Martin v. Aetna Life Insurance Co.

223 F. Supp. 3d 973, 2016 U.S. Dist. LEXIS 166120, 2016 WL 6997484
CourtDistrict Court, C.D. California
DecidedNovember 30, 2016
DocketCV 15-7355-RSWL-FFMx
StatusPublished
Cited by2 cases

This text of 223 F. Supp. 3d 973 (Martin v. Aetna Life Insurance Co.) is published on Counsel Stack Legal Research, covering District Court, C.D. California primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Martin v. Aetna Life Insurance Co., 223 F. Supp. 3d 973, 2016 U.S. Dist. LEXIS 166120, 2016 WL 6997484 (C.D. Cal. 2016).

Opinion

RULING AND ORDER Re: BENCH TRIAL

HONORABLE RONALD S.W. LEW, Senior U.S. District Judge

On November 15,2016, the above matter commenced in a bench trial before this Court. Plaintiff Greg Martin (“Plaintiff’) filed this Employee Retirement Income Security Act of 1974 (“ERISA”) disability benefits action against Defendant Aetna Life Insurance Company (“Aetna”), Federal Express Corporation Short Term Disability Plan (“STD Plan”), and Federal Express Corporation Long Term Disability Plan (“LTD Plan”) (collectively, “Defendants”),1 after Aetna denied him short-term disability benefits under the STD Plan provided by his employer, Federal Express Corporation (“FedEx”).

Having received, reviewed, and considered the evidence presented, as well as the Parties’ arguments at trial, the Court makes the following ruling: IT IS HEREBY ORDERED, ADJUDGED, AND DECREED that Judgment be entered in favor of Defendants.

I. FINDINGS OF FACT

Plaintiff worked for FedEx as a “Sr. Service Agenf/Non-DOT.” Admin. R. (“A.R.”) at 0215, ECF No. 31. Some of his essential job duties and responsibilities were assisting customers, tracking packages, preparing reports, keying alphabetic and numeric information into keypads, and checking paperwork. Id. at 0215-16. Under the “knowledge, skills, and abilities” section, Plaintiff required an “ability to lift 75 lbs ... ability to maneuver packages of any weight above 75 lbs ... with appropriate equipment and or assistance from another person.” Id. at 0216.

A. STD and LTD Benefits Plans

FedEx established a group benefits plan to provide Plaintiff with benefits in the event of a short-term or long-term disability. Id. at 0343, 0543. The FedEx STD Plan is self-funded; FedEx pays benefits from its own funds, but retains an insurance company, Aetna, to administer claims for STD Plan benefits. Id. At 0344. Benefits are payable at the rate of 70% of basic weekly pay before disability, less any offset. Id. at 0417, 0418. The benefits are paid for up to 26 weeks that the employee remains disabled. Id.

The employee has the burden of establishing a disability. Id. at 0566. The STD Plan defines disability as an “Occupational Disability;” that is, a “medically-determinable physical impairment” that prevents the employee from performing the duties of his regular occupation. Id. at 0548. The disability should be “substantiated by significant objective findings which are defined as signs which are noted on a test or medical exam and which are considered significant anatomical, physiological, or psychological abnormalities which can be [977]*977observed apart from the individual’s symptoms.” Id. at 0545-46. Proof of disability is based on “significant objective findings like: medical exams, test results, X-ray results, and observation of anatomical, physiological, or psychological abnormalities.” Id. at 0422. But “pain alone is not proof of disability.” Id. Benefits are denied when the provided medical information fails to support the disability. Id. at 424,

Aetna has authority to “interpret the Plan’s provisions in its sole and exclusive discretion in accordance with its terms with respect to matters properly brought before it ... including, but not limited to, matters relating to the eligibility of a claimant for benefits under the Plan.” Id. at 0501. In denying a claim for benefits, Aetna shall provide the claimant with written notice setting forth the specific reasons, refer to pertinent plan provisions supporting the denial, and describe necessary additional material to perfect the claim. Id. at 0500.

The FedEx LTD Plan pays benefits once STD benefits are exhausted. Id. at 0417. Benefits continue until the employee reaches age 65 or remains unable to perform occupational duties for 25 hours per week, whichever comes first. Id The LTD Plan pays up to 60% of basic monthly earnings, less offsets for other sources of income. Id.

B. Aetna Grants STD Plan Benefits for November 7, 2014 to February 14, 2015

On February 22, 2012, Plaintiffs primary care provider, Dr. Michael Thompson, assessed Plaintiff for right carpometa-carpal (“CMC”) instability, right thumb CMC pain, left IP joint pain, fifth metacar-pophalangeal joint pain sprain, and left thumb IP joint arthritis. Id at 0018. On March 16, 2012, Dr. Thompson performed various thumb and wrist surgery on Plaintiff. Id. at 0036. By November 16, 2012, Plaintiff still had left-handed multiple joint arthritis, and Dr. Thompson recommended he take six to eight weeks off of work and refrain from lifting more than five pounds or repetitively pinching, gripping, or grasping. Id. at 0123. On October 31, 2014, Plaintiff had his first full day of absence from work. Id. at 0177,210.

Plaintiff received benefits under the STD Plan for the period of November 7, 2014 to February 14, 2015. Id at 0004. He substantiated his claim with clinical documentation from Dr. Bruno Seeman, occupational medicine. Dr. Seeman discharged Plaintiff to return to work on October 30, 2014 with restrictions to not use his hands. Id. at 0180. On November 4, 2014, Dr. Seeman instructed Plaintiff to return to work with an added restriction of “no gripping and grasping,” and provided an expected maximum medical improvement (“MMI”) of December 31, 2014. Id. at 0184. Aetna approved the STD Plan benefits due to his “inability to perform heavy cores of his job ... due to work related wrist injuries.” Id at 0247.

C. Aetna Denies STD Plan Benefits for February 15, 2015 to May 7, 2015

Plaintiff presented to Dr. Enass Rick-ards, hand surgeon, on January 22, 2015, complaining of bilateral hand pain, numbness, and weakness. Id at 0194. A hand and wrist examination showed normal range of motion, strength, and sensations; the X-rays revealed a well-healed metacarpal trapezial fusion, but were otherwise negative. Id. at 0195. Dr. Rickards recommended an EMG nerve conduction study to rule out carpal tunnel syndrome, and recommended Plaintiff return to modified duties at work, with no lifting greater than three pounds, no repetitive keying, or typing more than three hours a day. Id. at 0195-96.

[978]*978Plaintiff returned to Dr. Rickards on February 19, 2015, complaining of multiple joint pain and ligament tears. Id. at 0197. His EMG nerve conduction study was normal, and there was no change from his prior hand examination. Id. Dr. Rickards diagnosed Plaintiff with bilateral hand arthritis. Id. at 0197-98. He was able to work modified duty so long as a rheumatologist evaluated him to rule out polyarthropathy (a type of arthritis). Id.

On March 4, 2015, Dr. Michael Wheat-ley, an Aetna-retained physician, conducted a peer review of Plaintiffs medical records. He noted that Plaintiff self-reported pain in multiple joints, but the hand and wrist examination, X-ray, and nerve conduction test were all normal. Id. at 0200-01. Dr. Wheatley concluded that Plaintiff had not presented significant objective clinical documentation that he could not perform the essential duty of lifting up to 75 pounds at his job. Id.

Plaintiff submitted a claim for unpaid STD Plan benefits for the period beginning February 15, 2015, which Aetna denied on March 4, 2015. Id. at 0006. Aetna reviewed November 2014—February 2015 visits with his treating health care providers Dr. Seeman and Dr. Rickards, workers compensation documented notes, and Dr. Wheatley’s report. Id.

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Bluebook (online)
223 F. Supp. 3d 973, 2016 U.S. Dist. LEXIS 166120, 2016 WL 6997484, Counsel Stack Legal Research, https://law.counselstack.com/opinion/martin-v-aetna-life-insurance-co-cacd-2016.