Valentine v. Aetna Life Ins. Co., 14–cv–1752 (JFB)(GRB).

• Decision Date: 25 August 2015
• Docket Number: No. 14–cv–1752 (JFB)(GRB).,14–cv–1752 (JFB)(GRB).
• Citation: 125 F.Supp.3d 425
• Parties: Carol VALENTINE, Plaintiff, v. AETNA LIFE INSURANCE COMPANY, Defendant.
• Court: U.S. District Court — Eastern District of New York

125 F.Supp.3d 425

Carol VALENTINE, Plaintiff,

v.AETNA LIFE INSURANCE COMPANY, Defendant.

No. 14–cv–1752 (JFB)(GRB).

United States District Court, E.D. New York.

Signed Aug. 25, 2015.

Ronald L. Epstein, Grey and Grey LLP, Farmingdale, NY, for Plaintiff.

Michael Bernstein, Sedgwick LLP, New York, NY, for Defendant.

MEMORANDUM AND ORDER

JOSEPH F. BIANCO, District Judge.

Plaintiff Carol Valentine ("plaintiff") brings this action under the Employee Retirement Income Security Act of 1974, 29 U.S.C. § 1001 et seq. ("ERISA"), challenging the termination of her long-term disability ("LTD") benefits by defendant Aetna Life Insurance Company ("Aetna," or "defendant"). Plaintiff was employed by Hubbard Broadcasting ("Hubbard"), where she was a participant in an LTD policy administered by Aetna (the "Plan"), until she allegedly became disabled under the provisions of the Plan due to a trigeminal nerve disorder

. Plaintiff now challenges Aetna's partial rejection of her claim for LTD benefits. Specifically, plaintiff alleges that Aetna's finding that plaintiff's disability ended on June 30, 2012, and its resultant decision to terminate her benefits subsequent to that date was arbitrary and capricious.

Plaintiff and defendant now both move for summary judgment pursuant to Federal Rule of Civil Procedure 56. Defendant moves for summary judgment on the grounds that sufficient evidence in the record supports defendant's decision to deny plaintiff benefits in addition to those benefits already provided. Plaintiff cross-moves for summary judgment, asserting that the evidence in the record establishes that plaintiff had an ongoing disability, or in the alternative for a remand to the plan administrator for reconsideration of her claim. For the reasons set forth below, the Court denies defendant's motion, and grants plaintiff's motion to the extent that plaintiff's claim is remanded to Aetna for reconsideration.

I. BACKGROUND ¹

A. The Plan

The Plan is an employee welfare benefit plan governed by ERISA. ("ERISA Rights," VAL 38–39.) Hubbard established and maintains the Plan to provide LTD benefits to eligible employees, and Aetna acts as the Plan's claims administrator. (Id. )

1. Discretionary Authority

The Plan provides that:

Under Section 503 of Title 1 of the Employee Retirement Income Security Act of 1974, as amended (ERISA), Aetna is a fiduciary. It has complete authority to review all denied claims for benefits under this policy. In exercising such fiduciary responsibility, Aetna shall have 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.

Aetna shall be deemed to have properly exercised such authority. It must not abuse its discretion by acting arbitrarily and capriciously. Aetna has the right to adopt reasonable:

• policies;

• procedures;

• rules; and

• interpretations;

Of this policy to promote orderly and efficient administration.

("Policyholder and Insurance Company Matters" at "ERISA Matters," VAL 105.)

2. Eligibility for LTD Benefits

The Plan provides that

From the date that you first become disabled and until Monthly Benefits are payable for 24 months, you will be deemed to be disabled on any day if:

• You are not able to perform the material duties of your own occupation solely because of disease or injury; and

• Your work earnings are 80% or less of your adjusted pre–disability earnings.

After the first 24 months that any Monthly Benefit is payable during a period of disability, you will be deemed to be disabled on any day if you are not able to work at any reasonable occupation solely because of:

• Disease; or

• Injury.

("Long Term Disability Coverage" at "Test of Disability," VAL 4 (emphasis in original).) The Plan further states that:

A period of disability starts on the first day you are disabled as a direct result of a significant change in your physical or mental condition occurring while you are insured under this Plan. You must be under the regular care of a physician. (You will not be deemed to be under the regular care of a physician more than 31 days before the date he or she has seen and treated you in person for the disease or injury that caused the disability.)

Your period of disability ends on the first to occur of:

• The date Aetna finds you are no longer disabled or the date you fail to furnish proof that you are disabled....

• The date an independent medical exam report or functional capacity evaluation fails to confirm your disability....

("Long Term Disability Coverage" at "A Period of Disability," VAL 5 (emphasis in original).)

The Plan further provides that benefits are "payable after the elimination period ends for as long as the period of disability continues." ("Long Term Disability Coverage" at "When Benefits Are Payable," VAL 5.) The elimination period under the Plan is 180 days. ("Disability Coverage" at "Long Term Disability Benefits," VAL 33.)

B. Plaintiff's Disability

Valentine was employed by Reelz TV, an affiliate of Hubbard, as a Director of Ad Sales Planning starting on or about December 1, 2008, until her last day of work on November 15, 2011. (VAL 729.) Plaintiff's salary at the end of her employment was approximately $225,000 plus commissions, amounting to gross pay of $316,868.56 in 2011. (Id. at 490, 722.) Plaintiff's job description reflects that some of her duties were to conduct negotiations on advertising time, create marketing platforms, maintain current business while "aggressively" seeking new business, interact with clients/agencies and account executives including entertaining them at industry events, present competitive research, and travel out of town. (Id. at 652–53.) It also notes that her position required "average sitting, standing, and office-type movement," the "ability to stand and present to a group for many hours," the "ability to travel via taxi, bus, personal car, commercial airline & train," and "average lifting, moving and pulling abilities." (Id. at 653.)

On or about April 4, 2012, Valentine filed a claim for LTD benefits claiming to be disabled and unable to work as of December 14, 2011 due to symptoms related to her diagnosis of a "trigeminal nerve disorder

, unspecified" originally caused by an injury to her trigeminal nerve during a root canal in February 2010. (Id. at 107–108, 120, 122.) Plaintiff alleged that her symptoms (which increased in November 2011 after another dental procedure) in combination with side effects from prescribed medication included "daily persistent headache" and "fatigue, diminished memory, poor concentration, clouded thought combined with constant pain," causing her neurocognitive effects which limited her work performance. (Id. at 120–22.)

Plaintiff's treating physician for her allegedly disabling condition during this period was Dr. David Sirois, DMD, PhD, a specialist in cranial nerve injuries

.² (Id. at 107, 122.) Dr. Sirois submitted an Attending Physician Statement ("APS") in support of plaintiff's LTD claim, dated March 30, 2012. (Id. at 731–32.) In it, Dr. Sirois stated that plaintiff "suffers from constant moderate to severe head and facial pain which has also resulted in an unusual pattern of pain and dysesthesia affecting the back, occipital and upper extremity." (Id. at 731.) In addition to the neurocognitive issues, Dr. Sirois stated plaintiff exhibited objective symptoms of "diminished strength and widespread mechanical allodynia."³ (Id. ) Overall, he found that plaintiff was "disabled from her usual work activity." (Id. )

Dr. Sirois noted that, although he had noted mild improvement with treatment, "overall the prognosis is poor in that her condition is permanent and symptoms will remain to some degree indefinitely." (Id. ) Dr. Sirois stated, "There is no objective test to prove or otherwise quantify her pain condition and I must rely on her self-report of limitations." (Id. ) He also noted that he had prescribed plaintiff a number of medications, and that the side effects of those medications were part of plaintiff's disability, though as plaintiff's treatment evolved he planned to adjust her medications to ameliorate those effects. (Id. ) Dr. Sirois concluded that plaintiff's prognosis would be clearer after six months of further treatment, i.e. through September 2012, and that he "reasonably expect[ed] she would remain disabled" during that period. (Id. ) Dr. Sirois concurrently noted on the Aetna APS form that plaintiff's disability began on December 14, 2011 and would be continue "indefinite[ly] pending outcome to ongoing treatment." (Id. at 732.)

C. Initial Denial of Plaintiff's Claim

Aetna claim analyst Elizabeth Wing conducted a phone interview with plaintiff on April 16, 2012, after which she referred the claim to a nurse consultant, Jeanette Stehly, for a review. (Id. at 121–26.) Stehly reviewed plaintiff's records and concluded that her claim should be denied, finding that Dr. Sirois' APS indicated plaintiff "can work sedentary and he has not imposed restrictions yet it seems he is saying she is impaired."⁴ (Id. at 125.) Stehly stated that Dr. Sirois did not provide sufficient "exam findings, diagnostics, etc. to support inability to perform job duties," and questioned how a trigeminal neuralgia

could cause plaintiff's symptoms. (Id. )

After requesting and receiving further information from Valentine, including the older evaluations from Dr. Loria and Dr. Snyder, Wing conducted a phone interview with Dr. Sirois on May 14, 2012. (Id. at 152–53, 157.) During the interview, Dr. Sirois averred that his original APS was intended to state that plaintiff was disabled due to illness and pain, and that he would fill out a new APS if it would be helpful; though some of her symptoms (the diminished memory and poor concentration) were based on "self reports" and not on formal or structured testing, Dr. Sirois said he believed plaintiff's complaints, and that both the distraction caused by her illness/pain and the...