Webber v. Aetna Life Insurance Co.
375 F. Supp. 2d 663 (E.D. Tenn. 2005).
In this case, the plaintiff worked as a sales agent for Cendant. Prior to his employment, he was diagnosed with HIV and received treatments for this condition since at least February 2000. In 2001 plaintiff suffered an acute asthma attack and applied for STD. His treating physician, Dr. Kemp stated that he could not return to work at this point due to his fatigue, decreased endurance and concentration. Dr. Kemp then submitted a second APS further describing the plaintiff’s condition, explaining that he suffered from fatigue, adenopathy, lipodystrophy, gland swelling, neuropathy and asthma. He opined that the plaintiff could not perform any tasks that need stamina, concentration, prolonged sitting or standing and concluded that the plaintiff could not work. In November 2001 the plaintiff was diagnosed with avascular necrosis (AVN) in his hips, which is the death of bone tissue due to a lack of blood supply that can lead to breaks in the bone and the eventual bone collapse. The plaintiff reported that his hip problem inhibited his movement and tired him out because it took so much effort to walk and avoid hip pain. His doctor stated he was unable to work due to severe physical limitations.
Aetna reviewed his claim for LTD and denied it, pointing to a pre-existing condition exclusion. Plaintiff requested a review of this decision. Plaintiff did not deny that his HIV was pre-existing; however, he later developed asthma, a swollen gland condition and AVN. He asserted that his asthma and AVN were not related to his HIV. His doctor, Dr. Kemp, supported this. Aetna’s doctors reviewed the file and agreed that his asthma was not related to his HIV. However, Aetna’s doctor concluded that his AVN could be a result of HIV as one of the known complications of HIV medication is AVN. Based on their doctors’ opinions, Aetna denied LTD again.
After this denial the plaintiff went on to have a total hip replacement of both hips; however, Aetna’s doctor concluded that he was not necessarily significantly impaired from performing sedentary (his own occupations) activities. She also stated that there was no evidence that his AVN was pre-existing or related to his HIV. Aetna denied LTD again based on her opinion that the plaintiff was not totally disabled from performing his own occupation.
The plaintiff argued that Aetna’s decision to deny his benefits was arbitrary and capricious. The court determined that there were three issues in this case: (1) whether Aetna’s application of the Active Work Rule to exclude plaintiff from being covered was arbitrary and capricious; (2) whether Aetna’s determination that the plaintiff’s AVN was pre-existing was arbitrary and capricious; and (3) whether Aetna’s determination that the plaintiff’s AVN was not disabling was arbitrary and capricious.
First, the plaintiff stated that Aetna’s denial of his LTD benefits based on the Active Work Rule was arbitrary and capricious. The plan contained an Active Work Rule, which stated that coverage for illness or injury would not take effect until the employee return to full-time work. Here, plaintiff left work due to asthma but then developed AVN. Aetna argued that since the plaintiff left work because of asthma and then developed AVN without returning to work, plaintiff was excluded from coverage under the Active Work Rule. The court concluded that the Active Work Rule spoke in terms of coverage under the plan, not in terms of coverage for a particular disability. Thus, since the Plaintiff was eligible for benefits when he first became disabled, the court concluded that it was not reasonable to use the Active Work Rule to deny his coverage for AVN.
Second, the plaintiff asserted that Aetna’s denial based on treating his AVN as a pre-existing condition was also arbitrary and capricious. Only one physician ever noted that his AVN could be related to his HIV. Four other medical opinions in the record concluded the opposite, that his AVN was not a preexisting condition. The opinions of two of the plaintiff’s doctors, Dr. Strader and Dr. Kemp, both stated that the AVN was not related to the plaintiff’s HIV. Aetna’s DMA came to the same conclusion that the plaintiff’s AVN was not caused by a preexisting condition . Finally, the opinion of one of Aetna’s own file reviewer, Dr. Hopkins, concluded that there was no evidence the plaintiff’s AVN was pre-existing or related to his HIV. Despite these four opinions, Aetna chose to rely on one file reviewer who concluded that plaintiff’s AVN was a pre-existing condition. Aetna is not required to give special deference to the plaintiff’s treating physician; however, Aetna may not arbitrarily rely on one of its own consultants in the face of all other contrary evidence. See Spangler v. Lockheed Martin Energy Sys., Inc., 313 F.3d 356, 362 (6th Cir. 2002)(insurance company acted arbitrarily in relying on one report from physician instead of entire file); Williams v. International Paper Co., 227 F.3d 706, 713 (6th Cir. 200)(administrators decision not to consider all of the medical evidence was arbitrary and capricious). Thus, the court concluded that Aetna’s conclusion that plaintiff’s AVN was preexisting was nor reasonable based on all the evidence.
Finally, one of Aetna’s doctors, Dr. Hopkins, concluded that the plaintiff would not necessarily been impaired from sedentary duties due to his AVN. Aetna based its denial on this doctor’s opinion. However, several other doctors, Dr. Kemp, the DMA reviewer, and Dr. Taiwo all agreed that plaintiff would not be able to work as a result of his AVN. In fact, the record was full of evidence from these three that the plaintiff suffered from significant pain and physical limitations. His condition was so severe that the plaintiff had to undergo two hip surgeries and rehabilitation. In light of the evidence provided in the record regarding his pain, physical limitations, surgery and rehabilitation, the court found it hard to understand why Aetna would accept Dr. Hopkins opinion over all this contrary evidence. Thus, the court found Aetna’s conclusion that the plaintiff’s AVN was not disabling was arbitrary and capricious.