Virginia Lawyers Weekly VA Lawyers Weekly
Where an insurer relied on medical records, an independent medical exam report, two independent physician peer review reports and the 2017 transferrable skills analysis, or TSA, in concluding a man was not fully disabled, and thus no longer entitled to long-term disability, or LTD, benefits, it prevailed on the claim.
Background
Jeremy Smith, a former employee of Cox Enterprise Inc., suffered from a herniated disc in January 2012. As a result of his medical condition, plaintiff claims he was totally disabled. Plaintiff received LTD benefits for approximately seven years under an ERISA-governed employee welfare benefit plan, until his benefits were terminated on July 16, 2019.
Plaintiff alleges that Aetna improperly disqualified him for LTD benefits under the plan’s definition of “total disability.” Both parties have filed motions for summary judgment.
Record
Plaintiff argues that though Aetna had adequate materials, it failed to rely on those materials in deciding to terminate plaintiff’s LTD benefits. However, the court finds that the materials upon which Aetna based its termination decision – plaintiff’s medical records, an independent medical exam report, two independent physician peer review reports and the 2017 TSA – constitute substantial evidence as (1) its quantity represents more than a scintilla and (2) a reasoning mind would accept the materials as sufficient to support the conclusion that plaintiff was not totally disabled and was capable of working.
Plaintiff specifically takes issue with the fact that Aetna allegedly did not rely on any of the three in-person exams conducted by Dr. Hartline, Dr. Lee and Dr. Harris, none of which concluded that plaintiff could sit for most of the workday. Plaintiff contends that Aetna should have especially deferred to Dr. Hartline because he was plaintiff’s treating physician.
The court disagrees. Dr. Hartline stated, after being plaintiff’s physician for only one week, that the two hour per day, two days per week limitations he opined were based on another doctor’s opinion. It was not unreasonable for Aetna to give less weight to the opinion of a doctor who had only seen plaintiff for a short time at the time of his attending physician statement; had not conducted a full examination; attributed his opinion to an unnamed, prior doctor and the patient’s subjective responses and provided incomplete responses.
Moreover, a claims administrator is “not obliged to accord special deference to the opinions of treating physicians.” The court accordingly finds that the medical reviews and conclusions of Dr. Lee, Dr. Walker and Dr. Gupta constitute adequate materials upon which Aetna could reasonably rely in making its termination decision.
Aetna also relied on the analysis and results of the TSA performed by the vocational expert that concluded that there were four sedentary jobs plaintiff could perform that met “all required criteria, including reasonable wage, education, experience, training and functional capacity.” Finally, it is clear from the record that Aetna also considered Dr. Harris’ July 2018 SSDI Consultative Examination Report. Individually and collectively, these materials support the finding that plaintiff is not totally disabled and he can return to work full time.
Process
Plaintiff contends Aetna’s decision to terminate his LTD benefits was not the result of the deliberate and principled reasoning process because: (1) the definition of a sedentary job is incompatible with all examining physicians’ opinions, (2) Aetna ignored plaintiff’s claims of pain, (3) Aetna failed to consider Dr. Harris’ July 2018 SSDI Consultative Examination Report and (4) Aetna failed to explain its reasoning.
Despite plaintiff’s references to Dr. Harris and Dr. Hartline’s opinions, Aetna’s finding that plaintiff could work four sedentary occupations is consistent with most of the physicians’ conclusions. All three of these opinions are compatible with the sedentary positions identified in the TSA. Next, the record makes clear that Aetna did consider plaintiff’s pain. The record also does not support plaintiff’s allegation that Aetna did not consider Dr. Harris’ July 2018 SSDI Consultative Examination Report. Finally, the court finds Aetna addressed conflicting evidence and articulated why it found the evidence unpersuasive, most notably, Dr. Hartline’s opinion regarding plaintiff’s capacity to work.
Plaintiff’s motion for summary judgment on the administrative record denied. Defendant’s motion for summary judgment on the administrative record granted.
Smith v. Cox Enterprises Inc. Welfare Benefits Plan, Case No. 1:20-cv-01434, Sept. 30, 2022. EDVA at Alexandria (Giles). VLW 022-3-454. 23 pp.
