United States District Court, D. Colorado
ORDER ON ADMINISTRATIVE RECORD
MARCIA S. KRIEGER, Chief District Judge.
THIS MATTER comes before the Court upon review of the denial by Aetna Life Insurance Company ("Aetna"), acting as Claims Administrator for the Defendant, of long-term disability benefits to the Plaintiff under an insurance plan governed by the Employment Retirement Income Security Act of 1974, 28 U.S.C. § 1001, et seq. ("ERISA"). The parties filed an Administrative Record (# 21). The Plaintiff ("Ms. Campbell") moved for judgment on the Administrative Record (# 39), reflecting the parties' agreement that the matter should be determined on the briefs (# 30, 38, 43).
The Court has jurisdiction pursuant to 29 U.S.C. § 1132, which allows a participant in an ERISA plan to bring suit to enforce the participant's rights or to recover benefits due to the participant under the terms of the plan.
The Court briefly sketches the relevant facts here, elaborating as necessary in its analysis. Ms. Campbell worked at Ball Aerospace and Technologies Corporation ("Ball") from 1994-2002. From 1998-2002, Ms. Campbell served as an Operations Analyst. During her employment, she was covered by a long-term disability policy. In May 2002, Ms. Campbell left employment and began to receive long-term disability benefits from the Defendant because of recurring cluster migraine headaches. The Social Security Administration also determined that she was entitled to monthly disability benefits. Aetna has served as the Defendant's independent Claims Administrator since 2009.
Aetna conducts periodic reviews of claimants receiving ongoing disability benefits and in 2011, it had Dr. Janice Miller, a neurologist, conduct a medical examination of Ms. Campbell. On Aetna's Capabilities and Limitations Worksheet, Dr. Miller marked that Ms. Campbell was capable of sitting for up to five hours of a workday, and that she had similar limitations regarding her ability to do fine manipulation. Dr. Miller also marked that Ms. Campbell could lift up to five pounds for up to five hours per day, and up to ten pounds "occasionally." The documents that Aetna sent to Dr. Miller defined a "Sedentary" occupation in terms of the claimant's "Strength Level, " only requiring "occasional" lifting of one to ten pounds. Dr. Miller wrote that "I am not seeing any objective evidence that [Ms. Campbell] would not be able to work in a relatively sedentary position as she has."
Effective July 1, 2012, a Disability Benefits Manager employed by Aetna terminated Ms. Campbell's claim for disability benefits. Aetna's denial letter to Ms. Campbell stated that her plan "defines total disability" as the inability to perform her own occupation and the inability to earn more than eighty percent of her pre-disability earnings. In the initial denial of Ms. Campbell's claim, Aetna stated that it was "terminating" Ms. Campbell's claim for disability benefits effective June 30, 2012, on the basis that she was "not totally disabled from performing [her] own occupation." The letter said that Ms. Campbell was employed by Ball "as an Operations Analyst, " which a Vocational Rehabilitation Consultant had concluded was a "sedentary" occupation according to the Dictionary of Occupational Titles ("DOT"). The letter relied upon Dr. Miller's report, which Aetna construed to conclude that Ms. Campbell could work "an 8 hour day, 40 hour week in a sedentary capacity." The determination was contrary to the assertions of Ms. Campbell's treating physicians, Dr. Joshua Renkin and Dr. Richard Smith.
Following Ms. Campbell's appeal of the termination decision, Dr. Stephen Gerson, specializing in psychiatry, and Dr. Eric Kerstman, specializing in physical medicine and rehabilitation, provided physician reviews at Aetna's request. Dr. Gerson's Physician Review states "we have no data to validate substantial functional impairment on a psychiatric or cognitive basis from 7/1/12 through 11/19/12." Dr. Kerstman's review asserts that "there is clinical evidence to support the claimant's... medical conditions of chronic pain, cervical dystonia, and intractable headaches. However, there is no clinical evidence to support that any of these medical conditions individually or in combination are causing significant impairment, or require restrictions and/or limitations that would preclude the claimant from performing her Sedentary PDL occupation as a Computer Technician." Dr. Kerstman also wrote that there was "no evidence to support" the restrictions that Dr. Miller noted on the Capabilities and Limitations Worksheet concerning Ms. Campbell's ability to work.
An Appeals Specialist employed by Aetna issued a decision affirming the termination of Ms. Campbell's benefits. On appeal, Aetna purported to apply the "plan" that was "in effect at the time of Ms. Campbell's disability commencement, " although the terms of that plan had changed in the interim. The appeal determination defined total disability as: "[Y]ou must be unable to perform any job for which you are reasonably qualified by training, education, or experience." The decision conceded "that Ms. Campbell has chronic pain, chronic and intractable headaches, and dystonia as her primary diagnoses, as well as diagnosed depression, knee pain, neck pain, and positional vertigo as secondary diagnoses." It stated that she had been "employed as a Computer Technician at the time she stopped working, " which it repeatedly referred to as "a sedentary occupation." The decision concluded that none of Ms. Campbell's "diagnoses, alone or in combination, preclude Ms. Campbell from performing her usual job or any job for which she is reasonably qualified by her education, training and experience." Ms. Campbell seeks relief from this determination.
III. Standard of Review
In Metropolitan Life Ins. Co. v. Glenn, 554 U.S. 105, 110-11 (2008), the Supreme Court summarized its prior rulings setting forth the standard of review in suits to recover benefits under an ERISA plan: (i) the court must conduct a de novo review of the determination unless the plan provides to the contrary; (ii) if the plan provides discretionary authority to the Plan Administrator to make eligibility determinations, the court should instead apply a deferential arbitrary and capricious standard of review; and (iii) if the Plan Administrator is operating under a conflict of interest, the nature and extent of that conflict must be "weighed as a factor" in determining whether the Plan Administrator has abused his or her discretion. See Foster v. PPG Indus., Inc., 693 F.3d 1226, 1231-32 (10th Cir. 2012). In addition, pursuant to precedent of the United States Court of Appeals for the Tenth Circuit, certain procedural irregularities may require the Court to apply de novo review. LaAsmar v. Phelps Dodge Corp. Life, Accidental Death & Dismemberment & Dependent Life Ins. Plan, 605 F.3d 789, 796 (10th Cir. 2010).
If a court determines that the arbitrary and capricious standard applies, it will reverse a determination if the Plan Administrator's decision is not supported by substantial evidence in the record, its construction of policy language is unreasonable, or if the determination was made in bad faith. See Graham v. Hartford Life & Acc. Ins. Co., 589 F.3d 1345, 1357 (10th Cir. 2009). Under that standard, a determination does not need to be the best or only logical resolution, but it does need to be reasonably supported by the record. Nance v. Sun Life Assur. Co., 294 F.3d 1263, 1269 (10th Cir. 2002). Review is limited to the materials compiled by the administrator in the course of making its decision - that is, to the Administrative Record. See Cardoza v. United of Omaha Life Ins. Co., 708 F.3d 1196, 1201 (10th Cir. 2013). However, the Court only needs to consider the specific grounds upon which the administrator relied in its administrative denial of benefits. Spradley v. Owens-Ill. Hourly Employees Welfare Ben. Plan, 686 F.3d 1135, 1141 (10th Cir. 2012).
The parties dispute which standard of review the Court should apply. Normally, the Court would resolve this dispute by first looking to the relevant plan documents. The parties, however, also disagree about which plan documents apply. Ms. Campbell asserts the relevant documents were those in place at the time she commenced receiving disability, the Ball Corporation Consolidated Welfare Benefit Plan for Employees, restated as of January 1, 1998, as supplemented by the January 2002 Long-Term Disability Plan for Salaried Employees. The Defendant, by contrast, argues that revised documents apply, the Ball Corporation Consolidated Welfare Benefit Plan for Employees, restated as of January 1, 2003, as supplemented by the January 1, 2011 Long-Term Disability Plan Summary of Benefits for Salaried Employees.
The Court notes that in Ms. Campbell's appeal, Aetna appears to have conceded that Ms. Campbell's disability benefits are controlled by the "plan in effect at the time of Ms. Campbell's disability commencement." The Defendant, therefore, may be estopped from arguing that Ms. Campbell's claim is governed by the newer policy documents. Nonetheless, the Court does not need to decide which plan applies. Under the terms of both plans, the Court finds that Aetna's determination was arbitrary and capricious.
a. Plan ...