interest it may have.
There may have been a structural conflict of interest, but the Court concluded “there is no evidence in the record that Aetna’s decision was influenced by the conflict.”
The Court concluded, “Plaintiff has failed to prove that Aetna’s decision was unreasonable under the Booth factors.”
This case was not handled by our firm, but we believe it can be instructive to those whose medical records currently may lack the support of their disability benefits claim. For questions about this case, or any question about your disability claim, contact one of our disability attorneys at Dell & Schaefer for a free consultation.