United States District Court, W.D. Virginia, Roanoke Division
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. ...