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Lee v. Aetna Life Insurance Co., Inc.

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

January 6, 2017



          Hon. Glen E. Conrad, Chief United States District Judge

         In this 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.

         Factual and Procedural Background

         Lee 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.

         The 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 predisability earnings.
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.

         Lee was 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 219.

         Approximately 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.

         As part 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.

         On 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. ...

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