Opinion
2:11-cv-00652-ECR-GWF
08-07-2012
SANDRA RADA, Plaintiff, v. COX ENTERPRISES, INC., a Georgia Corporation, as Plan Administrator of the Cox Enterprises, Inc. Welfare Benefits Plan; AETNA LIFE INSURANCE COMPANY, as Claims Administrator of the Cox Enterprises, Inc. Welfare Benefits Plan; DOES I through V; and ROE CORPORATIONS I through V Defendant.
Order
Now pending are a Motion for Judgment on the Pleadings and Administrative Record (#20) and a Counter-Motion for Judgment on the Pleadings and Administrative Record (#21) arising out of a complaint regarding the wrongful termination of disability benefits under an employer-provided Long Term Disability Plan.
The motions are ripe, and we now rule on them.
I. Factual and Procedural Background
Plaintiff Sandra Rada ("Plaintiff"), a Clark County, Nevada resident, was employed by Defendant Cox Enterprises, Inc. ("Cox") beginning January 1, 2005. (Compl. ¶¶ 4-5 (#1).) For the relevant time period, Defendant Aetna Life Insurance Company ("Aetna") was Cox's agent and the designated Claims Administrator of Cox's Long-Term Disability Plan for its employees, providing administrative services under the plan as outlined in the Administrative Services Agreement between Aetna and Cox. (Id. ¶ 6.) Cox fully insured the plan, but Aetna handled claims and made the ultimate decision of whether to accept, deny, or terminate long-term disability claims. (Id.)
On March 13, 2008, Plaintiff suffered a motor vehicle accident leaving her with head trauma, scalp laceration requiring 30 sutures, multiple contusions, and sprain/strain injuries to her neck and back. (Id. ¶ 8.) Plaintiff continues to experience post-concussive symptoms including depression, anxiety, headaches, memory loss, difficulty concentrating, word-finding problems, sleep disturbance, confusion, and fatigue. (Id.)
As of March 13, 2008, Plaintiff was employed 40 hours a week as a Customer Service Representative at Cox, with duties including handling incoming calls, introducing and selling new products and services, handling customer problems and queries and providing responses, initiating billing adjustments, and other clerical and administrative tasks. (Id. ¶ 9.)
Due to her accident, Plaintiff was unable to return to work. She applied for and received short term disability benefits for six months from her short term disability insurance carrier, UNUM. (Id. ¶ 11.) In August, 2008, Plaintiff applied for long-term disability benefits under Cox's Long Term Disability Plan. (Id. ¶ 12.) Under Cox's plan, an employee is eligible for benefits in the first 24 months of total disability if "[they] are not able, solely because of injury or disease, to work at [their] own occupation." (Id. ¶ 10.) After the first 24 months, an employee is eligible for benefits if "[they] are not able, solely because of injury or disease, to work at any reasonable occupation." (Id.) "Any reasonable occupation" is further defined under the plan as "any gainful activity for which [an employee is], or may reasonably become, fitted by education, training, or experience. It does not include work under an approved rehabilitation program." (Id.) Aetna accepted Plaintiff's claim and paid Plaintiff's long-term disability benefits from September 14, 2008 through April 9, 2010. (Id.)
On January 22, 2010, through Aetna's referral to its vendor Allsup, Plaintiff was awarded Social Security Disability benefits from the Social Security Administration ("SSA"). (Id. ¶ 13.) The SSA deemed Plaintiff disabled as of December 6, 2009, and Plaintiff continues to receive Social Security benefits. (Id. ¶ 13.)
On December 12th, 2009, Dr. Cruz, Plaintiff's primary physician, completed an Attending Physician's Statement as requested by Aetna, with a primary diagnosis of traumatic brain injury with complications of cognitive and physical impairment. (Id. ¶ 14.) Plaintiff was seen by neurologist Daniel J. Broeske, MD, on January 5, 2010, where he stated that Plaintiff exhibited symptoms of "short-term memory impairment, distractibility, and inattention "partially borne out by objective testing today." (Id. ¶ 15.) On January 7, 2010, at Aetna's request, Plaintiff filled out an Activities of Daily Living form, describing symptoms of memory loss, difficulty understanding directions, sleep disturbances, headache, lightheadedness, burning and tingling into her right arm, back, and legs, word finding difficulty, right arm pain, and right leg pain increased on prolonged standing. She noted that she did not feel she could return to work due to her head injury and understanding difficulties. (Id. ¶ 16.)
On February 25, 2010, Aetna referred Plaintiff's claim for peer review by an occupational medicine specialist. (Id. ¶ 17.) The specialist stated that the medical documentation did not indicate a functional impairment from any occupation. (Id.) Aetna forwarded the review to Dr. Cruz for his opinion on the matter, stating that if he failed to respond within 15 days, his failure to respond would be taken as a confirmation of the peer reviewer's analysis. (Id.) Dr. Cruz did not respond within 15 days but did respond on April 22, 2010. (Id.)
After 24 months had passed, shifting Plaintiff's occupational analysis under the Long Term Disability Plan from "her occupation" to "any occupation," Aetna concluded on April 8, 2010 that Plaintiff would be eligible for several different occupations based on her training and education and the findings of its peer reviewer that she could work at a sedentary job. (Id. 18.) The occupations listed included Customer Service Representative, Circulation Clerk, Dispatcher, and Credit Card Clerk. (Id.) In a letter to Plaintiff dated April 14, 2010, Aetna terminated Plaintiff's long-term disability benefits effective April 9, 2010 for the foregoing reasons along with Dr. Cruz's failure to respond to the peer reviewer's letter. (Id. ¶ 19.) In the letter, Aetna informed Plaintiff that she could appeal Aetna's decision if she prepared a narrative report outlining the extent of her disability. (Id. ¶ 20.).
Plaintiff submitted her appeal letter to Aetna on January 10, 2011 through her attorney. (Id. ¶ 21.) Her letter included updated medical records from several of her doctors including Dr. Cruz, additional records from Drs. Dylan Wint, MD, and Thomas Kinsora, Ph.D, the pertinent parts of which are discussed in subsequent sections. (Id. ¶ 21.) The appeal letter also included the disability benefits award letter from the SSA. (Id.)
In a February 21, 2011 letter, Aetna "partially overturned" its April 14, 2010 decision, re-extending Plaintiff's benefits from April 9, 2010 through November 30, 2010. (Id. ¶ 24.) Aetna refused to extend benefits beyond November 30, 2010, stating that "the records presented for review do not provide any abnormal examination findings, imaging studies, or behavioral observations, dated after 11/30/10, to document any specific impairment that would prevent [Plaintiff] from performing the work of any occupation." (Id.) The denial was based on new physical examinations, doctors' reports, and peer-to-peer conversations, further discussed in subsequent sections. (Id. ¶ 25.)
On March 7, 2011, Plaintiff's attorney wrote a letter to Aetna inquiring whether Aetna had received confirmation that the comments attributed to Plaintiff's doctors in peer-to-peer conversations were accurate and urging Aetna to obtain Plaintiff's Social Security benefits documents. (Id. ¶ 28.) On March 9, 2011, Dr. Wint wrote a letter to Aetna clarifying his comments made during peer-to-peer conversation, discussed further in subsequent sections. (Id. ¶ 30.) On March 18, 2011, Aetna wrote a letter to Plaintiff's attorney refusing to reconsider its denial of benefits. (Id. ¶ 31.)
On April 26, 2011, Plaintiff filed her Complaint (#1) with this court, seeking relief for wrongful termination of her disability benefits under 29 U.S.C. § 1132(a)(1)(B). On May 31, 2011, Defendants Cox and Aetna filed their Answer (#7). On June 16, 2011, this court issued an Order (#11) demanding that Defendants produce the administrative record. On September 15, 2011, Defendants supplied the administrative record (#16). On November 8, 2011, Plaintiff filed a Rule 52 Motion for Judgment on the Pleadings and Administrative Record (#20). On December 8, 2011, Defendants filed their Response and a Counter-Motion for Judgment on the Pleadings and Administrative Record (#21). On January 11, 2012, Plaintiff filed a Reply (#22) to Defendants' Response and Counter-Motion. On February 7, 2012, Defendants filed a Reply (#23) in support of their Counter-Motion.
II. Judgment on the Pleadings and Administrative Record Standard
A party may move for judgment on the pleadings and administrative record pursuant to Federal Rule of Civil Procedure 52. "Although Rule 43(a) requires that 'testimony' be taken in open court, the record should be regarded as being in the nature of exhibits, in the nature of documents, which are routinely a basis for findings of fact even though no one reads them out loud." Kearney v. Standard Ins. Co., 175 F.3d 1084, 1094 (9th Cir. 1999). District courts are permitted to "try the case on the record that the administrator had before it," a method that is "vastly less expensive to all parties." Id. at 1095.
In a bench trial on the record, "the judge will have to make findings of fact under Federal Rule of Civil Procedure 52(a)." Id. Under Federal Rule of Civil Procedure 52 (a)(1), "in an action tried on the facts without a jury or with an advisory jury, the court must find the facts specially and state its conclusions of law separately." This standard amounts to findings of fact in "narrative form, i.e., which appear in a 'memorandum of decision filed by the court.'" In re Girardi, 611 F.3d 1027, 1040 n.3 (9th Cir. 2010).
Findings of fact are reviewed for "clear error" and not set aside "unless clearly erroneous." Edgmon v. United States, 449 Fed Appx. 576, 577 (9th Cir. 2011); Fed. R. Civ. P. 52(a)(6). A finding of fact is clearly erroneous if the district court is "left with a definite and firm conviction that a mistake has been made." Beech Aircraft Corp. v United States, 51 F.3d 834, 838 (9th Cir. 1995).
III. Discussion
A. Standard of Review
Plaintiff seeks relief under the Employee Retirement Income Security Act for wrongful termination of her long-term disability benefits. 29 U.S.C. § 1132(a)(1)(B). Plaintiff maintains that Aetna's termination of her claim should be reviewed de novo by this court because the Long Term Disability Plan contains no reference to the plan administrator retaining discretion to decide claims. (Pl.'s Mot. J. Pleadings and Administrative R. at 2 (#20).) Aetna contends that its termination should be reviewed under an abuse of discretion standard because of language in the Administrative Services Contract between Aetna and Cox conferring discretionary power upon Aetna. (Defs.' Resp. at 2 (#21).) When a plan does not confer discretionary power upon an entity, the standard of review is de novo. Abatie v. Alta Health & Life Ins. Co., 458 F.3d 955, 963 (9th Cir. 2006). When the plan does grant discretionary authority upon an entity, the entity's action is reviewed under an abuse of discretion standard. Id.
A document that is not "itself part of the plan" cannot confer discretionary power on an entity. CIGNA Corp. v. Amara, 131 S. Ct. 1866, 1878 (2011). Cases have upheld such additional documents only when they are integrated with the plan itself in some way. See, e.g., Langlois v. Metropolitan Life Ins. Co., 833 F. Supp.2d 1182, 1185 (N.D. Cal. 2011) (recognizing other plan documents because they were included under a specific integration clause in the plan); Lee v. Kaiser Foundation Health Plan Long Term Disability Plan, 812 F. Supp.2d 1027, 1036 (N.D. Cal. 2011) (recognizing other plan documents because they were "within [the plan's] umbrella"); Eugene S. v. Horizon Blue Cross Blue Shield of New Jersey, 663 F.3d 1124, 1131 (10th Cir. 2011) (finding that discretionary authority was conferred because the plan language indicated that the summary plan document "is the plan"). The Administrative Services Contract cited to by Aetna is not part of the plan, integrated or otherwise, and is not distributed to employees. It does not confer discretionary authority on Aetna for reviewing Plaintiff's claims.
Aetna claims language in the plan itself is consistent with a grant of discretionary authority to Aetna. (Defs.' Resp. at 3 (#21).) It points to language (1) requiring a claim to be submitted to Aetna; (2) allowing Aetna to request proof from a claimant; (3) giving Aetna the right to have a physician or dentist examine a claimant; and (4) requiring Aetna to approve a program for rehabilitation. (Id.) However, this language is too narrow to constitute a broad grant of discretionary authority. While there is no "magic word" that creates discretionary authority, Abatie, 458 F.3d at 963, a small list of narrow areas in which an entity has authority does not confer complete discretionary authority upon the entity. The plan language must "unambiguously provide discretion to the plan administrator." Feibusch v. Integrated Device Technology, Inc. Employee Ben. Plan, 463 F.3d 880, 883 (9th Cir. 2006). The plan language cited to by Aetna does not unambiguously create discretionary authority, and the standard of review adopted by this court is therefore de novo.
Under a de novo standard of review, "[t]he court simply proceeds to evaluate whether the plan administrator correctly or incorrectly denied benefits, without reference to whether the administrator operated under a conflict of interest." Abatie, 458 F.3d at 963. District courts are required under this standard to "undertake an independent and thorough inspection of an administrator's decision." Silver v. Executive Car Leasing Long-Term Disability Plan, 466 F.3d 727, 733 (9th Cir. 2006). The burden of proving wrongful termination of benefits is on the claimant. Muniz v. Amec Const. Management, Inc., 623 F.3d 1290, 1294 (9th Cir. 2010). Plaintiff must therefore satisfy her burden of proving that her disability benefits under Aetna's Long Term Disability Plan were wrongfully terminated.
B. Aetna's Review of Plaintiff's Medical Evidence
Plaintiff claims that Aetna failed to give proper weight to the statements of three of her physicians, Drs. Wint, Kinsora, and Cruz, regarding limitations on her ability to work. (Pl.'s Mot. J. Pleadings and Administrative R. at 7-10 (#20).) Plan administrators abuse their discretion when they focus only on "slivers" of the record supporting their decisions and ignore other relevant parts of the record. Metropolitan Life Ins. Co. v. Conger, 474 F.3d 258, 265 (6th Cir. 2007). Moreover, "[p]lan administrators . . . may not arbitrarily refuse to credit a claimant's reliable evidence, including the opinions of a treating physician." Black & Decker Disability Plan v. Nord, 538 U.S. 822, 834 (2003). However, administrators need not accord special weight to the statements of a treating physician, nor are they barred from crediting reliable evidence from sources that contradict the treating physician(s). Id.
Plaintiff points to language from her neurologist, Dr. Wint, in an itemized job restriction and limitation report. (Pl.'s Mot. for J. on the Pleadings and Administrative R. p. 7 (#20).) In his report, Dr. Wint indicates that Plaintiff could perform non-creative sedentary tasks not "dependent on interpersonal interaction" for "limited periods" and that a "slow introduction to the workplace" was necessary. (AETNA at 000989-000990 (#16).) While Aetna does not directly address this report in its letter terminating Plaintiff's benefits, it extensively addresses Plaintiff's various appointments with Dr. Wint, from a period where her psychological symptoms were preventing her from functioning to her last visit with Dr. Wint, where she showed marked improvement in her psychological symptoms and showed no severe cognitive deficits in a neuropsychological test ordered by Dr. Wint and performed by Dr. Kinsora. (Id. at 001093-001098.) Moreover, the itemized report by Dr. Wint does not conclusively indicate that she would be unable to work at any reasonable occupation. Dr. Wint lists several job activities that would be appropriate for Plaintiff and indicates that a "slow introduction to the workplace" would be appropriate. (Id. at 000989-000990).
Dr. Wint's March 9, 2011 letter to Aetna clarifying statements he made during a peer-to-peer conversation does not significantly change the evidence. In his letter of clarification, Dr. Wint acknowledges that Plaintiff's cognitive abilities are only mildly impaired but clarifies that her emotional capacity is extremely impaired. (Id. at 001079.) Nevertheless, he still refrains from precluding Plaintiff from gainful employment and instead argues for "a slow re-introduction to work under special circumstances." (Id.) Indeed, the first two paragraphs of his letter are dedicated to what types of work Plaintiff would be fit for, far from an outright denial of her ability to work.
Plaintiff further argues that Aetna ignored evidence from Dr. Kinsora that indicates that Plaintiff may not be able to return to the workplace. (Pl.'s Mot. J. Pleadings and Administrative R. at 8-9 (#20).) In particular, Plaintiff directs this court to language from a neurocognitive assessment where Dr. Kinsora stated that "the intensity of her depression, anxiety, and [MVA]-related PTSD symptoms . . . suggests that it may be difficult for her to return to work on a full-time basis." (AETNA at 001006 (#20).) This language, while urging caution regarding Plaintiff's return to the workplace, does not definitively preclude Plaintiff from gainful employment. In the same report, Dr. Kinsora describes most of Plaintiff's cognitive problems as "mild" and indicates that they will "worsen with anxiety, and when she is in a noisy, or chaotic environment." (Id.) Plaintiff provides no evidence that her occupational choices will be limited to noisy and anxiety-inducing environments. Additionally, as Aetna points out in its termination letter, Plaintiff showed no cognitive deficits in her neuropsychological examination by Dr. Kinsora. (Id. at 001093-001098.) Finally, in the same report cited to by Plaintiff, Dr. Kinsora states that Plaintiff "should be encouraged to remain as socially and physically active as possible." (Id. at 001007.)
While Aetna did not cite in its termination letter some of the passages that Plaintiff mentions, it did consider the results of Dr. Kinsora's neuropsychological examination in general. Id. at 001093-001098.) Moreover, the above statements by Dr. Kinsora about Plaintiff's fitness for employment do not render Aetna's decision unreasonable. On the contrary, Dr. Kinsora's statements could be interpreted as urging a cautious re-introduction of Plaintiff to the workforce.
Plaintiff also cites an October 2010 statement by her primary care physician, Rafael Cruz, where he states that "it is difficult for me to understand how this patient can be deemed as functional, considering her accident, mentation, cognition in lieu of her job description." (Id. at 000976.) However, Cruz deferentially adds that "if the [patient] is deemed functional, then a functional capacity [evaluation] should be obtained and any assistance necessary for her gainful employment should be provided." (Id.) These statements do not preclude Plaintiff from gainful employment, and, as they arise out of a routine physical examination by a general practitioner, they should be given less weight than the more specialized neurological examinations and evaluations provided by Drs. Kinsora and Wint.
While Aetna does not discuss every equivocation by each doctor in its termination letter, it provides a sufficiently thorough review of the relevant evidence. Aetna acknowledges the ongoing emotional difficulties that may hinder Plaintiff in the workplace. (Id. at 001097) However, Aetna's review also reveals a neuropsychological examination indicating no cognitive deficits, a normal EEG, and statements by Drs. Wint and Kinsora that indicate Plaintiff would be fit for certain occupational settings. (Id.) Aetna further conducted peer-to-peer conversations with Drs. Broeske and Owens, who confirmed that they had treated her but were unable to comment on her fitness for an occupational setting. (Id.) Aetna appears to have weighed the relevant evidence and come to a conclusion that is well supported by the administrative record. Aetna has not ignored any evidence that would unequivocally suggest that Plaintiff cannot work.
C. Aetna's Peer to Peer Conversations During Plaintiff's Appeal
Plaintiff claims that Aetna failed to fulfill its obligation to afford Plaintiff "a reasonable opportunity . . . for a full and fair review," 29 U.S.C. § 1133, by obtaining peer-to-peer medical conversations with Plaintiff's doctors during the appeal process that Plaintiff and her doctors could not address before the final denial. (Pl.'s Mot. J. Pleadings and Administrative R. (#20).) Plaintiff cites Halpin v. W.W. Grainger, Inc., 962 F.2d 685, 689 (7th Cir. 1992), for the proposition that the administrator must provide the claimant with all of the relevant evidence it relied upon and give the claimant the opportunity to address the accuracy and reliability of that evidence.
Plaintiff overstates the law. A plan administrator is required by regulation to disclose to the claimant all documents relevant to the appeal. 29 C.F.R. § 2560.503-1(i)(5). However, after a claimant has submitted an appeal, an administrator can prepare further documents relevant to Plaintiff's appeal and is only required to disclose them upon request after it makes its final determination. Silver v. Executive Car Leasing Long-Term Disability Plan, 466 F.3d 727, 731 n.2 (9th Cir. 2006); 29 C.F.R. 2560.503-1(h)(2)(iii). To require administrators to allow claimants to review every document it prepares on appeal before it makes its final decision would "lead to an interminable back-and-forth between the plan administrator and the claimant." Silver, 466 F.3d at 731 n.2; see also Metzger v. Unum Life Ins. Co. of Am., 476 F.3d 1161, 1166-67 (10th Cir. 2007) (finding that allowing claimants to review and rebut reports generated during the appeal process would lead to an "unnecessary cycle of submission, review, re-submission, and re-review"). Allowing such claimant review on appeal would also "prolong the appeal process, which, under the regulations, should normally be completed within 45 days." Metzger, 476 F.3d at 1166 (citing 29 C.F.R. § 2560.503-1(i)(3)(i)). As long as the claimant has access to the documents generated on appeal at the district court where she brings her claim, the claimant is deemed to have "had ample opportunity to respond." Silver, 466 F.3d at 731 n.2.
Aetna was therefore justified in conducting peer-to-peer conversations during Plaintiff's appeal and not disclosing information from the conversations until it made its final determination. Aetna provided in its termination letter the peer-to-peer statements it relied upon in its decision. Plaintiff has had ample opportunity to raise any objections her doctors may have to Aetna's portrayal of their statements at the district court level. The one clarification she provided, Dr. Wint's March 9th, 2011 letter (AETNA 001079 (#16)), does not significantly change the evidence Aetna relied upon. See supra Part III.B. Plaintiff has not requested any additional documents from Aetna regarding the peer-to-peer conversations, nor has she disputed other statements attributed to her doctors in Aetna's termination letter.
Plaintiff argues that she was not given a full and fair review because comments attributed to her doctors were "provided by unidentified individuals." (Mot. J. Pleadings and Administrative R. at 7 (#20).) However, Plaintiff cites no legal authority requiring conductors of peer-to-peer conversations to be specifically identified, nor does there appear to be any. See Midgett v. Washington Group Intern. Long Term Disability Plan, 561 F.3d 887, 896 (8th Cir. 2009) ("we are aware of [no established law] requiring peer reviews to be performed by examining physicians, requiring a plan administrator to provide detailed credentials of peer reviewers, or prohibiting peer reviews from appearing on a plan administrator's form"). Moreover, because the evidence obtained by Aetna from the peer conversations consists only of Plaintiffs' doctors' statements and involves no independent judgment by the peer reviewers, this court will not require further information about Aetna's peers. Nor will we question the validity of the statements attributed to the doctors unless Plaintiff provides a compelling reason to do so, which she has not.
D. Aetna's Lack of Vocational Evidence
Plaintiff claims that Aetna failed to give her a full and fair review by failing to provide vocational evidence regarding whether Plaintiff would be fit for "any occupation" with the restrictions provided by her doctors. (Mot. J. Pleadings and Administrative R. at 9 (#20).) However, in cases where the "any occupation" standard applies, "consideration of vocational evidence is unnecessary where the evidence in the administrative record supports the conclusion that the claimant does not have an impairment which would prevent him from performing some identifiable job." McKenzie v. General Telephone Co. of California, 41 F.3d 1310, 1317 (9th Cir. 1994). See also Regula v. Delta Family-Care Disability Survivorship Plan, 266 F.3d 1130, 1149 (9th Cir. 2001) (holding that because there "is ample evidence in the record to support [the plan administrator's] conclusion that [Plaintiff] could perform some occupation," the plan administrator is not required to provide specific vocational evidence stating what jobs Plaintiff can perform).
Here, there is no evidence that unequivocally suggests that Plaintiff is not fit for any job, and several of Plaintiff's doctors provide guidelines for returning to a vocational setting. Dr. Wint indicates that Plaintiff's most debilitating impairments at this point are emotional and can be managed with a slow-reintroduction to the workforce. (AETNA at 001079 (#16).) Dr. Kinsora suggests that it would be unadvisable for Plaintiff to work in a noisy or chaotic environment, (AETNA at 001006 (#16).), but there is no reason to assume that Plaintiff's choice of sedentary office jobs would be restricted to noisy or chaotic ones. Aetna had sufficient evidence to determine that Plaintiff was fit for some form of "gainful activity in which [she is], or may reasonably become, fitted by education, training, or experience."
E. Plaintiff's Social Security Award
Plaintiff argues that Aetna failed to give proper weight to Plaintiff's Social Security benefits award. (Mot. J. Pleadings and Administrative R. at 10-11 (#20).) However, the cases she points to supporting the conclusion that a plan administrator conducted an insufficient review by failing to adequately consider Social Security benefits list such a failure as one among several factors amounting to an insufficient review. See, e.g., Montour v. Hartford Life & Acc. Ins. Co., 588 F.3d 623, 637 (9th Cir. 2009) (finding signs of bias, insufficiency in the surveillance of plaintiff's activities, failure to ensure a neutral review process, and failure to conduct a physical exam along with failure to consider plaintiff's award of Social Security benefits to amount to an abuse of discretion); Pierce v. American Waterworks Co., Inc., 683 F.Supp. 996, 1001 (W.D. Pa. 1988) (finding that the overall decision was "not supported by substantial evidence"). While a plan administrator's failure to review a social security decision is a factor in demonstrating an arbitrary or insufficient review, it "does not render the decision arbitrary per se." Glenn v. MetLife, 461 F.3d 660, 669 (6th Cir. 2006). Plaintiff has failed to establish that Aetna conducted an insufficient review in any other way, so it is not clear that Aetna's review would be insufficient even if it had failed to review the SSA's decision.
Additionally, Aetna points to several differences in how disability is assessed by the Social Security Administration and under the Long Term Disability Plan drafted by Cox. (Defs.' Resp. at 15-16 (#21).) The Social Security Act defines an individual as "disabled" if "he is not only unable to do his previous work but cannot, considering his age, education, and work experience, engage in any other kind of substantial, gainful work which exists in the national economy." 42 U.S.C. § 423(d)(2)(A). Comparatively, Cox's Long Term Disability plan defines an individual as disabled if "after the first 24 months of a period of total disability, [they] are not able solely because of injury or disease to work at any reasonable occupation," further clarifying that "reasonable occupation" means "any gainful activity for which you are, or may reasonably become, fitted by education, training, or experience." (AETNA at 000004 (#16).)
As Aetna points out, the Social Security definition of "disabled" narrows the jobs a claimant is considered eligible for by taking into account the claimant's age and restricting the job market to the "national" economy. The Social Security Act also requires that a claimant be able to find "substantial" gainful employment, while Cox's Long Term Disability Plan recognizes "any" reasonable gainful employment, though Aetna does not explain what difference this makes as a practical matter. Also, unlike the SSA, Aetna is not bound by the treating physician rule, which requires the SSA to accord "special weight" to the opinions of a claimant's treating physician. Black & Decker Disability Plan, 538 U.S. at 831.
The most important difference between the Social Security Administration's review and Aetna's review, however, is that Aetna was reviewing Plaintiff's claim with more updated information. Plaintiff was awarded her Social Security benefits in the fourth quarter of 2009. (AETNA at 001042.) Aetna's determination regarding Plaintiff's disability status was made nearly a year after that, taking into consideration new medical records and doctor testimony. Much of the information that Aetna relied upon for its latest decision would not have been available to the SSA at the time they composed their January 22, 2010 letter.
In its termination letter, Aetna acknowledges the SSA's decision but points out the differences in the records relied upon and the entities' methodologies. (Id. at 001097.) Given the foregoing analysis of the differences between the two entities' methods and information, Aetna was justified in acknowledging the SSA's decision but refusing to treat it as dispositive.
IV. Conclusion
Plaintiff has failed to show that Aetna did not give her a full and fair administrative review under its Long Term Disability Plan. Plaintiff's Motion for Judgment on the Pleadings and Administrative Record (#20) is denied, Aetna's termination of Plaintiff's benefits is upheld, and Defendants' Counter-Motion for Judgment on the Pleadings and Administrative Record (#21) is granted.
IT IS, THEREFORE, HEREBY ORDERED that Plaintiff's Motion for Judgment on the Pleadings and Administrative Record (#20) is DENIED .
IT IS FURTHER ORDERED that Defendants' Motion for Judgment on the Pleadings and Administrative Record (#21) is GRANTED .
The Clerk shall enter the judgment accordingly.
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UNITED STATES DISTRICT JUDGE