SUSAN C. BUCKLEW, United States District Judge.
This cause comes before the Court on Defendants', Aetna Life Insurance Company ("Aetna") and Federal Express Corporation ("FedEx"), Motion for Summary Judgment (Dkt. 37), to which Plaintiff, Patricia Street, has filed a response in opposition (Dkt. 46).
Summary judgment is appropriate "if the movant shows that there is no genuine dispute as to any material fact and the movant is entitled to judgment as a matter of law." Fed. R. Civ. P. 56(a). The Court must draw all inferences from the evidence in the light most favorable to the non-movant and resolve all reasonable doubts in that party's favor. See Porter v. Ray, 461 F.3d 1315, 1320 (11th Cir.2006) (citation omitted). The moving party bears the initial burden of showing the Court, by reference to materials on file, that there are no genuine issues of material fact that should be decided at trial. See id. (citation omitted). When a moving party has discharged its burden, the non-moving party must then go beyond the pleadings, and by its own affidavits, or by depositions, answers to interrogatories, and admissions on file, designate specific facts showing there is a genuine issue for trial. See id. (citation omitted).
When the deferential standard of review applies, evidence is rarely taken and the usual tests for summary judgment, such as whether genuine issues of material fact exist, do not apply. Curran v. Kemper Nat. Servs., Inc., No. 04-14097, 2005 WL 894840, at *7 (11th Cir. March 16, 2005) ("In an ERISA benefit denial case...in a very real sense, the district court sits more as an appellate tribunal than as a trial court. It does not take evidence, but, rather, evaluates the reasonableness of an administrative determination in light of the record compiled before the plan fiduciary."); see Providence v. Hartford Life & Acc. Ins. Co., 357 F.Supp.2d 1341, 1342 (M.D.Fla.2005); Garrett v. Prudential Ins. Co. of Am., 107 F.Supp.3d 1255, 1264 (M.D.Fla.2015).
Plaintiff was insured under the employee welfare benefit plan known as The Federal Express Corporation Long Term Disability Plan, which provides for the funding and payment of long-term disability benefits to employees that are covered under the Plan. Dkt. 24-10 at 29; AR 01884. FedEx is the Plan administrator and Aetna is the Claims Paying Administrator of the Plan. The Plan gives Aetna, as the Claims Paying Administrator, "sole and exclusive discretion...with respect to all matters ... relating to the eligibility of a claimant for benefits under the Plan." Dkt. 24-10 at 3. Further, "[t]he determination of the Claims Paying Administrator shall be made in a fair and consistent manner in accordance with the Plan's terms and its decision shall be final, subject only to a determination by a court of competent jurisdiction that the individual's or committee's decision was arbitrary and capricious." Id. at 3-4.
If an eligible FedEx employee becomes "Disabled" as defined by the Plan, then the employee "shall be entitled" to receive Long-Term Disability ("LTD") benefits. Dkt. 24-10 at 47. The employee shall be paid a monthly disability benefit that is equal to 60% of that covered employee's monthly income. Id. The Plan provides the following definition for "Disabled":
Dkt. 24-10 at 33-34.
An employee is an "Eligible Employee" if she is "an Employee who is engaged in a Permanent Full-Time Employment...." Dkt. 24-10 at 34. However, an employee that is "classified as casual, temporary, permanent part-time...or who is on a personal family (other than a family leave for his own illness or injury), unapproved disability or other leave of absence ...shall not be an Eligible Employee." Id. at 34-35.
In order to prove a qualifying disability, the employee or the employee's health care professional must provide proof that the employee is disabled, based on significant objective findings, such as: (1) medical examination findings; (2) test results; (3) X-ray results; and/or (4) observation of anatomical, physiological or psychological abnormalities. Pain alone is not proof of a disability.
If a covered employee suffers from an Occupational Disability, the Plan provides long-term benefits equal to 60% of the employee's monthly income for up to two years. An "Occupational Disability" means "the inability of a Covered Employee, because of a medically-determinable physical or functional impairment... to perform the duties of his regular occupation." Dkt. 24-10 at 37-38.
In order to receive LTD benefits for more than two years under the Plan, a Covered Employee must be Totally Disabled. A "Total Disability" means "the complete inability of a Covered Employee, because of a medically-determinable physical or functional impairment ...to engage in any compensable employment for twenty-five hours per week." Id. at 41.
Coverage under the Plan automatically terminates under a number of scenarios, including the date an employee ceases to meet the definition of an Eligible Employee. Id. at 44.
Plaintiff worked as a Senior Business Systems Advisor at FedEx. Dkt. 24-2 at 7. Plaintiff was given Short-Term Disability benefits from March 28, 2011 to September 25, 2011 when she suffered an intrailac thromboembolism, which resulted in Plaintiff not being able to work in her normal position at FedEx. Id. at 1. Plaintiff also suffered from other ailments, including emphysema, hypertension, chronic obstructive pulmonary disease ("COPD") and complained of weakness and numbness in her thighs. Dkt. 24-1 at 2. Plaintiff then received LTD benefits under the Plan from September 26, 2011 to September 25, 2013. Dkt. 24-2 at 1. Because Plaintiff had received LTD benefits for the maximum of two years, she needed to qualify as having a Total Disability in order to continue to receive LTD benefits. On September 26, 2013, Plaintiff was denied LTD benefits because there was "a lack of significant objective findings to substantiate a claim under the Plan for Total Disability," i.e., she was unable to engage in any compensable employment for a minimum of 25 hours per week. Dkt. 24-1 at 1.
Defendants also point to the peer review conducted by Dr. Wendy Weinstein, who conducted a review of Plaintiff's medical records. Dkt. 24-2 at 122-129. Dr. Weinstein found that the following ailments would not preclude Plaintiff from performing the job duties of any occupation for twenty-five hours per week:
Plaintiff complained of numbness and weakness in her legs, but her balance and gait were routinely described as normal in her medical records. Dkt. 24-2 at 206, 211, 219. A September 7, 2012 record states that Plaintiff reported she had claudation
As she was permitted to do under the Plan, Plaintiff appealed the denial of the LTD benefits (Dkt. 24-2 at 7-14), and on June 23, 2014, the decision was upheld (Dkt. 24-1). The final denial letter explains why, according to Aetna, Plaintiff's medical records and reports did not establish her entitlement to LTD benefits. Dkt. 24-1. For example, while Plaintiff complained that she could not walk or stand for more than a short period of time, there was no objective medical evidence or documentation indicating that she had an inability to walk, stand, or sit (rather, the only notes regarding Plaintiff's walking complaints were Plaintiff's own complaints and not any doctor's finding or conformation).
In addition, the denial letter noted that although Plaintiff had received a disability determination from the Social Security Administration ("SSA"), the criteria utilized by the SSA for the determination of Social Security disability awards are different from the definition for Total Disability in the Plan. Id. at 3. In making its final determination, the review committee "considered all submitted documentation, noted the conclusions of the peer physicians, and determined that there was no significant objective findings to substantiate that a functional impairment exist[ed] that would preclude work in any compensable employment for twenty-five hours per week." Id. The Plan's requirement of a significant objective finding to substantiate eligibility for Total Disability benefits (LTD benefits) was not met in Plaintiff's case. Id.
Finally, the denial letter noted that the committee recognized that Plaintiff's medical condition did support a functional impairment as of April 1, 2014 (in denying benefits for the time period of April 1, 2014 to April 5, 2014) due to placement of a unibody bifurcated endovascular device. However, Federal Express confirmed that Plaintiff was not on approved Family Medical Leave for her own illness or injury as of April 1, 2014. Thus, under the Plan, no benefits could be authorized for that time period from April 1, 2014 to April 5, 2014 because Plaintiff was not an "Eligible Employee" as defined above.
Plaintiff then filed the instant case on February 24, 2015 and challenges Aetna's denial of LTD benefits.
The United States Supreme Court, in Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115, 109 S.Ct. 948, 103 L.Ed.2d 80 (1989), set forth the standard of review that a court must apply when reviewing a denial of ERISA benefits: "a denial of benefits...is to be reviewed under a de novo standard unless the benefit plan gives the administrator or fiduciary discretionary authority to determine eligibility for benefits or to construe the terms of the plan." The Eleventh Circuit has adopted three standards of review for plan interpretations: (1) de novo, applicable where the claims administrator is not afforded discretion, (2) arbitrary and capricious, applicable where the plan grants the administrator discretion, and (3) heightened arbitrary and capricious, applicable where the
More recent cases from the Eleventh Circuit have expanded the Firestone test into a six-step analysis to guide district courts in reviewing an administrator's benefits decision:
Capone v. Aetna Life Ins. Co., 592 F.3d 1189, 1195 (11th Cir.2010) (citing Williams v. BellSouth Telecomms., Inc., 373 F.3d 1132, 1137 (11th Cir.2004)).
Initially, the Court must evaluate Defendants' decision from the perspective of a de novo review and determine whether it is "wrong." See HCA Health Services of Georgia, Inc. v. Employers Health Ins. Co., 240 F.3d 982, 993 (11th Cir.2001). A decision is "wrong" if, after reviewing the administrative record that was before the claims administrator at the time that the decision was made, the Court disagrees with Defendant's decision. See id. at 993 n. 23.
If the Court determines that Defendant's decision was not wrong, the Court's inquiry ends and summary judgment is entered in favor of Defendant. Williams v. BellSouth Telecommunications, Inc., 373 F.3d 1132, 1138 (11th Cir.2004). "A decision is wrong if, after a review of the decision of the administrator from a de novo perspective, the court disagrees." Glenn v. Am. United Life Ins. Co., 604 Fed.Appx. 893, 897 (11th Cir.2015) (citation omitted).
Under the six-step analysis described above, the Court must first assess whether the decision to deny Plaintiff's claim for LTD benefits was "wrong" under the de novo standard — that is, whether the Court disagrees with that decision. Jones v. Federal Express. Corp., 984 F.Supp.2d 1271, 1276 (M.D.Fla.2013). "Review of the... administrator's denial of benefits is limited to consideration of the material available to the administrator at the time it made its decision." Blankenship v. Metro Life Ins. Co., 644 F.3d 1350, 1354 (11th Cir.2011). Under the LTD Plan, "Total Disability" is defined as "the complete inability of a Covered Employee, because of a medically-determinable physical or functional impairment...to engage in any compensable employment for twenty-five hours per week." Dkt. 24-10 at 41. Thus, given the terms of the LTD Plan, in analyzing whether the decision to deny Plaintiff's claim for long term disability benefits was de novo "wrong," the Court must ultimately determine whether the Administrative
Defendants argue that they are entitled to summary judgment on Plaintiff's claims because the decision to deny Plaintiff's claim for LTD benefits was not de novo wrong. Plaintiff asserts several arguments in support of her conclusion that Aetna's decision was wrong. For the reasons stated below, the Court rejects Plaintiff's arguments and finds that Aetna's decision was not wrong, and as such, Defendants' motion for summary judgment must be granted.
It is not disputed that Plaintiff's treating physicians diagnosed her as having a number of medical issues and conditions, such as COPD, blood clots, emphysema, and hypertension. However, the law is clear that a "diagnosis does not by itself establish disability" for purposes of qualifying for a benefits under a LTD plan. See, e.g., Jordan v. Northrop Grumman Corp. Welfare Benefit Plan, 370 F.3d 869, 880 (9th Cir.2003); Howard v. Hartford Life & Acc. Ins. Co., 929 F.Supp.2d 1264, 1294 (M.D.Fla.2013), aff'd 563 Fed.Appx. 658 (11th Cir.2014) ("Indeed, doctors' diagnoses do not in and of themselves, establish a disability and inability to work."). Further, a claimant's "subjective complaints do not become objective simply because a doctor wrote them down." Id. at 1294-95. Thus, Plaintiff cannot carry her burden of proving a Total Disability by only pointing to doctors' notes that included a diagnosis or her own subjective complaints.
It is also undisputed that the independent medical examination performed by Dr. Cosmo and the peer review performed by Dr. Weinsten found that Plaintiff did not have a Total Disability and was able to work twenty-five hours a week. While Plaintiff points to certain doctor's notes that would indicate medical issues different than those described by Dr. Cosmo and Dr. Weinstein, such notes do not contradict the ultimate finding that Plaintiff was not totally disabled and Aetna's decision to deny LTD benefits was not de novo wrong. An administrator may reasonably rely on the opinions of consulting experts in order to determine whether medical evidence supports a finding of disability. As for the treating physicians, although an administrator "may not arbitrarily refuse to credit a claimant's reliable evidence, including the opinions of a treating physician," an administrator is not required to give special deference to the opinions of a claimant's treating physicians. Black & Decker Disability Plan v. Nord, 538 U.S. 822, 834, 123 S.Ct. 1965, 155 L.Ed.2d 1034 (2003); Ray v. Sun Life & Health Ins. Co., 443 Fed.Appx. 529, 533 (11th Cir.2011) ("No special weight is to be accorded the opinion of a treating physician."). The administrator also has no burden of explanation when it credits reliable evidence that conflicts with a treating physician's evaluation. Nord, 538 U.S. at 834, 123 S.Ct. 1965. The independent consulting physicians concluded that Plaintiff was capable of working twenty-five hours per week. "It is well-settled law that individuals capable of performing sedentary-to-light work are not totally disabled" under an `any occupation' ERISA policy." Richey v. Hartford Life & Accident Ins. Co., 608 F.Supp.2d 1306, 1311 (M.D.Fla.2009) (citation omitted). It is Plaintiff's burden to establish her disability. It is the opinion of the Court that she has not.
Plaintiff argues that she may need to take rest breaks such that she could not engage in part-time employment for twenty-five
Plaintiff argues that the Plan's requirement that she provide proof of her disability through "significant objective findings" is ambiguous. As discussed above, determinations of a disability require "significant objective findings," which are defined as "signs which are noted on a test or medical exam and which are considered significant anatomical, physiological or psychological abnormalities which can be observed apart from the individual's symptoms." The Plan further defines "total disability" as "the complete inability...because of a medically-determinable physical or functional impairment...to engage in any compensable employment for twenty-five hours per week." Defendants point out that many courts in this Circuit have dealt with the "significant objective findings" standard and have not found it to be ambiguous. See, e.g., Oliver v. Aetna Life Ins. Co., 613 Fed.Appx. 892 (11th Cir.2015); Jones v. Federal Exp. Corp., 984 F.Supp.2d 1271, 1277 (M.D.Fla.2013) (agreeing with the administrator that the plaintiff failed to meet the Plan's decision of Total Disability as the plaintiff's pain was unsubstantiated by significant objective findings). It is the Court's determination that the Plan's requirement that Plaintiff provide proof of a Total Disability through significant objective findings is not ambiguous. Plaintiff has failed to provide such proof.
Plaintiff also appears to argue that the Plan cannot condition an award on the existence of significant anatomical physiological abnormalities because doing so is arbitrary and capricious. Dkt. 45 at 5. The Plan requires that a disability be "substantiated by significant objective findings which are defined as signs which are noted on a test or medical exam and which are considered significant anatomical, physiological or psychological abnormalities which can be observed apart from the individual's symptoms." (emphasis removed). In response, Defendants point to the court's discussion in Brucks v. Coca-Cola Co., 391 F.Supp.2d 1193, 1205 (N.D.Ga.2005), wherein the court explained the need for a plan to require objective evidence of the impact of a diagnosed disease, illness, or other condition as being "logical and necessary." The court stated:
Id. The Court agrees with this analysis and finds that Plaintiff's argument is not supported by the law. Requiring the existence of "significant anatomical, physiological or psychological abnormalities which can be observed apart from the individual's symptoms" is not contrary to the law.
Finally, Plaintiff challenges the denial of LTD benefits for the time period from April 1, 2014 through April 5, 2014. While Plaintiff was unable to work during this time, as discussed above, Plaintiff was not an Eligible Employee under the Plan. During that time, Plaintiff was on unapproved leave and was therefore not an Eligible Employee. Aetna does not have to insure claimants under the Plan if they are not entitled to such benefits. In this case, Plaintiff was not eligible to receive benefits from April 1, 2014 to April 5, 2014. Aetna's denial of benefits for that time period was not de novo wrong.
Under the Eleventh Circuit's six-step analysis, a finding that the claim administrator's decision was not de novo wrong ends the analysis in favor of the claim administrator. Based on the information available to the administrator at the time Plaintiff's request for LTD benefits was denied, the Court finds that Aetna's decision to deny LTD benefits was not de novo wrong. This finding ends the Court's analysis in favor of Defendants.
Although it is not necessary to address Plaintiff's argument that there was a conflict of interest since the Court finds that the administrator's decision was not de novo wrong, the Court will nonetheless address Plaintiff's argument. Despite Plaintiff's attempt to argue otherwise, there is no conflict of interest. As stated above, the Plan gives Aetna, as the Claims Paying Administrator, "sole and exclusive discretion...with respect to all matters...relating to the eligibility of a claimant for benefits under the Plain." Dkt. 24-10 at 3.
This Court discussed the conflict of interest issue with respect to the FedEx LTD Plan in Braden v. Aetna Life Ins. Co., No. 8:13-cv-535-T-30EAJ, 2013 WL 6086460 (M.D.Fla. Nov. 19, 2013), aff'd, 597 Fed.Appx. 562 (11th Cir.2014). There, the Court stated:
Id. at *6. Moreover, it is not the defendant's burden to prove that its decision was not tainted by self-interest, rather, it is the plaintiff's burden to show the decision was arbitrary or wrong. Doyle v. Liberty Life Assurance Co. of Boston, 542 F.3d 1352, 1360 (11th Cir.2008). Here, Plaintiff has failed to show that the decision was wrong and there is no conflict of interest.
Accordingly, it is
