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Mark v. Aetna Life Insurance Co.

United States District Court, D. Colorado

April 25, 2018

JULIA MARK, Plaintiff,
v.
AETNA LIFE INSURANCE COMPANY and FEDEX OFFICE AND PRINT SERVICES, INC., Defendant.

          REPORT AND RECOMMENDATION ON THE PARTIES' JOINT MOTION FOR DETERMINATION (DOCKET NO. 38)

          Michael J. Watanabe, United States Magistrate Judge.

         This case is before the Court on Plaintiff Julia Mark's (“Mark”) Complaint (Docket No. 1) to recover short term disability (“STD”) benefits under section 29 U.S.C. § 1132(a)(1)(B) of the Employee Retirement Income Security Act of 1974 (“ERISA”), 29 U.S.C. §§ 1001, et seq. Judge William J. Martinez referred the parties' Joint Motion for Determination (Docket No. 38) to the undersigned Magistrate Judge for a recommended disposition. (Docket No. 34.) The Court has reviewed the Administrative Record (“AR”) (Docket No. 25), Mark's Opening Brief (Docket No. 29), Defendants Aetna Life Insurance Company (“Aetna”) and FedEx Office and Print Services, Inc.'s (“FedEx Office”) (collectively “Defendants”) Response Brief (Docket No. 33), and Mark's Reply Brief. (Docket No. 37.) The Court has taken judicial notice of the Court's file, and considered the applicable Federal Rules of Civil Procedure and case law. The Court now being fully informed makes the following findings of fact, conclusions of law, and recommendation.

         I. BACKGROUND

         a. Procedural History

         Mark was employed by FedEx Office and sought medical benefits under the FedEx Office and Print Services, Inc. Short Term Disability Plan (the “Plan”). The Plan is self-funded by FedEx Office. (AR 8.) Aetna acts as the Claims Administrator under the Plan. (AR 4.) FedEx Office has delegated to Aetna the authority “to interpret the Plan's provisions in its sole and exclusive discretion in accordance with its terms with respect to matters properly brought before it . . . including, but not limited to, matters relating to the eligibility of a claimant for benefits under the Plan.” (AR 31.) Aetna's determination “shall be final, subject only to a determination by a court of competent jurisdiction that the Claims Administrator's decision was arbitrary and capricious.” (AR 32.)

         Mark sustained injuries to her mid-back, neck, right ankle, and, most significantly, left knee when she fell on a sidewalk. (AR 397.)[1] She was placed on leave and her last day of work was March 10, 2016. (AR 200.) As a production specialist, Mark's job duties included processing large orders, operating and maintaining equipment, and providing customer service. (AR 223.) The job functions required the ability to stand the entire shift, move and lift 55 pounds, and consistently bend/twist at the waist and knees. (Id.)[2]Given her injuries and her job requirements, Mark filed a claim for STD benefits on May 24, 2016. (AR 200-01, 782-85.) On May 31, 2016, Aetna determined Mark was disabled under the Plan and approved STD benefits from March 11, 2016 through May 26, 2016. (AR 230-31.)

         On June 8, 2016, Aetna informed Mark it was no longer approving her STD benefits as of May 27, 2016 because it determined “that there are insufficient clinical exam findings to support your inability to perform essential functions of your own occupation.” (AR 245-46.) Thereafter, Aetna requested, and Mark supplied, additional medical records, including physical therapy notes. Aetna also requested “diagnostic test results” and “supporting clinical information” from Mark and her treating physician. Mark eventually appealed the denial of STD benefits on August 30, 2016. (AR 312-47.) Aetna denied her appeal on November 16, 2016, again finding that “there are no significant objective findings to substantiate that a functional impairment exists that would render you unable to perform your heavy job duties as a Production Specialist effective 05/27/16.” (AR 391-92.) Mark then filed the Complaint at issue on February 17, 2017. (Docket No. 1.)

         b. The Relevant Plan Provisions

         There are essentially two Plan provisions at issue here. First, the Plan provides that “Disability or Disabled”

shall mean a sickness, illness, or injury that (1) limits a Covered Team Member from performing the material and substantial duties of his or her regular occupation due to the sickness, illness, or injury; and (2) results in the Covered Team Member having a 20% or more loss in Weekly Earnings due to the same sickness, illness, or injury. A Covered Team Member's regular occupation is the occupation that the Covered Team Member routinely performed at the time the Covered Team Member's Disability began. However, a Covered Team Member shall not be deemed to be Disabled or under a Disability unless the Team Member is, during the entire period of Disability, under the direct regular care and treatment of a Practitioner and such Disability is 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. A Covered Team Member will be required to provide proof of continuing Disability within 30 days of any request by the Claims Administrator or Disability Benefits will be terminated. In the absence of significant objective findings, conflicts with managers, shifts and/or work place setting will not be factors supporting disability under the Plan.

(AR 5-6.)

         Second, the “Proof of Disability” provision states:

No benefits shall be paid under the Plan unless and until the Claims Administrator has received the Covered Team Member's application for benefits and information sufficient for the Claims Administrator to determine pursuant to the terms of the Plan that a Disability exists. Such information may, as the Claims Administrator shall determine, consist of a certification from the Team Member's attending Practitioner in the form prescribed by the Claims Administrator, information in the form of personal references, narrative reports, pathology reports, x-rays and any other medical records or other ...

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