United States District Court, W.D. Virginia, Roanoke Division
January 6, 2017
LAURIE LYNN LEE, Plaintiff,
AETNA LIFE INSURANCE COMPANY, INC., Defendant.
Glen E. Conrad, Chief United States District Judge
action, brought pursuant to the Employee Retirement Income
Security Act of 1974 ("ERISA"), 29 U.S.C.
§§ 1001-1461, plaintiff Laurie Lynn Lee claims that
defendant Aetna Life Insurance Company, Inc.
("Aetna") wrongfully denied her claim for long-term
disability benefits under an employee welfare benefit plan
(the "Plan). The case is presently before the court on
the parties' cross-motions for summary judgment. For the
reasons set forth below, the court will grant defendant's
motion and deny plaintiffs motion.
and Procedural Background
previously worked as a Business Manager for iHeartMedia,
Inc., formally known as Clear Channel Communications, Inc.
("iHeartMedia"). As an employee, Lee participated
in the Plan, which is governed by ERISA and provides
short-term and long-term disability benefits. iHearthMedia
sponsors and maintains the Plan. A group life and accident
health insurance policy issued by Aetna funds it. Under the
terms of the Plan, Aenta has "discretionary authority to
determine whether and to what extent eligible employees and
beneficiaries are entitled to benefits" Administrative
Record ("AR") 1124.
Plan provides the following "Test for Disability":
From the date that you first became disabled and until
monthly benefits are payable for 24 months you meet the test
of disability on any day that:
■ You cannot perform the material duties of your own
occupation solely because of an illness, injury or disabling
pregnancy-related condition; and
■ Your earnings are 80% or less of your adjusted
After the first 24 months of your disability that monthly
benefits are payable, you meet the plan's test of
disability on any day you are unable to work at any
reasonable occupation solely because of an illness, injury,
or disabling pregnancy-related condition.
AR 1138 (emphasis omitted). "Material duties" are
defined as "[d]uties that: Are normally needed for the
performance of your own occupation; and Cannot be reasonably
left out or changed. However, to be at work more than 40
hours per week is not a material duty." AR 1154.
"Own occupation" means "[t]he occupation that
you are routinely performing when your period of disability
begins" and is specifically "viewed as it is
normally performed in the national economy instead of how it
is performed: For your specific employer; or At your location
or work site, and Without regard to your specific reporting
relationship." Id. It is undisputed that
Lee's occupation is sedentary in nature and that driving
is not a material duty. Def.'s Br. in Supp. 5, Docket No.
17; PL's Br. in Supp. 3, Docket No. 15.
diagnosed with spinal instability and diskogenic back pain.
She underwent surgery on September 20, 2012. AR 180. Due to
her surgery, she applied for, and received, the maximum
short-term disability benefits. AR 111. On December 20, 2012,
Dr. Spott Jamison, Lee's internist, reported that Lee
could not be up for more than three hours at a time and could
not drive. He also released her to at-home work for five
hours a day, five days a week. AR 137. iHeartMedia allowed
Lee to work from home, and Aetna approved Lee's claim for
partial long-term disability benefits. On January 21, 2013,
Dr. Jamison noted that Lee was "able to increase her
work load to 8 hours a day over [the] next two weeks."
AR 983. Because Lee was able to return to a foil-time
schedule when working from home, Aenta terminated Lee's
long-term disability benefits effective January 21, 2013. AR
six months later, iHeartMedia informed Lee that they would no
longer accommodate her working foil-time from home after July
15, 2013. Lee again sought long-term disability benefits.
Upon a review of Lee's claim, Aetna requested a
Capabilities and Limitations Worksheet to be completed by Dr.
Jamison, which he did on July 25, 2013. In the Capabilities
and Limitations Worksheet, Dr. Jamison indicated that Lee
could occasionally kneel, lift, pull, push, reach above
shoulder height, reach forward, and carry. AR 531-32. Lee
could frequently sit and stand and walk but could not stoop.
Id. She was approved for head and neck movements,
and lifting frequently up to ten pounds. Id. The
Worksheet noted that Lee could not drive for prolonged
periods and that she had to change positions every fifteen
minutes. Id. Aetna found driving not to be a part of
Lee's job duties and concluded that the remaining
limitations, including her "restriction of changing
position every 15-20 minutes while sitting, " are
"normally accommodated." AR 384-86. On October 3,
2013, Aetna notified Lee that her claim would be denied.
Id. Lee appealed, asserting that she could only work
from home. Working from home allowed her to lie down and ease
the swelling in her leg as well as take breaks to stand and
walk because prolonged sitting caused her pain. AR 265. Lee
claimed that these limitations extended her workday, which
sometimes spanned from 5:00 a.m. to 11:00 p.m. AR 537. While
awaiting Aetna's determination of her appeal, Lee
continued to follow up with Dr. Jamison, seeing him on
October 3, 2013 and October 16, 2013. At these follow up
visits, Dr. Jamison noted that Lee required regular laying
down to reduce swelling in her leg; that Lee had to change
her position by standing or walking to relieve pain every
five to ten minutes; that Lee may have received the maximum
benefit of her recovery; that Lee was unable to maintain
meaningful work; that Lee was "severely limited";
and that Lee required disability. AR 884-887. In the records
of these visits, Dr. Jamison did not include a comprehensive
history and physical examination indicating functional
deficits. AR 884-887, 399.
of the appeal, Aetna requested an independent physician
"peer review." Dr. Martin Mendelssohn, M.D., who is
board certified in orthopedic surgery, completed this review
on November 25, 2013. AR 429-34. In his report, Dr.
Mendelssohn summarized the medical records in Lee's case
file, including treatment notes from Dr. Jamison and
Lee's orthopedic surgeon, Dr. Jonathan Carmouche. AR
429-30. Dr. Mendlessohn, however, was not able to speak with
Dr. Jamison. Id. Dr. Mendlessohn concluded that,
"based on the lack of any functional or neurological
deficits and progressive healing of the claimant's
fusion, the medical evidence does not substantiate a
functional impairment for the claimant from her regular
unrestricted occupation." AR 433. Accordingly, Dr.
Mendelssohn opined that "the claimant could return to
her regular unrestricted occupation ... as of 7/15/2013
through 11/21/13 as a business manager, which is a sedentary
occupation, without the need for any accommodations." AR
434. After Dr. Mendlessohn completed his review, Dr. Jamison
was afforded five days to respond and note the portions of
the reviewer's conclusions that he agreed and disagreed
with. AR 397. Dr. Jamison did not respond. AR 399.
December 12, 2013, Aetna upheld its denial of Lee's claim
for long-term disability benefits, stating that there was a
lack of medical evidence supporting a functional impairment
that would have prevented Lee from performing the material
duties of her own occupation. AR 399. Specifically, it its
letter to Lee, Aetna cited to several pieces of the medical
(1) A progress report dated September 23, 2013 observing no
signs of complications from Lee's September 20, 2012
(2) Records from October 5, 2012 noting no complications and
no neurological deficits and stating that Lee was able to
return to part-time work from home;
(3) Records from November 2, 2012 in which Lee's gait was
described as stable and her neurological evaluation normal.
These records noted that Lee complained of pain in her left
(4) A progress note from November 30, 2012 observing that Lee
was recovering slowly;
(5) Records from a January 21, 2013 visit with Dr. Jamison
that included no clinical examination findings of
(6) A March 26, 2013 progress note from Dr. Carmouche in
which Dr. Carmouche again documented that Lee had a stable
gait and balanced standing posture;
(7) The Capabilities and Limitations Worksheet from Dr.
Jamison dated July 25, 2013; and
(8) Dr. Jamison's notes from his October 3, 2013
revaluation of Lee.
As to the October 3, 2013 notes, Aetna specifically stated
that these records did not include a comprehensive history
and physical examination indicating functional deficits.
Aetna also noted that it had requested a peer review from Dr.
Mendelssohn and that Dr. Jamison had not responded to
requests to evaluate the peer review. AR 399. On July 28,
2014, Lee was awarded social security benefits with an onset
date of July 14, 2013.
exhausted her administrative remedies, Lee filed this instant
action on June 23, 2015. The parties subsequently filed
cross-motions for summary judgment. Lee argues that summary
judgment should be granted because Aenta's denial of
benefits was not the result of a reasoned and principled
decision-making process supported by substantial evidence. In
response, Aetna contends that its decision should be upheld.
The motions have been fully briefed and are ripe for review.
parties agree that the Plan grants Aetna "discretionary
authority to determine whether and to what extent eligible
employees and beneficiaries are entitled to benefits. . .
." AR 1124; Def.'s Br. in Supp. 3; PL's Reply in
Supp. 2, Docket No. 18. Accordingly, the court reviews
Aetna's decision for abuse of discretion. See DuPerry
v. Life Ins. Co. of N. Am., 632 F.3d 860, 869 (4th Cir.
2011). Under this standard, an administrator's decision
will not be disturbed unless it is unreasonable. Id.
To be reasonable, the decision must be "the result of a
deliberate principled reasoning process" and be
"supported by substantial evidence." Brogan v.
Holland, 105 F.3d 158, 161 (4th Gir. 1997) (internal
quotation marks omitted). Substantial evidence is
"evidence which a reasoning mind would accept as
sufficient to support a particular conclusion."
LeFebre v. Westinghouse Elec. Corp., 747 F.2d 197,
208 (4th Cir. 1984) (internal quotation marks omitted). In
assessing the existence of substantial evidence, the court
does not "undertake to re-weigh conflicting evidence,
make credibility determinations, or substitute [its] judgment
for that of the [administrator]." Laws v.
Celebrezze, 368 F.2d 640, 642 (4th Cir. 1966); see
also Giles v. Bert Bell/Pete Rozelle NFL Player Ret.
Plan, 925 F.Supp.2d 700, 716 (D. Md. 2012) ("The
court does not reweigh the evidence."). Instead, the
court inquires as to whether the administrator considered all
relevant evidence and sufficiently explained the weight
accorded thereto. Sterling Smokeless Coal Co. v.
Akers, 131 F.3d 438, 439 (4th Cir. 1997); Love v.
Nat'l City Corp. Welfare Benefits Plan, 574 F.3d
392, 395 (7th Cir. 2009). However, "[i]f the plan
administrator failed to make adequate factual findings or
failed to adequately explain the grounds for the decision,
then the proper remedy is to remand the case for further
findings or additional explanation." Gorski v. ITT
Long Term Disability Plan for Salaried Employees, 314
F.App'x 540, 548 (4th Cir. 2008) (internal citations
omitted); see also DuPerry, 632 F.3d at 875-876;
Elliott v. Sara Lee Corp., 190 F.3d 601, 609 (4th
Cir. 1999) (noting that the court may either reverse the
decision or remand it to the administrator for further review
when the administrator has abused its discretion).
Booth v. Wal-Mart Stores, Inc. Assocs. Health &
Welfare Plan, 201 F.3d 335 (4th Cir. 2000), the Fourth
Circuit set forth eight nonexclusive factors to be considered
by courts in reviewing a plan 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 decisionmaking
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.
Id. at 343-343. These factors continue to guide the
court's abuse-of-discretion review under ERISA. See
DuPerrv, 632 F.3d at 869.
Denial of Benefits
makes five arguments as to why Aetna's denial of benefits
was not the result of reasoned decision-making supported by
substantial evidence: (1) that Aetna did not take into
consideration Dr. Jamison's repeated findings that Lee
was "unable to drive greater than 10 minutes due to
severe pain"; (2) that Aetna recharacterized Lee's
limitation, stating that she had to change positions every
fifteen to twenty minutes, when on October 3, 2013 Dr.
Jamison noted that Lee had to stand or walk every five to ten
minutes to relieve pain; (3) that Aetna did not address
Lee's claim that she needed to lie down to relieve the
swelling in her leg several times per day and that doing so
prolonged her work day; (4) that Aetna failed to account for
Dr. Jamison's October 3, 2013 observations that he did
not expect Lee to be able to return to work; and (5) that the
court should consider that Lee was retroactively awarded
social security disability benefits. Lee also argues that the
court should consider Aetna's conflict of interest as
Aetna both evaluates and pays benefit claims.
Aetna argues that the court should not give its conflict of
interest any greater weight than the other factors, as Lee
has not proffered any evidence suggesting that a conflict of
interest affected the contested decision. Aetna further
asserts that the court should not consider Lee's
retroactive award of social security disability benefits, as
Lee did not receive the award until July 28, 2014, several
months after Aetna made its determination of Lee's
appeal. Last, Aetna maintains that consideration of the
Booth factors warrants granting of its motion for
plan administrator both evaluates and pays disability
benefits, this dual role creates a conflict of interest.
Champion v. Black & Decker (U.S.) Inc., 550 F.3d
353, 359 (4th Cir. 2008). However, absent evidence tending to
show that the administrator's dual role affected its
decision making, the administrator's conflict of interest
is "only 'one factor among many'" that the
district court reviews "in determining the
reasonableness of the administrator's decision."
Champion, 550 F.3d at 362 (quoting Metropolitan
Life Ins. v. Glenn, 554 U.S. 105, 107 (2008));
Carden v. Aetna Life Ins. Co., 559 F.3d 256, 260
(4th Cir. 2009) ("[A] conflict of interest becomes just
one of the 'several, often case-specific, factors' to
be weighed together in determining whether the administrator
abused its discretion.") (quoting Glenn, 554
U.S. at 107). Here, Lee has not presented evidence suggesting
that Aetna's structural conflict of interest affected the
decision to deny Lee long-term disability benefits.
Accordingly, the court will consider the conflict as one of
the many applicable factors without any specific greater
emphasis. Champion, 550 F.3d at 359 (noting that any
conflict of interest is accounted for by "considering
the relevant factors, as identified in Booth").
"it is well-established in the Fourth Circuit that the
[Social Security Administration's] determination of
someone's disability status is evidence that can be
considered by a court ruling on the denial or termination of
disability benefits, " the Social Security
Administration's decision is not determinative.
Turner v. Ret, and Benefit Plans Comm, Robert
Bosch Corp., 585 F.Supp.2d 692, 705 (D.S.C. 2007)
(citing sources). That the claimant is entitled to social
security disability benefits does not determine whether she
is entitled to long-term disability under a disability plan
governed by ERISA because, unlike social security disability
cases, "ERISA does not impose a treating physician rule,
under which a plan must credit the conclusions of those who
examined or treated a patient over the conclusions of those
who did not." White v. Sun Life Assurance Co. of
Canada, 488 F.3d 240, 254 (4th Cir. 2007). Therefore,
although a claimant has been awarded social security
disability benefits, an administrator may deny benefits under
ERISA upon presenting grounds that "a reasoning mind
would accept as sufficient" for such a decision.
court next turns to whether consideration of the factors set
forth in Booth necessitates a determination that
Aetna abused its discretion. Applying these factors, the
court agrees with Aetna that its decision was the product of
reasoned decision-making based on substantial evidence. In
reaching this decision, the court focuses primarily on the
language of the Plan, the sufficiency of the evidence upon
which Aetna based its conclusion, and the reasonableness of
Aetna's decision-making process.
court begins with the language of the Plan. In order to meet
the test for disability, the Plan requires that the claimant
"cannot perform the material duties of [his or her] own
occupation solely because of an illness, injury or disabling
pregnancy-related condition; and [his or her] earnings are
80% or less of [his or her] adjusted predisability
earnings." AR 1138. The Plan defines the claimant's
"own occupation" as "[t]he occupation that [he
or she is] routinely performing when [the] period of
disability begins" and specifies that the claimant's
occupation "will be viewed as it is normally performed
in the national economy" instead of how it is performed
for the individual's employer, at the individual's
location, and without regard to the individual's specific
reporting relationship. Id. "Material
duties" are those "normally needed for the
performance of [the individual's] own occupation; and
cannot be reasonably left out or changed." Thus,
Lee's case turned on the question of whether she was able
to perform the material duties of sedentary work as viewed in
the national economy. See DuPerry, 632 F.3d at 871
(reviewing an adverse decision for abuse of discretion and
noting that "DuPerry's case turned on the question
of whether she was in fact unable to perform the material
duties of her job.").
court interprets ERISA plans under ordinary principles of
contract law, giving meaning to the plan's plain language
in its ordinary sense. Wheeler v. Dynamic Engineering,
Inc., 62 F.3d 634, 638 (4th Cir. 1995). Here, the Plan
is unambiguous: the test for disability is evaluated in
relation to the claimant's own occupation without regard
for, among other things, the claimant's individual
location. AR 1154. Lee had been performing the material
duties of her job, full-time, from home for the six months
prior to her request for long-term disability benefits.
Adhering to the common and ordinary language of the Plan, the
court believes Aetna's determination that Lee could not
sustain a claim for disability benefits when she could
perform the material duties of her job at home but not at
iHeartMedia's work site to be reasonable. AR 303; see
Coleman v. Nationwide Life Ins. Co., 969 F.2d 54, 56
(4th Cir. 1992) ("ERISA . . . places great emphasis upon
adherence to the written provisions in an employee benefit
the court reviews the adequacy of the materials considered to
make the decision and the degree to which they support it.
Booth, 201 F.3d at 343. Here, Aetna relied upon
progress notes from Lee's treating physicians as well as
Dr. Mendelssohn's peer review, as it explained in its
letter affirming the denial of benefits. Aside from the
October 3, 2016 records, the progress notes suggested no
complications with the surgery, and that Lee's gait was
stable. Notably, there were no clinical findings indicating
any neurological deficits. Dr. Jamison's July 25, 2013
Capabilities and Limitations Worksheet indicated that Lee
could occasionally kneel, lift, pull, push, reach above
shoulder height, reach forward, and carry, that she could
frequently sit and stand and walk but could not stoop, that
she was approved for head and neck movements and lifting
frequently up to ten pounds, that Lee could not drive for
prolonged periods, and that Lee had to change positions every
fifteen minutes. AR 531. Aetna determined that this
information "provided from Dr. Jamison [did] not support
a functional impairment." AR 399. Aetna also found that
Lee's limitation of changing position every "15-20
minutes" while sitting "is normally
accommodated." AR 386.
asserts that Aetna recharacterized her limitation to require
repositioning every fifteen to twenty minutes when Dr.
Jamison noted, on October 3, 2012, that she had to reposition
every five to ten minutes. Lee also argues that Aetna did not
consider that Lee's driving limitation also meant that
she had a similar sitting limitation. However, Dr. Jamison
clearly noted that Lee had to reposition every fifteen
minutes on July 25, 2013, and then on October 3, 2013, that
Lee had to reposition every five to ten minutes. AR 531.
Similarly, while Dr. Jamison indicated that Lee could not
drive for prolonged periods of time, he also reported that
Lee could "frequently sit." Id.
Accordingly, Aetna relied upon the July 25, 2013 Worksheet,
in addition to previous progress notes and Dr.
Mendelssohn's peer review, in determining that Lee was
not disabled as defined by the Plan. The court believes that
such reliance was reasonable as this evidence was of a type
that "a reasoning mind would accept as sufficient to
support a particular conclusion." LeFebre v.
Westinghouse Elec. Corp., 747 F.2d at 208.
court thus considers whether Aetna's decision was
reasoned and principled. Booth, 201 F.3d at 343.
When "a reasoning mind would accept [the evidence relied
upon by the plan administrator] as sufficient to support a
particular conclusion, " it is not an abuse of
discretion for a plan administrator to deny benefits in the
face of conflicting evidence. LeFebre, 747 F.2d at
208. However, an administrator "abuses its discretion
when it fails to address conflicting evidence."
Helton v. AT&T, Inc., 798 F.3d 343, 359 (4th
Cir. 2013). In those instances, it cannot be said that the
administrator engaged in "a reasoned and principled
decision-making process, as required by the fifth
Booth factor." Id; see also Donovan v.
Eaton Corp., 462 F.3d 321, 329 (4th Cir. 2006) (finding
an abuse of discretion where there was a "wholesale
disregard" of evidence in the claimant's favor);
Harris v. Holland, 87 F.App'x 851, 859 (4th Cir.
2004) (holding that the trustees of the pension plan abused
their discretion in denying plaintiffs claim for disability
benefits, where they "apparently gave no
consideration" to an opinion provided by a treating
physician, which directly addressed one of the issues in
dispute). Here, plaintiff argues that Aetna failed to address
several pieces of conflicting evidence. The court cannot
instances in which courts have found an administrator abused
its discretion, Aetna did not engage in a "wholesale
disregard" of Lee's supporting evidence. Donovan
v. Eaton Corp. Long Term Disability Plan, 462 F.3d 321,
329 (4th Cir. 2006); cf Glenn v. Metro. Life Ins.
Co., 461 F.3d 660, 672 (6th Cir. 2006) (finding an abuse
of discretion in a case where the administrator "offered
no explanation for its resolution of [an inconsistency in the
evidence] or, for that matter, whether it was given any
consideration at all"). Aetna noted that Lee could not
drive more than ten minutes, but explained that a vocational
review revealed that driving was not a part of Lee's job
duties. AR 386, 556-557. Similarly, Aetna acknowledged that
Lee continued to complain of pain and that, on October 3,
2013, Dr. Jamison continued to find Lee symptomatic. In
making these observations, Aenta was addressing the
conflicting evidence before it. More importantly, Aetna
pointed to what it did rely upon, the July 25, 2013
Capabilities and Limitations Worksheet and previous progress
notes, and explained why it did not credit Dr. Jamison's
opinions from October 3, 2013: because "[a]
comprehensive history and physical examination indicating
functional neurological deficits was not provided." AR
399; see Harris, 87 F.App'x at 859 (noting that
the court cannot "impose on plan administrators a
discrete burden of explanation when they credit reliable
evidence that conflicts with a treating physician's
this record, the court cannot find that Aetna failed to
engage in a reasoned decision-making process. Its decision
was based on evaluation of Lee's progress notes and
medical records, upon a Capabilities and Limitation Worksheet
completed by Lee's treating physician, a vocational
evaluation, and by an independent review of the record. See
Hilton v. UNUM Life Ins. Co. of Am.. 967 F.Supp.2d
1114, 1124 (E.D. Va. 2013) ("A principled reasoning
process can be determined by consideration of the complete
record, reliance on independent medical evaluations, and
assessment of the claimant's vocational capacity.").
Aetna also addressed conflicting evidence and explained that,
absent clinical examination findings indicating any
neurological deficits, such evidence did not support a
finding of a functional impairment that would have prevented
Lee from performing the material duties of her own
occupation. Therefore, because the court finds that Aetna did
not abuse its discretion and relied upon substantial
evidence, the court will grant Aetna's motion for summary
Attorneys Fees & Costs
also seeks reimbursement for her attorney's fees and
costs incurred in the instant action. Pursuant to 29 U.S.C.
§ 1132(g)(1), a court may, in its discretion, allow
reasonable attorney's fees and costs to either party. 29
U.S.C. § 1132(g)(1). To be eligible for an award, the
party must achieve some degree of success on the merits.
Hardt v. Reliance Standard Life Ins. Co., 560 U.S.
242, 254 (2010). In the ERISA context, a party who obtains
remand can be said to have some success on the merits. See
Scott v. PNC Bank Corp. & Affiliates Long Term
Disability Plan, No. WDQ-09-3239, 2011 WL 2601569, at
*4-*9 (D. Md. June 28, 2011) (in concluding that a party may
be entitled to fees and costs, the district court provided a
detailed analysis of whether obtaining remand qualifies as
some degree of success on the merits); W.Va. Highlands
Conservatory v. Kempthorne, 569 F.3d 147, 152 (4th Cir.
2009) ("A party who obtains a remand order requiring an
administrative agency to perform properly its regulatory
duties has achieved some degree of success on the
merits."). Here, the court has determined that Aetna did
not abuse its discretion and will not remand the case. Lee
has failed to demonstrate some degree of success on the
merits, and her request for attorney's fees and costs
will be denied.
reasons stated, Aetna's motion for summary judgment will
be granted and Lee's motion for summary judgment will be
denied. The Clerk is directed to send certified copies of
this memorandum opinion and the accompanying order to all
counsel of record.