McDonough v. Aetna Life Ins. Co.
| Decision Date | 15 April 2015 |
| Docket Number | No. 14–1293.,14–1293. |
| Citation | 783 F.3d 374 |
| Parties | Joseph McDONOUGH, Plaintiff, Appellant, v. AETNA LIFE INSURANCE COMPANY, Defendant, Appellee. Biogen Inc. and Biogen Inc. Group Long Term Disability Plan, Defendants. |
| Court | U.S. Court of Appeals — First Circuit |
Mala M. Rafik, with whom Socorra A. Glennon and Sean K. Collins were on brief, for appellant.
Stephen D. Rosenberg, with whom Caroline M. Fiore and The Wagner Law Group were on brief, for appellee.
Before BARRON, SELYA and STAHL, Circuit Judges.
This case, brought under the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. §§ 1001 –1461, presents two issues. The first concerns the operation of an “own occupation” test within the definition of disability contained in a long-term disability (LTD) plan. The second concerns the operation of ERISA's penalty provision for late disclosure or non-disclosure of relevant plan documents. See 29 U.S.C. § 1132(c)(1)(B). After careful consideration, we vacate the district court's entry of summary judgment with respect to the termination of disability benefits and remand that issue for further consideration by the claims administrator. At the same time, we affirm the district court's imposition of a $5,000 penalty for the belated production of a plan document.
Plaintiff-appellant Joseph McDonough worked in the information technology division of Biogen Idec, Inc., now known as Biogen Inc. (Biogen). In March of 2007, he assumed the position of Senior Analyst III, Systems Administration. This was a high-pressure job, with responsibility for providing support for the server infrastructure at Biogen locations around the world (24 hours a day, 365 days a year).
In November of the following year, the appellant suffered the sudden onset of right-side numbness, dizziness, and blurred vision. He was hospitalized and provisionally diagnosed with a stroke
. Although this diagnosis could not be confirmed, some of his symptoms persisted and he did not return to work.
The appellant was eligible for disability benefits through a Biogen employee welfare benefit plan underwritten by defendant-appellee Aetna Life Insurance Company (Aetna). Biogen serves as the plan administrator and Aetna serves as the claims administrator. Withal, Aetna has plenary discretion to determine “whether and to what extent employees and beneficiaries are entitled to benefits.”
A plan participant is disabled within the meaning of the plan on any day that the participant is “not able to perform the material duties of [his] own occupation solely because of: disease or injury; and [his] work earnings are 80% or less of [his] adjusted predisability earnings.” A participant's material duties are those “normally required for the performance of [the participant's] own occupation,” so long as they “cannot be reasonably [ ] omitted or modified.” The plan defines a participant's “own occupation” as the occupation “routinely perform[ed]” by the participant at the time the disability began as that occupation is “normally performed in the national economy,” rather than how it is performed for the employer.
The appellant successfully applied for LTD benefits under the plan, commencing May 23, 2009. From that point forward, he and his health-care providers kept Aetna informed of his treatment and prognosis. Despite extensive therapy, the appellant continued to experience physical symptoms including sudden right-side weakness and loss of balance. He also suffered from anxiety, panic attacks, and the like. With this in mind, the appellant's primary care physician (PCP) referred him for mental health care in June 2009. Some of his health-care providers suggested that his physical symptoms might be a reaction to stress associated with the demanding nature of his job.
In September of 2009, the appellant's PCP reported that the appellant was continuing to experience right-side weakness but had a “sedentary level of functionality” and “could work 5 days a week and 8 hours per day.” Based on this report, Aetna began to evaluate the appellant's continued eligibility for benefits. Soon thereafter, two of the appellant's mental health providers jointly reported that he suffered debilitating panic attacks four to five times per week and projected that—due to a combination of these attacks, sleeplessness, and anxiety—the appellant would be unable to work for a year.
On October 29, 2009, Aetna informed the appellant by letter that his LTD benefits would be terminated as of October 31, 2009. In Aetna's judgment, the appellant no longer met the plan's definition of disability. This judgment was premised in large part on his PCP's conclusion that he could perform sedentary work 40 hours per week. Aetna wrote off the contradictory report of the appellant's mental health providers, concluding that it “lacked examination findings [sufficient] to support a functional impairment from a clinical standpoint.”
The appellant challenged the benefits-termination decision through Aetna's internal appeals procedure. In support, he submitted medical records from physicians, mental health providers, and physical therapists, highlighting the symptomatology that (in his view) precluded him from satisfying the physical and cognitive requirements of his job. These symptoms included right-side numbness and weakness, which he said significantly impeded his fine-motor skills for typing and writing. They also included anxiety, sleeplessness, and frequent panic attacks, which he said would impair his ability to cope with the stressful and time-intensive nature of his position. Finally, he submitted a report by a vocational consultant who reviewed his medical records to assess his work capacity.
At this juncture, Aetna engaged four doctors, two specializing in occupational medicine and two specializing in psychology, to review the appellant's medical records and other documents submitted in support of his appeal. Aetna has conceded that all four of these doctors should be treated as Aetna employees rather than independent medical reviewers. In written reports, each of the four purposed to evaluate the medical evidence in detail. All of them concluded that the appellant was no longer disabled, stating variously that the record “[f]ails to support functional impairment,” that the appellant's “functional deficits would not preclude him from working in his own sedentary level occupation,” that “from a psychological/psychiatric perspective, the claimant is not impaired from working.... in his own job or any job,” and that the medical evidence “does not support a functional impairment, from a psychological perspective.” These reports uniformly listed among the documents reviewed, in what seems to be a boilerplate formulation, a job description, job analysis worksheet, and occupation description—yet none of the reviewers discussed either the demands of the appellant's position as it is normally performed in the national economy or how his symptoms would affect his ability to meet those demands.
In November of 2010, Aetna denied the internal appeal. In doing so, Aetna determined that “[f]rom an [o]ccupational [m]edicine perspective,” the appellant did not suffer from the sequelae
of a stroke ; and that while he had some functional impairment, his functional deficits “would not preclude him from working in his own sedentary level occupation.” Aetna acknowledged, “[f]rom a psychology perspective,” the reports of panic attacks and anxiety, as well as the reported likelihood that these symptoms would cause the appellant to miss more than four work days per month. It concluded, however, that the medical records did not warrant a finding that any of the appellant's mental health problems were of “a severity likely to have impaired his occupational functioning.” Aetna's denial letter did not discuss, directly or indirectly, the requirements of the appellant's position as it is normally performed in the national economy.
Dismayed by this decision, the appellant decamped to the federal district court, invoked ERISA, and sued for wrongful termination of benefits. See 29 U.S.C. § 1132(a)(1)(B). Although his suit named multiple defendants, the parties later agreed that Aetna was the only proper defendant with respect to the benefits-termination claim.
Early on, the appellant made written requests of both Aetna and Biogen, pursuant to 29 U.S.C. § 1024(b)(4), for “a complete copy of [his] plan, summary plan description, policy, and any and all attachments and amendments relating to his [LTD] Plan.” Aetna responded by providing documents entitled “Your Group Plan” and “Summary of Coverage.” But as the deadline neared for filing summary judgment motions, Aetna disclosed for the first time the policy agreement between Aetna and Biogen. Unlike the previously disclosed plan documents, the policy agreement contained language granting Aetna complete discretion over all benefits-eligibility decisions. This language was important: it had the effect of altering the standard of judicial review. See McDonough v. Aetna Life Ins. Co., No. 11–11167, 2014 WL 690319, at *12 (D.Mass. Feb. 19, 2014). The appellant promptly amended his complaint to add a request for penalties for failure to produce all relevant plan documents within the statutorily prescribed time. See 29 U.S.C. § 1132(a)(1)(A), (c)(1)(B).
In due season, the parties cross-moved for summary judgment. The district court granted summary judgment for Aetna on the benefits-termination claim. See McDonough, 2014 WL 690319, at *19. With respect to the appellant's other claim, the court determined that a relevant document had been disclosed belatedly and assessed a $5,000 penalty against Aetna.1 See id.
The appellant advances two claims of error. The first relates to the district court's finding that Aetna's benefits-termination decision is supportable. The second relates to what the appellant regards as the skimpiness of the penalty assessed. We address...
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