Halley v. Aetna Life Insurance

141 F. Supp. 3d 855, 2015 U.S. Dist. LEXIS 132279, 2015 WL 5731853
CourtDistrict Court, N.D. Illinois
DecidedSeptember 30, 2015
DocketCase No. 13 C 6436
StatusPublished
Cited by7 cases

This text of 141 F. Supp. 3d 855 (Halley v. Aetna Life Insurance) is published on Counsel Stack Legal Research, covering District Court, N.D. Illinois primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Halley v. Aetna Life Insurance, 141 F. Supp. 3d 855, 2015 U.S. Dist. LEXIS 132279, 2015 WL 5731853 (N.D. Ill. 2015).

Opinion

MEMORANDUM OPINION AND ORDER

John Robert Blakey, United States District Judge

This is an ERISA denial of benefits case about Plaintiff Ronald Halley’s entitlement to benefits under his employer’s disability insurance policy. The policy was underwritten and administered by Defendant Aetna Life Insurance (“Aetna LTD Policy”) and is governed by ERISA; 29 U.S.C. § 1001 et seq. In 2007 and 2008, Plaintiff was diagnosed with, among other things, multiple spinal disorders and osteoarthritis, and he ceased working on October 30, 2009. For more than three years, from December 29, 2009 to January 31, 2013, Defendant covered Plaintiff, but thereafter discontinued coverage based upon a reevaluation of Plaintiffs medical condition and a change in the criteria for coverage.

Plaintiff brought suit seeking to have this Court reinstate his benefits, and the parties now cross-move for entry of judgment [98][112] under Federal Rule of Civil Procedure 52. Rule 52 allows this Court to conduct a trial on the papers, and -to resolve factual disputes, and this Court agrees that Rule 52 is an appropriate procedural mechanism for resolving this ease. See, e.g., Myers v. Life Insurance Co. of North America, No. 07-6197, 2009 WL 742718, at *1 (N.D.Ill. March 19, 2009); Marshall v. Blue Cross Blue Shield Association, No. 04-6395, 2006 WL 2661039, at *1 (N.D.Ill. Sept. 13, 2006); Crespo v. Unum Life Insurance Co. of America, 294 F,Supp.2d 980, 991-92 (N.D.Ill.2003). This Court grants Plaintiffs motion for entry of judgment [98] and denies Defendant’s cross-motion [112].

I. Standard of Review

This Court already has determined that it will engage in a dé novo review — and not an arbitrary and capricious review — of Defendant’s denial of Plaintiffs application for benefits. PFF ¶ 9 (citing 3/25/14 Hr’g Tr.); see also Joint Memorandum [30]; Statement [37]. Neither party has- asked this Court to reconsider that prior decision.

. Under de novo review, the ultimate question is whether Plaintiff was entitled to the benefits he sought under the Aetna LTD Policy after January 31, 2013. Diaz v. Prudential Insurance Co. of America, 499 F.3d 640, 643 (7th Cir.2007). This Court does not actually review Defendant’s decision to deny benefits but rather makes an independent decision about whether, as a. matter of contract interpretation applying federal common law rules, Plaintiff is entitled to benefits under the Aetna -LTD Policy. Krolnik v. Prudential Insurance Co. of America, 570 F.3d 841, 843 (7th Cir.2009); Diaz, 499 F.3d at 643. Thus what happened before Defendant is “irrelevant.” Diaz, 499 F.3d at 643.

II. Findings of Fact1

Plaintiff is a former Vice President of Sales at.Chamberlain Group (a subsidiary of Duchossois Industries), a garage door manufacturer.. PFF ¶¶6, 11. Plaintiff holds, .a Bachelor’s Degree in Marketing. DFF ¶ 12, Plaintiff held. the Vice President of Sales, position for the 10 years before he ceased working on October 30, [858]*8582009. PFF ¶ 11; Response to PFF ¶ 11; App. at 00434. As the Vice President of Sales, Plaintiff spent about half his time traveling to trade shows and visiting with customers, and the other half was spent on administrative tasks. PFF ¶ 12. While traveling, Plaintiff carried and sometimes lifted over his head a suitcase that weighed between 13 pounds (unloaded) and 25 pounds (loaded). PFF ¶ 12.

Through his employer’s parent company Duchossois Industries, Plaintiff participated in a “Group Life and Accident Insurance Policy” with Policy No. GP-657484 that was underwritten and administered by Defendant Aetna Life Insurance Company (“Aetna LTD Policy”). PFF ¶ 1; App. at 00002. The Aetna LTD Policy included total disability coverage. DFF ¶ 1. The requirements for total disability coverage became more demanding once an employee received coverage for 36 months. During the first 36 months, Plaintiff qualified for coverage only if he could not perform the “material duties of [his] own occupation,” whereas, thereafter, Plaintiff had to show that he was not able to “work at any reasonable occupation.” DFF ¶ 1; PFF ¶ 8.

This Court quotes the relevant portions of the Aetna LTD Policy for clarity. The total disability coverage form provided that:

You are deemed to be totally disabled while either of the following applies to you:
• During the period which ends right after the first 36 months benefits are payable in a period of total disability: You are not able, solely because of injury or disease, to perform the material duties of your own occupation; except that if you start work at a reasonable occupation you will no longer be deemed totally disabled.
• Thereafter during such period of total disability: You are not able, solely because of the injury or disease, to work at any reasonable occupation.

DFF ¶ 1; PFF ¶ 8. “Reasonable occupation” is a defined term that means any gainful activity that Plaintiff currently is or reasonably may become qualified for:

This is any gainful activity for which you are, or may reasonable become, fitted by education, training, or experience. It does not include work under an Approved Rehabilitation Program.

DFF ¶ 1; PFF ¶ 8. The Aetna LTD Policy contains a final relevant restriction that any occupation pay more than 80 percent of the employee’s pre-disability earnings:

You will not be deemed to be performing the material duties of your own occupation or working at any occupation on any day if:
• you are performing at least one, but not all of the material duties of your own occupation or you are working at any occupation (full-time or part-time); and
• solely due to disease of injury, your income from either is 80% or less of your adjusted pre-disability earnings.

DFF ¶ 1; PFF ¶ 8.

In 2007 and 2008, Plaintiff developed severe back and neck pain, and was ultimately diagnosed with, among other things, multiple spinal disorders and osteoarthritis. PFF ¶ 16; App. at 00420-21. Plaintiff underwent multiple surgeries, including, on June 3, 2009, a spinal fusion performed by the neurosurgeon Dr. Jerry Bauer. PFF ¶¶ 17, 19. Plaintiff attempted to return to work on a part-time basis but, on October 30, 2009, ceased working altogether. PFF ¶20. Plaintiff has not since returned to work. See PFF ¶¶ 11, 20

[859]*859A. Initial Benefits Period and Social Security Administration Decision

On January 4, 2010, Plaintiff submitted a claim for long-term disability benefits under the Aetna LTD Policy. DFF ¶ 5. Defendant ultimately approved the claim on August 12, 2010, and began paying benefits retroactive to December 29, 2009. DFF ¶ 5; PFF ¶ 24. Defendant continued to pay benefits until January 31, 2013. DFF ¶ 5.

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141 F. Supp. 3d 855, 2015 U.S. Dist. LEXIS 132279, 2015 WL 5731853, Counsel Stack Legal Research, https://law.counselstack.com/opinion/halley-v-aetna-life-insurance-ilnd-2015.