Maher v. Aetna Life Insurance Co.

186 F. Supp. 3d 1117, 2016 U.S. Dist. LEXIS 70559, 2016 WL 2937476
District Court, W.D. Washington·Decided May 5, 2016·No. C15-883-TSZ·Published·Cited by 3 cases

Opinion

ORDER

Thomas S. Zilly, United States District Judge

THIS MATTER comes before the Court upon the parties’ cross-motions for judgment under Federal Rule of Civil Procedure 52, docket nos. 13 & 16.1 This action concerns the appeal of the denial of plaintiff Vicki Maher’s application for Short Term Disability and Long Term Disability benefits. Having reviewed the Administrative Record and all papers submitted by the parties in favor and in opposition to the motions, the Court enters the following Order.

Background

Vicki Maher is a 52 year-old woman who began working for Boeing in 2001 performing data entry. AR 1, 6, 691. As an employee of Boeing, Maher participated in its ERISA Plan (the “Plan”) which provides both Short Term Disability (“STD”) and Long Term Disability (“LTD”) ■ benefits. AR 1049. The Plan’s Summary Plan Description (the “SPD”) defines “disabled” to mean an illness “prevents you from performing the material duties of your own occupation or other appropriate work the company makes available.” AR 1148. The LTD standard is the same initially, but requires that the applicant be prevented from working at “any occupation” after the first 30 months of disability. AR 1147. In addition, an applicant does not receive LTD benefits until 26 weeks after the onset of the disability. AR 1070. This period is referred to as either the “exclusionary period” or the “waiting period.” Boeing engaged Aetna to administer its disability programs. AR 1070; 1078.

Maher suffered injuries in a number of car accidents in the 1990s which resulted in chronic headaches and pain. AR 648; 650; 691. She received a spinal fusion surgery in 2009, which provided some relief. AR 691; 994. By January 2014, Maher’s pain had increased to the point that she visited Dr. Moffat, her primary care physician. AR 696-97. Dr. Moffat prescribed pain medications and referred Maher to Dr. Price, an orthopedic surgeon. AR 701. Maher applied for STD benefits the next day, AR 143, attaching an Attending Physician Statement completed by Dr. Moffat which stated Maher needed leave from work until April 21, 2014. AR 1047-48.

Aetna granted the application, concluding that Maher met the definition of disability, with benefits to begin February 3, 2014 and running through March 2, 2014. AR 476-77. The grant of benefits specifically noted that Maher needed to submit additional medical evidence in order to receive benefits beyond March 2. Id.; see also AR 358-59 (internal Aetna notes stating the grant gave Maher time to consult with orthopedic surgeon, i.e., Dr. Price). Maher thereafter met with Dr. Price on February 14, 2014, who in turn referred her to Dr. Nelson, a pain management specialist. AR 702. Dr. Price noted that [1122] pain symptoms had been ongoing for nearly two decades as a result of her earlier car accidents. AR 691. After receiving more information, Aetna extended her disability until March 23, 2014. AR 482. Maher met with Dr. Nelson who noted severe pain, rated as a “10/10.” AR 634.

Maher continued seeing Dr. Moffat, who completed an Aetna form that extended Maher’s leave until April 18, 2014, AR 1042; 1046. Maher then returned to Dr. Price on March 20, where his colleague PA-C Goble noted pain rated as a “7/10.” AR 801-02. Maher’s physical therapist, Dr. Mehta, similarly observed “severe pain.” AR 994.

The first suggested diagnosis for the pain came on April 10. PA-C Goble observed that Maher presented with some of the hallmark symptoms of Chronic Regional Pain Syndrome (“CRPS”) and noted that she “Suspected CRPS.” AR 796. Dr. Moffat completed another Attending Physician Statement on April 13, 2014, which noted “probable regional pain syndrome” as one of her diagnoses and concluding that Maher could not work until'July 27. AR 1009-10.

On April 16 Aetna wrote to Maher informing her that it was terminating her STD benefits. AR 491. The letter stated that Aetna expected “to see compelling abnormal exams and supportive diagnostics.” AR 492. Maher’s health did not improve subsequent to the termination of benefits and she stated that her pain medications were not effective. AR 793.- Dr. Nelson completed an Attending Physician Statement on June 12, concluding that Maher could perform sedentary work for 1-2 hours per day, 1-2 days per week. AR 903. Dr. Nelson cited “allodynia2 in cervical axial spine, myofascial banding in upper traps; CT myelogram..Id. Dr. Nelson completed a subsequent Attending Physician Statement, stating Maher could only work “0-1” hours per day because she was in constant pain. AR 746-47.

Maher was referred to another doctor, this time Dr. Neiman, a rheumatologist.3 Dr. Neiman first noted a suspected diagnosis of fibromyalgia on July 18 and prescribed prednisone. AR 825. PA-C Goble additionally began taking the suspected diagnosis of CRPS more seriously, writing to Aetna that Maher in fact had CRPS and that Aetna should reconsider its termination of STD benefits. AR 733. Aetna subsequently denied the request for reconsideration. AR 496.

Maher’s pain increased over the next few months, culminating with Dr. Nelson completing an Attending Physician Statement in October which concluded that Maher could not sit, stand, or walk for over one hour or reach above her shoulders. AR 332, Dr. Neiman five days later wrote that Maher “has all 18 tender points of fibromyalgia,” meaning she met the diagnostic criteria for that disorder. AR 820.

Maher ultimately appealed Aetna’s termination of her benefits on November 24, 2014. AR 623-907. In her appeal, Maher included a declaration from Dr. Nelson which affirmatively diagnosed her with CRPS. AR 634-36. Dr. Nelson’s declaration addressed each of Aetna’s four criteria for CRPS. Id. Dr. Neiman submitted a declaration which diagnosed Maher with fibromyalgia, concluding she met the diagnostic criteria. AR 817-18. Their declarations, along with that of Dr. Moffat, declared that Maher was incapable of performing the material duties of her occupation. AR 636; 818; 832.

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Maher v. Aetna Life Insurance Co., 186 F. Supp. 3d 1117, 2016 U.S. Dist. LEXIS 70559, 2016 WL 2937476 (W.D. Wash. 2016).

186 F. Supp. 3d 1117 (Maher v. Aetna Life Insurance Co.) — published by Counsel Stack Legal Research, free access to 12M+ legal documents.

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