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Carter v. Aetna Life Insurance Co.

United States District Court, D. Maine

January 2, 2019

COLON L. CARTER Plaintiff,



         Plaintiff 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.

         I. BACKGROUND

         A. Procedural History

         On 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) (Decl.).

         On 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.).

         B. Statement of Facts

         1. The Parties

         BIW, a 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.[1] Id. at 10, 16, 23. Mr. Carter received short-term disability benefits after he stopped working at BIW.[2] Id. at 23.

         “Aetna 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.

         2. The Long-Term Disability Plan

         Mr. 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.

         The 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.

         The 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).

         “Own 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.

         3. Mr. Carter's Long-Term Disability Claim

         a. Procedural History

         Mr. Carter applied for long-term disability benefits on May 4, 2016.[3] 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.[4] Id. at 401. Aetna denied Mr. Carter's appeal on April 3, 2017. Id. at 180-85.

         b. Mr. Carter's Medical History

         Mr. 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.

         On 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.[5] 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.

         In 2015, Mr. Carter went to physical therapy, and, in his patient discharge summary, Mr. Carter's physical therapist stated:

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.

         On May 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.

         In 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 visits.”[6] Id.

         In 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.

         On 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.”[7] Id. at 605-06.

         On 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 stated:

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 time.[8]

Id. at 939

         On May 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 eval[uation.]” Id.

         Mr. Carter underwent two lidocaine infusions on April 20, 2016 and May 27, 2016.[9] Id. at 613-23.

         On May 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 ...

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