Fisher v. Aetna Life Insurance

890 F. Supp. 2d 473, 2012 WL 3893779, 2012 U.S. Dist. LEXIS 45345
CourtDistrict Court, D. Delaware
DecidedMarch 30, 2012
DocketCiv. No. 10-740-SLR
StatusPublished
Cited by4 cases

This text of 890 F. Supp. 2d 473 (Fisher v. Aetna Life Insurance) is published on Counsel Stack Legal Research, covering District Court, D. Delaware primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Fisher v. Aetna Life Insurance, 890 F. Supp. 2d 473, 2012 WL 3893779, 2012 U.S. Dist. LEXIS 45345 (D. Del. 2012).

Opinion

MEMORANDUM OPINION

SUE L. ROBINSON, District Judge.

I. INTRODUCTION

On August 30, 2010, Linette Fisher (“Fisher”) filed this action against Aetna Life Insurance Company (“Aetna”) pursuant to the Employment and Retirement Income Security Act of 1974 (“ERISA”) § 502(a)(1)(B) and § 502(a)(3), 29 U.S.C. § 1132. (D.I.l) Aetna is a third-party claim administrator to Bank of America’s Short Term Disability (“STD”) plan. (Id.) Bank of America is Fisher’s employer. Plaintiff claims that she was unlawfully denied benefits under the STD plan. (Id.) Fisher asserts that denial of those benefits was arbitrary. (Id. at 4) Count I of Fisher’s complaint seeks declaratory relief of disability benefits plus interest, attorney fees, and costs pursuant to 29 U.S.C. § 1132(a) or, in the alternative, requiring the defendant to consider all evidence and its impact on Fisher. (Id. at ¶¶ 27-29) On October 4, 2010, Aetna motioned to dismiss count II of the complaint because 29 U.S.C. § 1132(a)(1)(B) does not permit a plaintiff to assert a breach of fiduciary duty and because 29 U.S.C. § 1132(a)(3) does not permit a plaintiff to assert a breach of fiduciary duty when an adequate remedy is available under 29 U.S.C. § 1132(a)(1)(B). (D.I. 7) On August 24, 2010, both parties stipulated to dismiss count II of the complaint without prejudice. (D.I. 9) Currently before the court are Fisher and Aetna’s cross motions for summary judgment as to count I of the complaint. (D.I. 18; D.I. 23)

The court has jurisdiction pursuant to 28 U.S.C. § 1331 and 29 U.S.C. § 1132(e)(1). For the reasons set forth below, the court: (1) grants Fisher’s motion for summary judgment; (2) denies Aetna’s motion for summary judgment; and (3) remands the decision to the claim administrator to make a claim determination consistent with this opinion.

II. BACKGROUND

A. Plan Details

Bank of America, Fisher’s employer, delegated authority to Aetna to act as the fiduciary to the plan “for purposefs] of [1] reviewing denied claims under the Plan ... [2] hav[ing] discretionary authority to determine entitlement to Plan benefits ... and [3] construing] the terms of the Plan.” (D.I. 20, ex. A at 29) Aetna “is acting solely as third party claim administrator and shall not be designated or deemed the [476]*476Plan administrator, Plan sponsor, or the employer under the plan.” (Id. at 46) Therefore, while the plan is paid for by Bank of America, eligibility decisions are made by Aetna. (Id.)

To qualify for short term disability benefits under Bank of America’s STD plan, an associate must be considered “disabled” under the plan. (D.I. 19, ex. B at 631) To be disabled, an associate must have the “inability to perform his or her essential occupation functions for more than seven consecutive calendar days because of a pregnancy, illness, injury, non-elective surgery or hospitalization.” (Id.) STD coverage is available to a full or part time associate with a minimum of one year of continuous service who has been disabled for more than seven consecutive days. (Id.) To maintain STD coverage, continuous care by a physician, nurse practitioner, or the like, must be established. (Id.) STD benefits do not cover associates when “the associate fails to have a physical examination and/or provide satisfactory objective medical evidence of disability or continuing disability or other information requested by the Claim Administrator.” (Id. at 633) STD benefits end when, inter alia: (1) “an associate is no longer considered disabled by his or her treating medical provider and/or the claims administrator;” (2) “an associate is capable of performing the essential functions of his or her occupation;” or (3) “an associate fails to have a physical examination and/or provide satisfactory objective medical documentation of continuing the disability when requested by the Claims Administrator.” (Id.)

If coverage is denied, a claimant maintains the right to appeal that decision. (Id. at 301) In addition to rights under ERISA, the plan allows the company to obtain a second opinion at its expense. (D.I. 28, ex. E at 238) Furthermore, “[i]f necessary to resolve a conflict between the original certification and the second opinion, the company may require the opinion of a third health care provider. [Claimant] and the company jointly select the third health care provider, and the company pays for the provider. This third opinion is considered final.” (Id.)

B. Factual and Medical History

For fourteen years, Fisher worked as a Credit Card Analyst for Bank of America. (D.I. 24, ex. A at AR 86) In that capacity, Fisher “analyze[d] credit information” and “prepare[d] report[s] of findings.” (Id.) Her work was mostly sedentary. (Id.)

On April 17, 2009, Fisher did not come to work and timely filed for STD, Family Medical Leave Act (“FMLA”) and Bank of America Medical Leave (“BACMED”) benefits. (D.I. 21 at 8, 80, 81) That same day, Aetna acknowledged receipt of Fisher’s STD claim and requested Fisher return an Authorization for Release of Medical Information form. (Id. at 8) Fisher signed and returned the authorization on April 24, 2009. (Id. at 12)

On May 1, 2009, Aetna denied Fisher’s STD benefits because “on 4/17/09, 4/21/09, and 5/1/09 [Aetna] contacted [Fisher’s] provider Dr. Townsend by phone and fax” and had not received any “specific clinical information that indicates specifically why [Fisher is] unable to perform the core elements of [her] own occupation.... ” (Id. at 14) Fisher timely filed an appeal request letter on May 7, 2009. (Id. at 17) In her letter, Fisher explained that her physician will be faxing the completed forms on Friday, May 81 and that Fisher will follow up on Monday, May 11. (Id. at 17)

[477]*477On May 7, 2009 Fisher underwent an MRI of the brain without contrast under the direction of Alexander Mark, M.D. (“Dr. Mark”) of Papastavros Associates. (Id. at 19) Dr. Mark stated that his impression was “no intracranial abnormality, [n]o findings to explain the patient’s neurological symptoms.” (Id.)

On May 12, 2009, Neurology Associates, P.A., the office of Fisher’s treating physician, John B. Townsend, III, M.D. (“Dr. Townsend”), faxed the Attending Physician Statement (“APS”)2 to Aetna. (D.I. 21 at 22) The APS was completed by Susan Townsend, M.S. A.P.N. (“Nurse Townsend”). (Id.) The APS noted that Fisher’s diagnosis was migraine headaches. (Id.) Nurse Townsend stated that Fisher had no ability to work, but could complete activities of daily living and drive a car for short distances. (Id.

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Bluebook (online)
890 F. Supp. 2d 473, 2012 WL 3893779, 2012 U.S. Dist. LEXIS 45345, Counsel Stack Legal Research, https://law.counselstack.com/opinion/fisher-v-aetna-life-insurance-ded-2012.