LaShondra Davis v. Aetna Life Insurance Company

699 F. App'x 287
CourtCourt of Appeals for the Fifth Circuit
DecidedJune 14, 2017
Docket16-10895
StatusUnpublished
Cited by10 cases

This text of 699 F. App'x 287 (LaShondra Davis v. Aetna Life Insurance Company) is published on Counsel Stack Legal Research, covering Court of Appeals for the Fifth Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
LaShondra Davis v. Aetna Life Insurance Company, 699 F. App'x 287 (5th Cir. 2017).

Opinion

PER CURIAM: *

Lashondra Davis appeals the district court’s grant of summary judgment in favor of Aetna Life Insurance Company. The district court held that Aetna did not abuse its discretion under the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. § 1132(a)(1)(B), in denying Davis ■ long-term disability (LTD) benefits. We agree with the district court that Aetna’s decision to terminate Davis’s benefits .did not constitute an abuse of discretion and therefore AFFIRM.

I

Between October 2005 and April 2010, Davis worked at Experian Information Systems, Inc. as a customer support associate. While she worked at Experian, Davis was enrolled in the Experian Long-Term Disability Plan (Plan). On April 21, 2010, Davis, who was thirty-four years old at the time, stopped working full-time at Experi-an due to health issues. Davis’s rheumatol-ogist and treating physician, Dr. Don E. Cheatum, diagnosed her with, inter alia, systemic lupus erythematosus (lupus), fatigue, and morning stiffness. Davis applied initially for short-term disability (STD) and then, when her condition did not improve, for LTD benefits under the Plan.

Aetna, the Plan’s underwriter and claims administrator, approved STD benefits to Dayis based on Dr. Cheatum’s diagnosis beginning April 23, 2010. In support of Davis’s claim, Dr. Cheatum provided Aet-na- with Attending Physician Statements (APSs), starting in May 2010 and lasting throughout the benefits period. The APSs described Davis’s diagnoses, limitations, and abilities, and summarized her treatment and medications. All of Davis’s APSs stated that she had “severe pain” and “fatigue” and that she was “chronically [and] permanently disabled.” During this period, Dr. Cheatum also submitted Capabilities and Limitations Worksheets (Worksheets) stating that Davis could never climb, crawl, kneel, pull, push, reach forward or above her shoulder, carry, bend, twist, use her hands for fine or gross manipulation or repetitive motions, and that Davis could not sit, stand, or walk for “prolonged” periods.

To determine Davis’s continued eligibility for STD benefits, in June 2010, Aetna asked Dr. Anne M. MacGuire, also a rheu-matologist, to conduct a peer review of Davis’s medical records and a peer-to-peer conversation with Dr. Cheatum. Dr. MacGuire agreed with Dr. Cheatum that Davis was disabled due to the pain, fatigue, and cognitive impairment that resulted from her medical condition. Aetna paid Dayis twenty-six weeks of STD benefits between April and October 2010. In September 2010, Aetna notified Davis that it was evaluating her eligibility for LTD benefits.

On October 20, 2010, Aetna advised Davis that she met the “own occupation” definition of disability, meaning that Davis was eligible to receive monthly LTD benefits for twenty-four months because she was unable to perform the material duties *289 of her own occupation. Aetna paid LTD benefits to Davis through the entire own-occupation period. During this period, Aet-na received additional progress notes, APSs, Worksheets, and laboratory results regarding Davis’s medical condition.

In July 2012, Aetna was notified that an Administrative Law Judge (ALJ) had recently denied Davis’s claim for Social Security Disability Insurance (SSDI). The ALJ had found that the evidence “did not demonstrate the requisite degree of joint, muscle, ocular, respiratory, cardiovascular, digestive, renal, hematologic, skin, neurological, mental involvement or the involvement of two or more organs/body symptoms with significant, documented, constitutional symptoms and signs of severe fatigue, fever, malaise and weight loss.” The ALJ also found that “[i]n activities of daily living and social function, the claimant has mild restriction,” and “[w]ith regard to concentration, persistence or pace, the claimant has mild difficulties.” The ALJ stated that “the medically determinable impairments cannot reasonably be expected to produce the symptoms to the degree alleged,” and that Davis’s “statements concerning the intensity, persistence and limiting effects of these symptoms are not found credible to the extent that they are outside the range of medically reasonable attribution.”

After the first twenty-four months of LTD benefits, in contrast to the own occupation period, Davis’s Plan provided for payment only if Davis was “not able, solely because of injury or disease, to work at any reasonable occupation.” The Plan gave Aetna “the discretionary authority to determine whether and to what extent employees and beneficiaries are entitled to benefits and construe any disputed or doubtful terms of this policy.”

In May 2012, as part of Aetna’s assessment of Davis’s continued eligibility for LTD benefits, a nurse performed a clinical review of Davis’s claim and concluded that the documentation regarding her functional impairment was inconsistent with Dr. Cheatum’s APSs stating that she was permanently disabled. The nurse found that there was inconsistent documentation as to her morning stiffness, that she had shown no synovitis (inflammation in the joints), and that her mental status examinations were not documented. The nurse recommended that Davis undergo an Independent Medical Examination (IME).

In November 2012, Dr. Charles R. Crane, board certified in physical medicine and rehabilitation, conducted the IME. Dr. Crane’s findings were consistent with those of Dr. Cheatum: Davis was able to do sedentary and light type activities, but only for brief periods of time. Due to the fatigue associated with her lupus and rheumatoid arthritis, Davis could not sustain prolonged periods of active work without having to take a break for rest and recovery. Based on Dr. Crane’s report, Aetna approved Davis’s LTD benefits under the “any reasonable occupation” standard and advised her that Aetna would periodically reevaluate her eligibility. In January 2013, a claims examiner conducted a telephone interview with Davis regarding her medical condition and daily activities. Davis reported that she did not drive and continued to suffer from severe fatigue, stiffness, and joint pain. Davis said that she could type and do laundry, and on good days she could go out and do some shopping, but that going to a place like Wal-Mart would be “overdoing it.” Quarterly lab tests from July 2012 and August 2013 showed that Davis exhibited inflammation, lupus, and rheumatoid arthritis.

In late 2013, Aetna referred Davis’s claim to its risk management unit. Aetna conducted a public records search on Davis. Aetna also obtained video surveil *290 lance of Davis’s activities over a twenty-two minute period on December 31, 2013, and over a one-hour-and-forty-seven-minute period on January 3, 2014. Davis was observed driving to three fast-food restaurants and a pharmacy, turning her body, bending down, leaning forward, reaching into the back seat of her car, carrying a bag over her shoulder, and walking quickly-

Aetna also performed a social media search of Davis and her husband. Davis’s Linkedln account confirmed that she was a student at Northcentral University, although Aetna never confirmed whether Davis was actually attending class. Her husband’s Facebook account reported that Davis visited several restaurants, a movie theater, and a bowling alley during four days in July and August of 2013.

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