Chellino v. Kaiser Foundation Health Plan, Inc.

548 F. Supp. 2d 779, 2008 U.S. Dist. LEXIS 23902, 2008 WL 820721
CourtDistrict Court, N.D. California
DecidedMarch 26, 2008
DocketC 07-03019 CRB
StatusPublished

This text of 548 F. Supp. 2d 779 (Chellino v. Kaiser Foundation Health Plan, Inc.) is published on Counsel Stack Legal Research, covering District Court, N.D. California primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Chellino v. Kaiser Foundation Health Plan, Inc., 548 F. Supp. 2d 779, 2008 U.S. Dist. LEXIS 23902, 2008 WL 820721 (N.D. Cal. 2008).

Opinion

MEMORANDUM AND ORDER

CHARLES R. BREYER, District Judge.

Plaintiff Marie Chellino appeals the termination of her long-term disability benefits under the Kaiser Permanente Welfare Benefit Plan. After carefully considering the administrative record, the Court concludes that oral argument is unnecessary and GRANTS defendant’s motion for summary judgment and DENIES plaintiffs motion. The Plan fiduciary’s determination that Chellino is no longer disabled from working at any occupation was not an abuse of discretion.

Background

Chellino was employed as a programmer analyst for Kaiser Foundation Hospitals. While employed she was covered by the “Kaiser Permanente Welfare Benefits Plan” (the “Plan”). Among other things, the Plan provided long-term disability benefits through Aetna Life Insurance Company (“Aetna”). Kaiser Foundation Health Plan, Inc. (“Kaiser Foundation”) was the Plan Administrator and Aetna the Claim Administrator.

The Plan defines “disability” for the purpose of receiving disability benefits as follows:

*781 You are considered totally disabled if, during the first 24 months of your disability, you are continuously unable to perform any and every duty pertaining to your occupation. After your disability continues for 24 months, you are considered totally disabled if you are continuously unable to engage in any and every occupation for compensation or profit for which are reasonably qualified by education, training or experience.

(AR 957)

Chellino last worked for Kaiser on June 26, 1996; she subsequently made a claim for long term disability benefits based on fibromyalgia. The then claims administrator, New York Life Insurance Company, approved her claim. Sometime thereafter Aetna succeeded York Life as claims administrator.

In September 2002, a nurse consultant reviewed the progress reports of Chellino’s treating physician, Dr. Padgett, and concluded that as the reports showed some progress, for example, that Chellino could tolerate horseback riding three times a week, a physician should review the file for some direction. (AR 760-61)

The following month Aetna had a nurse evaluate Chellino’s psychological symptoms as they relate to her physical illness. The nurse concluded that Chellino’s vocational potential was very low and that her disability appears long-term, significant and with little prospect for improvement. (AR 747) Chellino reported that after 30 minutes of activity, such as walking, cooking, or showering, she must lie down and rest and that sometimes she will drive to a local stable for horseback riding or just visiting the horses. (AR 754) According to the nurse’s notes, her riding consists of 20 minutes at most and usually someone assists her. (AR 755) Chellino explained that although she sees herself as permanently disabled and effectively out of the work force, she believes she will continue to improve. (Id.) The nurse thought that Chellino could benefit from an independent medical exam by a physician who specializes in fibromyalgia. (Id.)

A consulting clinical neuropsychologist reviewed Chellino’s file and issued a report dated December 31, 2002. The neuropsy-chologist noted that the medical file did not indicate that Chellino had a structured pain management plan or comprehensive psychosocial assessment. Although the neuropsychologist did not meet with Chel-lino, he noted that based on his review of the file, Chellino’s perceived impairment is greater than the objective medical data would support. (AR 743-44)

Aetna asked Chellino for updated medical information in June 2003. Chellino’s treating physician, Dr. Padgett, responded that Chellino remains totally and permanently disabled from fibromyalgia. He concluded that her prognosis is “extremely guarded,” “although we are more hopeful at this time than we have been in the past three years that [Chellino] will continue to have reduced pain. Prognosis for return to work though is very bleak; and I don’t anticipate she will ever be able to achieve gainful employment.” (AR 62) Dr. Pad-gett spoke with an Aetna representative in August 2003. Dr. Padgett reported that Chellino had made some gains in the past six months and that recently she had engaged in limited horseback riding. (AR 58)

In an “Attending Physician Statement” dated February 17, 2004, Dr. Padgett reported that Chellino has improved “very slowly,” but that she is not yet physically able to engage in vocational rehabilitation. (AR 59-61)

An Aetna medical reviewer’s diary note of April 20, 2004 suggested that it might be helpful to conduct surveillance on Chel-lino to determine if she is more active than *782 she reports. (AR 1250) Periodic surveillance was conducted on May 11, 12 and 15, 2004. Chellino was observed driving, grocery shopping, and riding a horse on May 11, and of driving, walking and shopping on May 12. On May 12 she was observed going for a 20 minute walk. (AR 17-26)

Aetna sent copies of the video surveillance to Dr. Padgett for his review. Dr. Padgett responded that although the videotape had shown that Chellino had been out of the house for 3.75 hours, it did not show the frequent breaks she must take, including lying down in the midst of riding her horse. He explained further that because Chellino almost always wears long sleeves, the videotape did not capture that Chellino wears bilateral wrist braces and that at nighttime she uses a headmaster collar. He also explained that he had encouraged Chellino to ride her horse, as he believes the rhythmic motions are good for spinal strenghtening and stability. He concluded that although Chellino has “tremendously improved” from when he first started seeing her five years ago, she is still unable “to work in any occupation.” (AR 225-26)

Aetna conducted further surveillance on April 17-19, 2005. Chellino was not observed at home on April 17 or April 18. On April 19 she was observed driving, leading horses, carrying a bucket, wearing her neck brace and not wearing her neck brace. (AR 1-16)

Dr. Elliot Krames conducted an independent medical exam on June 12, 2005. Chellino reported that pain, discomfort, and fatigue severely limit her ability to perform activities of daily living, but also disclosed that she enjoys horseback riding and at the direction of her physician and physical therapist visits her horse barn daily, a 15 to 20 minute drive from her house. She rides approximately 15 to 20 minutes at a time, and no more than two times a week. Based on his examination of Chellino and his review of the record, Dr. Krames concluded that “[ojbjectively, there are very few objective findings that would be consistent with this level of disability.” He nonetheless concluded that “[bjased on this woman’s own account of her inability to perform activities of daily living and based on her history of fibro-myalgia, it is my belief that this woman is unable to compete in open labor market for any and all occupations.” (AR 337) Dr. Krames then recounted Chellino’s physical limitations with the caveat that “[bjecause of very little objective findings in this case, most of these restrictions and work capacity is [sic] based on this patient’s self reported symptoms; there are not actual objective findings to support them.” (Id.)

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548 F. Supp. 2d 779, 2008 U.S. Dist. LEXIS 23902, 2008 WL 820721, Counsel Stack Legal Research, https://law.counselstack.com/opinion/chellino-v-kaiser-foundation-health-plan-inc-cand-2008.