United States District Court, D. Maine
COLON L. CARTER Plaintiff,
AETNA LIFE INSURANCE COMPANY, Defendant.
ORDER ON MOTIONS FOR JUDGMENT ON THE RECORD
A. WOODCOCK, JR., UNITED STATES DISTRICT JUDGE
alleges the defendant, an insurance plan administrator,
unlawfully denied his claim for benefits under a long-term
disability insurance policy that the defendant issued to and
through plaintiff's employer. Both parties move for
judgment on the administrative record. Having reviewed the
record and having applied the high arbitrary and capricious
standard to the insurer's denial of disability benefits,
the Court concludes that the insurer had a reasonable basis
and sufficient evidence to deny the plaintiff's claim for
benefits. The Court therefore grants the insurer's and
denies the plaintiff's motion for summary judgment.
October 10, 2017, Colon L. Carter, filed a complaint against
Aetna Life Insurance Company (Aetna), alleging that Aetna,
which provides long-term disability insurance governed by the
Employee Retirement Income Security Act (ERISA) through Mr.
Carter's employer, Bath Iron Works (BIW), arbitrarily and
capriciously denied Mr. Carter's claim for long-term
disability benefits. Compl. ¶¶ 6-7, 10, 30
(ECF No. 1). Aetna answered Mr. Carter's Complaint on
December 11, 2017. Answer (ECF No. 8). On January 3,
2018, Aetna filed the declaration of Adam Garcia, who is
employed by Aetna and who was familiar with Aetna's files
and records as they relate to Mr. Carter. Decl. of Adam
J. Garcia ¶¶ 1-3 (ECF No. 10)
March 20, 2018, Mr. Carter filed a motion to amend his
Complaint to assert that his claim is governed by a de novo
standard of review, Mot. to Amend (ECF No. 18); the
Magistrate Judge denied the motion to amend on May 17, 2018.
Decision and Order on Pl.'s Mot. to Amend (ECF
No. 21) (Order on Mot. to Amend). On June 5, 2018,
Mr. Carter filed a motion for judgment on the administrative
record. Mot. for J. on the Administrative R. with a
Supporting Mem. of Law (ECF No. 22) (Pl.'s
Mot.); Mot. for J. on the Administrative R. with a
Supporting Mem. of Law Attach. 1, App. to Mot. for
J. on the Administrative R. (ECF No. 22) (Pl.'s
App. of Facts). The next day, Aetna filed a motion for
summary judgment on the administrative record. Mot. for
Summ. J. on the Administrative R. (ECF No. 24)
(Def.'s Mot.); Mot. for Summ. J. on the
Administrative R. Attach. 1, Aetna Life Insurance
Company's App. Statement of Facts (ECF No. 24)
(Def.'s App. of Facts). On July 10, 2018, both
parties responded to each other's motions, with Aetna
also filing a response to Mr. Carter's statement of facts
from the administrative record. Pl.'s Resp. to
Def.'s Mot. for J. on the Administrative Record (ECF
No. 22) (Pl.'s Opp'n); Def.'s
Opp'n to Pl.'s Mot. for J. on the R. (ECF No.
29) (Def.'s Opp'n); Def.'s Opp'n
to Pl.'s App. of Facts (ECF No. 28) (Def.'s
Opp'n to Pl.'s App.).
Statement of Facts
subsidiary of General Dynamics, employed Colon L. Carter as
an estimating analyst. Administrative R. at 1104;
Def.'s Opp'n to Pl.'s App. ¶ 3. As
part of his job, Mr. Carter was responsible for:
“[d]eveloping cost proposals for new Navy and
commercial work; [d]eveloping and maintaining proposal
support documents and checklists; [c]reating financial
models; maintaining company baselines for all Programs;
[a]ssisting management with department staffing plans; [and]
Earned Value Management System (EVMS) Analysis.”
Administrative R. at 430. This position has a
sedentary physical demand level. Id. at 10, 384,
390. Mr. Carter's last day of work at BIW was December
20, 2015 and he applied for short-term disability benefits
thereafter, which BIW paid. Id. at 10, 16, 23. Mr.
Carter received short-term disability benefits after he
stopped working at BIW. Id. at 23.
is a fiduciary under [s]ection 503 of Title 1 of [ERISA] as
amended and has complete authority to review all denied
claims for benefits under [its] policy.” Id.
at 1098 (internal quotation marks omitted). Aetna has
discretionary authority in determining if, and to what
degree, beneficiaries are entitled to benefits. Id.
The Long-Term Disability Plan
Carter was eligible to participate in the General Dynamics
Non-Represented Long-Term Disability - Core and Buy-Up Plan
Long-Term Disability Plan (the Plan). Id. at 1065,
1078; Answer ¶ 6. The Plan is underwritten by
and provided as part of the group life and accident and
health insurance policy which is provided to General Dynamics
by Aetna with a group policy number of
“GP-100515.” (the Policy). Administrative
R. at 1042, 1075. The Plan provides that additional
provisions are applicable to beneficiaries, which “are
described . . . in the group contract.” Id. at
1055 (emphasis omitted). “[R]egular full-time employees
of Bath Iron Works who are non-represented salaried employees
are [eligible] for benefits under the Plan.”
Id. at 1065.
Plan's summary of coverage identifies the “Group
Policy” as “GP-100515” [and the summaries
of coverage (SOC) as 1a].” Id. at 1064, 1075.
The summary of coverage further identifies policy form
“GR-29”, which is imprinted on the bottom left
corner of Aetna's “Group Life and Accident and
Health Insurance Policy.” Id. at 1069. The
summary of coverage states that the summary plan description
consists of the information provided for in the section
entitled “Additional Information Provided by General
Dynamics Corporation.” Id. 1040-61.
Policy includes a “Face Page, Index, [a] Policy
Contents page, and all the provisions of Parts I and II; and
[t]he provisions found in the Certificate(s) [Cert Base 1 SOC
1a].” Id. at 1077. Certificate Base document
1, SOC 1A, is the long-term disability plan at dispute.
Id. Regarding ERISA matters, the Policy states
“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.” Id. at 1098. Under the
Policy, the test of disability provides:
From the date you first become disabled and until Monthly
Benefits are payable for 18 months, you will be deemed
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 predisability
earnings. After the first 18 months that any Monthly
Benefit is payable during any 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. If your own occupation requires a professional or
occupational license or certification of any kind, you will
not be deemed to be disabled solely because of the loss of
that license or certification.
Id. at 1043 (emphasis in original).
Occupation” is defined as:
[T]he occupation that you are routinely performing when your
period of disability begins. Your occupation will be viewed
as it is normally performed in the national economy instead
of how it is performed: for your specific employer; or at
your location or work site; and without regard to your
specific reporting relationship.
Id. at 1057. The term “Material Duties”
is defined as the duties that “are normally required
for the performance of your own occupation; and cannot be
reasonably: omitted or modified.” Id.
(emphasis omitted). The Plan limits coverage to 24 months for
certain conditions, including chronic pain syndrome.
Id. at 1045.
Mr. Carter's Long-Term Disability Claim
Carter applied for long-term disability benefits on May 4,
2016. Id. at 1103. He claimed
disability for chronic neuropathic pain, chronic spinal
disorder, and chronic pain syndrome. Id. at 180.
Aetna denied Mr. Carter's claim for long-term disability
benefits on August 2, 2016. Id. at 155-57. If
approved, Mr. Carter's benefits would have begun June 20,
2016. Id. at 180. He appealed this decision on
January 30, 2017. Id. at 401. Aetna denied Mr.
Carter's appeal on April 3, 2017. Id. at 180-85.
Mr. Carter's Medical History
Carter has a history of spinal surgeries. His first surgery
was in 2003 to remove a cancerous tumor on his lumbar spine.
Id. at 23, 579. In early June of 2012, Mr. Carter
underwent a left C6-7 microlaminotomy for a C7 radiculopathy
and a C7 root foraminotomy. Id. at 23, 494, 943. On
January 15, 2015, Mr. Carter had a C6-C7 anterior cervical
discectomy and fusion due to a C6-7 herniated disk osteophyte
complex with C7 radiculopathy, left greater than right,
performed by Dr. Robert Ecker. Id. at 540-41.
March 2, 2015, Mr. Carter was involved in a car accident
which resulted in shoulder pain, pain at the base of his
neck, as well as some numbness in his left arm, some of which
he experienced before the accident. Id. at 625-29.
After the accident, Dr. Samuel Umbriaco found Mr. Carter to
have normal strength in his bilateral upper extremities and
found his neurologic exam normal. Id. at 627.
2015, Mr. Carter went to physical therapy, and, in his
patient discharge summary, Mr. Carter's physical
I regret that Mr. Carter has reached the plateau with his
course of physical therapy. He continues to have left
shoulder pain that radiates into his left hand. His clinical
findings suggest nerve impingement. He is ready for discharge
to an independent program; however, may be appropriate for
return to physical therapy if his medical team is able to
lower his pain level. Goals achieved:
1. Able to perform all work tasks including keyboarding
without significant restrictions - not fully achieved as
patient is performing his tasks but with pain.
2. Able to sleep for greater than 6 hours without waking in
pain - not yet achieved.
3. Full and symptom-free AROM of the left shoulder and
cervical spine - not yet achieved. Able to lift and carry two
bags of groceries with good body mechanics and without
restrictions - improving. Independent with a home exercise
program - achieved.
Id. at 652.
6, 2015, Mr. Carter had an MRI on his lumbar spine which
indicated “a broad-based posterior disk bulge with
right-sided annular tear at ¶ 4-5 resulting in crowding
of the lateral recesses, right greater than left [, and
][t]here [was] contact of the traversing L5 nerve roots which
could be contributing to the his symptom, ” which was
“not significantly changed when compared to the prior
exam.” Id. at 561.
September of 2015, Mr. Carter went to Gardiner Family
Chiropractic “for evaluation and treatment of left
sided neck, shoulder, and left arm radiculopathy that was
exacerbated by a motor vehicle accident on 3/2/15.”
Id. at 775. Karen A. Biser, D.C., stated that after
the car accident, Mr. Carter's “symptoms did return
over time”, and while he had some temporary relief,
“his pain and the burning in his arm was . . . easily
exacerbated by the simplest tasks such as reaching in front
of himself to pick up a cup.” Id. She indicted
that “[h]is pain does indeed limit his ability to
perform work-related tasks such as reaching, lifting,
carrying, traveling, and prolonged computer work because
these activities can and often do aggravate his
symptoms.” Id. Dr. Biser stated Mr.
Carter's “care was spaced out . . . until he was
eventually dismissed . . .because his symptoms had
plateaued.” Id. She also noted, however, that
“Mr. Carter still comes in for care to help with his
pain levels about every 4 weeks or so at this point. This
helps temporarily with his range of motion and pain levels,
but does not eliminate his symptoms.” Id. Mr.
Carter's treatment plan with Dr. Biser was: “3x
times weekly for 2 weeks; twice weekly for 4-6 weeks; once
weekly for 6 weeks; and then every 2 weeks for 4-6
early January of 2016, Dr. Totta, a psychiatrist and pain
specialist, stated that Mr. Carter unfortunately had lost his
son in a motor vehicle incident and that the stress from this
event “flared his pain.” Id. at 958. Mr.
Carter described the pain to Dr. Totta as “constant
[and] burning” and Dr. Totta had the impression that
Mr. Carter had neuropathic pain. Dr. Totta did not conduct
any clinical examinations but stated, “[not] easy to
tell status [illegible] emotional stress. Some cognitive
effect -- ? -- concentration.” Id. On February
2, 2016, Dr. Totta met with Mr. Carter, and did not perform
an examination of Mr. Carter, but Mr. Carter stated he was
experiencing “intense left sided burning” and
“not seeing an [illegible] improvement.”
Id. at 957.
March 8, 2016, fifteen months post cervical discectomy and
fusion, Mr. Carter complained to his surgeon, Dr. Ecker, that
he was experiencing “significant pain down his right
arm over the biceps to his right thumb and index finger,
” and Dr. Ecker assessed that Mr. Carter had chronic
left C6 radiculopathy, and scheduled him “to speak with
Dr. Pisini about spinal cord simulator and this in
conjunction with pain management by his PCP are likely the
best choices at this time.” Id. at 605-06.
April 6, 2016, on referral from Dr. Ecker, Mr. Carter saw Dr.
James Pisini, a neurosurgeon, regarding the possibility of
surgery to implant a spinal cord stimulator to try and reduce
his current pain. Id. at 939. In his consultation
note, Dr. Pisini wrote, regarding Mr. Carter, “1.
Chronic neuropathic pain to left upper extremity and left
lower extremity. 2. Status postlaminectomy syndrome of both
the cervical and lumbar spine. 3. History of malignant spinal
tumor.” Id. at 939. In recommending that Mr.
Carter not undergo spinal cord stimulation, Dr. Pisini
First of all, the extensive location of his pain makes it
impossible to cover with a single or possibly even more
spinal cord stimulators, in which case the success rate is
extremely low when one cannot capture virtually 100% of a
patient's painful area. Whenever there is pain in
multiple regions of the body, particularly upper and lower
extremity, not only is it impossible to cover all that with a
spinal cord stimulator but often very difficult to treat it
effectively. In addition to that, the fact that he has had a
laminectomy at the C6-7 level would make it contraindicated
to pass a percutaneous electrode from the thoracic region up
into the cervical region, and therefore, the only possible
option would be a surgically placed paddle lead if even one
was to entertain spinal cord stimulation for his cervical and
arm pain. In addition, he does require routine MRIs because
of his history of malignant tumor, and having multiple
electrodes in the epidural spaces would certainly impair not
only potentially the ability to receive an MRI but also the
quality of the images. Given those 3 major drawbacks and my
opinion to consider spinal cord stimulation, I really do not
think it is a viable option for him at this
Id. at 939
5, 2016, in an attending physician statement, Dr. Totta noted
that Mr. Carter could not work due to neuropathic pain and
that his pain made sedentary work difficult. Id. at
1100-01. However, Dr. Totta also found Mr. Carter was able to
work with others, give supervision, work cooperatively with
others in group setting, endorse checks, and direct the use
of check proceeds. Id. at 1101. In terms of
objective measures to substantiate the impairment, Dr. Totta
stated, “pending spinal cord stimulation
Carter underwent two lidocaine infusions on April 20, 2016
and May 27, 2016. Id. at 613-23.
27, 2016, Dr. Totta completed Aetna's capabilities and
limitations worksheet and stated Mr. Carter's
“capacity is limited by perceived pain - there is no
specific neurological deficit or objective incapacity.”
Id. at 953. Dr. Totta wrote that Mr. Carter could
“occasionally” perform the activities described
therein, such as “lifting”,
“pulling”, and “carrying.”
Id. Approximately two weeks later, filling out an
attending provider statement, Dr. Totta ...