Storms v. Aetna Life Ins Co

156 F. App'x 756
CourtCourt of Appeals for the Sixth Circuit
DecidedJuly 29, 2005
Docket04-5621
StatusUnpublished
Cited by6 cases

This text of 156 F. App'x 756 (Storms v. Aetna Life Ins Co) is published on Counsel Stack Legal Research, covering Court of Appeals for the Sixth Circuit primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Storms v. Aetna Life Ins Co, 156 F. App'x 756 (6th Cir. 2005).

Opinion

OPINION

REEVES, District Judge.

Plaintiff-Appellant David Storms filed this action seeking long-term disability benefits under the Employee Retirement Income Security Act (“ERISA”), claiming that narcolepsy prevents him from performing his pervious job as a Center Administrator for Concentra Managed Care, Inc. (“Concentra”). He now appeals the district court’s entry of judgment in favor of Defendant-Appellee Aetna Life Insurance Company’s (“Aetna”). For the reasons that follow, we AFFIRM the district court’s judgment.

BACKGROUND

Storms was hired as Center Administrator for Concentra in March 1999. He was responsible for implementing and coordinating several of Concentra’s managed care treatment programs. In July 1999, Storms advised his family physician that he suspected he suffered from a sleep disorder. Storms was referred to neurologists and underwent a sleep study. The doctors concluded that he suffered from narcolepsy, a conclusion Aetna does not dispute. Storms was treated with various medications with varying success. On August 12, 2001, Storms left his job and sought long-term disability benefits through his employer’s ERISA long-term benefits plan (“Plan”), established pursuant to 29 U.S.C. § 1001, et seq., and administered by Aetna.

After reviewing the relevant medical records and submitting them to an Aetna medical consultant, Dr. Brent Burton, Aetna concluded that Storms was not disabled. In order to qualify for benefits, the Plan specified that the claimant must be unable “solely because of injury or disease, to perform the material duties of your own occupation.” And while agreeing that Storms suffered from narcolepsy, Aetna concluded that Storms was still capable of performing his job duties. It noted that commuting to work was not part of his job duties and further that he was considered “not disabled” as long as he could perform his job duties for any employer at another location.

Storms appealed this determination administratively. Aetna’s Medical Director, Dr. Oyebode Taiwo, reviewed the record and affirmed the earlier conclusion that Storms was not precluded from performing his job responsibilities. On October 8, 2002, Storms filed suit in the Circuit Court for Knox County, Tennessee, seeking to compel Aetna to provide long-term benefits. Aetna removed the action to the United States District Court for the Eastern District of Tennessee. The parties filed cross-motions for judgment. The district court granted Aetna’s motion, con- *758 eluding that Aetna’s decision was neither arbitrary nor capricious.

STANDARD OF REVIEW

In ERISA cases, “[t]his court reviews de novo the district court’s ruling, applying the same legal standards as the district court.” Whitaker v. Hartford Life & Accident Ins. Co., 404 F.3d 947, 949 (6th Cir. 2005). When, as here, plan administrators are vested with discretionary authority to determine eligibility for benefits and to construe the terms of the Plan, the court applies an “arbitrary and capricious” standard of review. Firestone Tire and Rubber Co. v. Bruch, 489 U.S. 101, 110-11, 109 S.Ct. 948, 103 L.Ed.2d 80 (1989); Whitaker, 404 F.3d at 949. “This standard is the least demanding form of judicial review of administrative action. When it is possible to offer a reasoned explanation, based on the evidence, for a particular outcome, that outcome is not arbitrary or capricious.” Killian v. Healthsource Provident Administrators, Inc., 152 F.3d 514, 520 (6th Cir.1998) (quotation omitted).

Storms argues that Aetna operates under an inherent conflict of interest because Aetna funds and administers the Plan. In such circumstances, the Court factors the “insurer’s dual role into its review under the arbitrary and capricious standard, rather than alter that standard.” Whitaker, 404 F.3d at 949 (citation omitted).

DISCUSSION

Storms makes two claims of error: (1) Aetna erred in finding that he had the ability to perform “the material duties” of his occupation and (2) the district court erred in failing to consider evidence outside the administrative record.

A. Material Duties of the Occupation

Storms notes that multiple physicians diagnosed him with narcolepsy. As noted above, Aetna does not dispute that diagnosis. Rather, it contends that Storms failed to demonstrate that he is unable to perform the material duties of his occupation. In denying Storms’ application for benefits, Aetna concluded that he was not prohibited from performing the material duties of his occupation, even if he was unable to safely drive to work.

While Storms points out some instances in the record referencing his difficulty at work due to sleep problems, those references are based entirely upon Storms’ subjective, self-serving statements. Dr. Radoff noted that Storms “is a very industrious person” who “is trying to set up a work program at home....” Several instances in the record discuss Storms’ inability to safely drive; however, virtually nothing in the record supports a conclusion that Storms was unable to perform the duties of his work, with the exception of one evaluation.

Storms cites an evaluation by Dr. David Calvert, his personal physician, responding to a questionnaire from Aetna. Dr. Calvert indicated that Storms had a “Class 5” work limitation, meaning he had a “severe limitation of functional capacity; incapable of minimal (sedentary) activity.” In dismissing this assessment, Aetna wrote that “the opinion expressed by Dr. Calvert is not supported by any medical data or by the opinions of the neurologists who previously evaluated” Storms. The record reveals that Dr. Calvert’s conclusory finding was not supported by objective medical data, useful analysis, or the other opinions in the record. Such reasons are sufficient to discount the opinion of a treating physician. See Wilson v. Comm’r of Soc. Sec., 378 F.3d 541, 546 (6th Cir.2004) (discussing treating physician rule in the context of a Social Security claim). In addition, in ERISA actions, treating physicians are not accorded special deference. The Black & Decker Disability Plan v. Nord, 538 U.S. *759 822, 123 S.Ct. 1965, 155 L.Ed.2d 1034 (2003). Here, Dr. Calvert’s conclusion was not supported by the record. Dr. Calvert, in fact, referred Storms to neurologists to get expert opinions regarding his condition. None of these experts concluded that Storms was unable to perform his job duties. Treating physician Dr. Sibyl Wray noted that Storms “doesn’t nap during the day but his work keeps him constantly moving.... He feels he can concentrate well at work despite this problem.” Both Dr. Calvert and Dr. Radoff noted that Storms was attempting to establish a home business.

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