Bishop v. Aetna Life Insurance

163 F. Supp. 3d 443, 2016 U.S. Dist. LEXIS 17331, 2016 WL 591765
CourtDistrict Court, E.D. Kentucky
DecidedFebruary 12, 2016
DocketCIVIL ACTION NO. 5:15-cv-104-KKC
StatusPublished

This text of 163 F. Supp. 3d 443 (Bishop v. Aetna Life Insurance) is published on Counsel Stack Legal Research, covering District Court, E.D. Kentucky primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Bishop v. Aetna Life Insurance, 163 F. Supp. 3d 443, 2016 U.S. Dist. LEXIS 17331, 2016 WL 591765 (E.D. Ky. 2016).

Opinion

OPINION AND ORDER

KAREN K. CALDWELL, CHIEF JUDGE, UNITED STATES DISTRICT COURT, EASTERN DISTRICT OF KENTUCKY

Plaintiff Scott Bishop (“Mr. Bishop”) filed this action pursuant to the provisions of the Employee Retirement Income Security Act of 1974 (“ERISA”), alleging that Defendant Aetna Life Insurance Company (“Aetna”) wrongfully terminated his long-term disability benefits. For the reasons stated herein, the Court finds that Aetna’s decision to terminate benefits was arbitrary and capricious, and is reversed and remanded for further consideration consistent with the reasoning of this opinion.

I. BACKGROUND

For approximately fourteen years, Mr. Bishop was an employee of Wausau Paper Corporation (“Wausau”) in Harrodsburg, Kentucky, where he worked as a converting machine operator. [DE 14-1 at 1.] Mr. Bishop purchased long-term disability insurance from Aetna, which was offered as part of his employment. [DE 14-1 at 1.] Mr. Bishop alleges that he has been unable to work since February 28, 2012, due to “diffuse osteoarthritis and swelling in his joints, gout, and degenerative joint disease in his left knee.” [DE 14-1 at 1.]

Due to his physical condition, Mr. Bishop applied for social security disability benefits (“SSD benefits”) as well as long-term disability benefits (“LTD benefits”) through Aetna. [DE 14-1 at 3; DE 15 at 6.] As part of his claim, the Social Security Administration (“SSA”) asked that Mr. Bishop be examined by Dr. David Winkle (“Dr. Winkle”). [DE 14-1 at 3; DE 15 at 6.] On February 11, 2013, Dr. Winkle examined Mr. Bishop and authored a report that is contained in the Administrative Record. [AR 607-612.]

On January 21, 2014, Aetna initially determined that Mr. Bishop was not entitled to any LTD benefits due to a lack of required paperwork. [DE 15 at 7.] Shortly thereafter, Mr. Bishop appealed that original determination and provided additional evidence in support of his claim. [DE 14-1 at 4; DE 15 at 8.] In addition, Aetna requested that Dr. Tracey Schmidt (“Dr. Schmidt”) conduct a paper review of Mr. Bishop’s file. [DE 14-1 at 4; DE 15 at 8.] Dr. Schmidt’s report is also contained in the Administrative Record. [DE 521-52.] Mr. Bishop’s attorney requested that Aet-na postpone its decision until after Mr. Bishop’s upcoming hearing with the SSA. [DE 15 at 8.]

On May 8, 2014, Mr. Bishop participated in an SSA hearing regarding his SSD benefits claim. [DE 14-1 at 5.] Joyce Forest, a vocational expert, also testified at the SSA hearing. [DE 14-1 at 6; AR 488.] The SSA found that Mr. Bishop “has the residual functional capacity to perform sedentary work,” but stated a number of other restrictions on that ability, including that he would routinely miss three or more days of work per month due to his health problems. [AR 485.] The SSA concluded that [446]*446“there are no jobs that exist in significant number in the national economy that the claimant can perform” and that Mr. Bishop was disabled under SSA standards. [DE 487.] Therefore, Mr. Bishop was awarded SSD benefits.

On July 23, 2014, Aetna overturned its initial decision and found that Mr. Bishop, at that point in time, met the LTD Plan’s definition of disability because he was unable to perform his former job at Wausau. [DE 15 at 9.] Importantly, the LTD Plan Test of Disability uses a different definition of disabled after 24 months. During the first 24 months, a claimant is disabled under the LTD Plan if he is unable to perform his own occupation. [DE 15 at 10.] Thus, Aetna found Mr. Bishop was disabled within the meaning of the Plan during the first 24 months because he could not perform his “own occupation” at Wau-sau and paid him LTD benefits. The LTD Plan terms permit Aetna to reduce its LTD benefits payments by the amount of SSD benefits a claimant receives. [DE 14-1 at 7.] Accordingly, Aetna reduced Mr. Bishop’s LTD benefits by the full amount of his SSD benefits. [AR 262-263.]

After the first 24 months, a claimant is only disabled if he is “unable to work at any reasonable occupation.” [DE 15 at 10.] In the Plan, “reasonable occupation” is defined as “any gainful activity for which you are, or may reasonably become, fitted by education, training, or experience” and which “results in, or can be expected to result in, an income of more than 60% of [the claimant’s] adjusted predisability earnings.” [DE 15 at 10.]

On August 28, 2014, Aetna sent Mr. Bishop a letter (the “August 28 Letter”) informing him that his LTD benefits were being terminated. [AR 282-285.] As part of its claim analysis, Aetna ordered a vocational assessment, which was performed by Diane Winiarski, [AR 116-119], and produced a Seeker Report. [AR 283; 460-461.] Aetna cited the Seeker Report in its August 28 Letter, and concluded the following: “In view of the above, Aetna is terminating your claim for disability benefits effective 08/31/2014, on the basis that you are not disabled from performing any reasonable occupation for which you are qualified by education, training or experience.” [AR 284.]

Mr. Bishop then appealed Aetna’s termination of his benefits. [DE 14-1 at 10; DE 15 at 12.] In support of his administrative appeal, Mr. Bishop provided a vocational report from Dr. Stephanie Barnes (“Dr. Barnes”), a vocational consultant. [AR 402-408.] Aetna ordered a second review of Mr. Bishop’s medical records, which was completed by Dr. Timothy Craven (“Dr. Craven”). [AR 359-363.] Aetna also ordered a second vocational analysis, which was performed by Kristen Hamilton (“Ms. Hamilton”), a Vocational Manager and Disability Specialist. [AR 350-56.] On March 27, 2015, Aetna sent Mr. Bishop another letter (the “March 27 Letter”), which cited Ms. Hamilton’s report and informed Mr. Bishop that Aetna was affirming its termination of benefits. [AR 186-188.]

Finally, with his administrative remedies exhausted, Mr. Bishop appealed Aetna’s decision to this Court pursuant to 29 U.S.C. § 1132(a)(1)(B).

II. STANDARD OF REVIEW

The parties stipulated that the arbitrary and capricious standard of review applies. [DE 11.] This standard is the “least demanding form of judicial review.” Perry v. United Food and Commercial Workers Dist. Unions 405 and 442, 64 F.3d 238, 242 (6th Cir.1995). “Despite this deferential standard, however, [a court’s] review is no mere formality.” Glenn v. MetLife, 461 F.3d 660, 666 (2006). “[T]he federal courts do not sit in review of the administrator’s decisions only for the pur[447]*447pose of rubber stamping those decisions.” Moon v. Unum Provident Corp., 405 F.3d 373, 379 (6th Cir.2005). A plan administrator’s decision will be upheld “if it is the result of a deliberate, principled reasoning process and if it is supported by substantial evidence.” Baker v. United Mine Workers of America Health and Retirement Funds, 929 F.2d 1140, 1144 (6th Cir.1991).

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Bluebook (online)
163 F. Supp. 3d 443, 2016 U.S. Dist. LEXIS 17331, 2016 WL 591765, Counsel Stack Legal Research, https://law.counselstack.com/opinion/bishop-v-aetna-life-insurance-kyed-2016.