Court Upholds Aetna’s Denial of LTD Benefits Under the “Any Occupation” Disability Definition
In Tanza Hadd v. Aetna Life Insurance Company, Plaintiff Hadd, was employed by UPS as an Operations Supervisor/Manager, also known as a Hub Supervisor. The job was classified as “heavy” and involved moving packages of up to 150 pounds. The working environment was filled with dust and dirt and kept at various temperatures. Plaintiff stopped working in April 2013.
Plaintiff was diagnosed with Churg-Strauss syndrome; an autoimmune disease marked by blood vessel inflammation. It is associated with symptoms of asthma and other breathing difficulties. Based on the diagnosis and her symptoms, Plaintiff was awarded long-term disability (LTD) benefits during the time she was unable to work in her own occupation.
After two years, in order to qualify for LTD benefits, the policy required her to prove she was unable to work in any occupation for which she was, or could be, “fitted by education, training, or experience.” As the time drew near for the reevaluation of her claim, a nurse employed by Aetna reviewed Plaintiff’s medical records.
On May 30, 2014 one of Plaintiff’s treating physicians had written a letter saying that she could do sedentary work if she was not exposed to any environment that would cause her lung problems. He said that she should particularly avoid exposure to “dust, chemicals and fumes.”
When Aetna reevaluated her claim for LTD benefits to see if she was disabled from performing any occupation, a clinical consulting nurse was unable to make a determination, so she requested an independent medical review. Dr. Craven, a board-certified occupational medicine physician, reviewed the records and talked to both of Plaintiff’s treating physicians. Dr. Craven concluded that Plaintiff could perform sedentary work as long as she was not exposed to anything that would exacerbate her Churg-Strauss syndrome, and did not require her to stand for long periods of time.
Aetna commissioned a vocational field case manager, Ms. Hamilton, who performed an assessment and transferable skills analysis (TSA) as well as a market analysis. The case manager identified several occupations that matched Plaintiff’s abilities and requirements.
Aetna reached out to Plaintiff’s treating physicians to determine if she had any bilateral upper extremity limitations. Dr. Craven was unable to reach the doctors, so he reported that it was unclear whether she had these limitations.
Meanwhile, Plaintiff received notice from the Social Security Administration that her application for Social Security Disability (SSDI) had been approved. The administrative law judge had approved her application based on her “advanced age” even though she had the capacity for “the full range of sedentary work.”
Aetna reviewed the SSDI decision as well as Dr. Craven’s report and other information in the administrative file. Aetna ultimately determined Plaintiff had the functional capacity to perform sedentary work. It therefore denied her claim for LTD benefits under the “any occupation” standard required by the policy. Plaintiff appealed and, after exhausting her administrative remedies, filed this ERISA lawsuit in the United States District Court for the District of Kansas.
The Court Held Aetna’s Decision Denying LTD Benefits Was Not Arbitrary and Capricious and That Aetna Conducted a Full and Fair Review
Hadd identified several errors to support her argument that Aetna denied her a “full and fair” review. The Court disagreed with each one of them and held that Aetna’s decision to deny her LTD benefits was based on substantial evidence that Plaintiff could perform full-time sedentary duties. Plaintiff failed to carry her burden of proving she was disabled.
To support her claim that Aetna acted arbitrarily and capriciously, Plaintiff claimed, among other things, that:
- Aetna failed to consult an expert in the field of medicine involved in her claim, a rheumatologist. Based on precedent, and ERISA regulations, the Court concluded that while reviewing physicians are to have “appropriate training and experience in the field of medicine,” they are not required to have the same specialty as the treating physician.
- Aetna failed to assess Plaintiff’s complaints of pain. The Court found this not to be supported by the record.
- When Ms. Hamilton conducted the TSA, she did not account for Plaintiff’s restrictions, skills, and education, and that some jobs identified for her required more training. The Court held that the policy language allowed for additional education and training to be required. Therefore, the fact that Plaintiff would need extra training was “anticipated and permitted by the relevant Policy language.”
The Court concluded that Aetna did not abuse its discretion in denying Plaintiff LTD benefits under the “any occupation” criterion. Aetna’s decision was based on:
- Review of all of Plaintiff’s medical records, examination notes, and statements from both Plaintiff and her medical providers.
- Nurse Cesar’s review of the records and her interview with Plaintiff.
- A review of Plaintiff’s medical records by two board-certified occupational medicine physicians.
- A vocational review.
- Findings associated with Plaintiff’s SSDI decision.
For all these reasons, the Court held that Aetna’s “decision was not arbitrary and capricious and, rather substantial evidence supported Defendant’s decision to deny Plaintiff LTD benefits under the Any Occupations test.”
This case was not handled by our office, but if you have any questions about this case, or any aspect of your own disability claim, contact one of our attorneys at Dell & Schaefer for a free consultation.
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