UNITED STATES DISTRICT COURT 

EASTERN DISTRICT OF MICHIGAN 

SOUTHERN DIVISION 

Miguel Mendez, 

Plaintiff, 

v. 

FedEx Express and AETNA, 

Defendants. 

________________________________/

Case No. 15-cv-12301 

Judith E. Levy 

United States District Judge 

Mag. Judge Anthony P. Patti 

OPINION AND ORDER GRANTING PLAINTIFF’S MOTION FOR 

SUMMARY JUDGMENT [17], DENYING DEFENDANTS’ 

MOTION FOR SUMMARY JUDGMENT [20], AND ORDERING 

ADDITIONAL BRIEFING 

Miguel Mendez sued FedEx Express and Aetna, alleging that they 

denied his claim for long-term disability benefits in violation of the 

Employee Retirement Income Security Act of 1974. Because Mendez 

was denied benefits to which he is clearly entitled, Mendez’s motion for 

summary judgment is granted, FedEx Express’s and Aetna’s motion for 

summary judgment is denied, and additional briefing is ordered 

regarding back-due benefits, applicable interest, and any other costs 

and fees that are appropriate. 

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I. Background 

Plaintiff Miguel Mendez worked as a delivery driver for defendant 

FedEx Express for approximately twenty-eight years until an autoaccident in July 2012. Mendez was covered by FedEx Express’s longterm disability plan, which is governed by ERISA. Defendant Aetna 

was the claims paying administrator of FedEx Express’s plan, which 

provided Aetna with “sole and exclusive discretion . . . with respect to 

all matters . . . relating to the eligibility of a claimant for benefits under 

the Plan.” (Dkt. 19-5 at 4-5.) 

On July 14, 2012, Mendez collided with an oncoming truck while 

riding a motorcycle, causing severe orthopedic injuries (for example, a 

crushed comminuted fracture, or splintering, of his pelvis) and mild 

traumatic brain injury (“TBI”). (See Dkt. 19-3 at 327.) Aetna paid 

Mendez short-term disability benefits from July 23, 2012, to January 

20, 2013, when he began receiving long-term disability benefits under 

the Plan’s Occupational Disability definition, based on his inability to 

work in his previous position. (See Dkt. 19-2 at 2.) Aetna paid Mendez 

long-term Occupational Disability benefits for the full available time 

period, two years, from January 21, 2013, to January 20, 2015. (See id.) 

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During that time, the Plan also required Mendez to apply for Social 

Security Disability Income (“SSDI”). (See Dkt. 19-4 at 103.) Mendez 

applied, and in May 2013, the Social Security Administration 

determined that Mendez was totally disabled and awarded him SSDI. 

(Dkt. 19-3 at 124.) 

In July 2014, Aetna informed Mendez that “in order to receive 

more than [the] 24 months of LTD benefits” available for an 

Occupational Disability, he was required to “meet the definition of Total 

Disability.” (See Dkt. 19-2 at 4.) Under the Plan, a Total Disability is 

“the complete inability . . . , because of a medically-determinable 

physical or functional impairment (other than an impairment caused by 

a mental or nervous condition or a Chemical Dependency), to engage in 

any compensable employment for twenty-five hours per week.” (Dkt. 

19-5 at 42; see Dkt. 19-1 at 2.) 

Mendez submitted medical records regarding the treatment he 

received shortly after his accident, when he underwent two significant 

orthopedic surgeries in a matter of days. On July 16, 2012, Dr. Alfred 

Faulkner, D.O., performed the following procedures for Mendez’s 

multiple comminuted fractures: “[c]losed reduction and application of 

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distal femoral traction pin to the right femur,” “[c]losed reduction of 

bilateral superior and inferior pubic rami fractures with application of 

anterior pelvic external fixator,” “[i]liosacral screw fixation of right 

vertical shear pelvic injury,” and “[l]eft iliosacral screw placement for 

____ posterior left pelvis.” (Dkt. 19-2 at 120-21.) On July 19, 2012, Dr. 

Faulkner performed the following additional procedures on Mendez: 

“[o]pen reduction and internal fixation of right anterior column 

acetabulum fracture,” “[o]pen reduction and internal fixation of pubic 

symphyseal disruption,” and “[o]pen reduction and internal fixation of 

left superior and inferior pubic rami fracture.” (Id. at 132-33.) 

Mendez also submitted medical records regarding his longer-term 

treatment at the TBI unit at Oakwood Heritage in Taylor, where he 

was in residential rehabilitation from July 23, 2012, until August 15, 

2012, (see id. at 134-35), when he was transferred to Special Tree, 

another nursing and rehabilitation center. (See id. at 154-84.) On 

December 12, 2012, Dr. Adam Pourch, D.O., and Dr. Jay Methaler, 

M.D., diagnosed Mendez with a TBI. (Id. at 182-84; see also id. at 201 

(“University Physician Group 2/6/2013 . . . . TBI injury with poly 

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trauma.”).) He was released from rehabilitation at Special Tree on 

December 15, 2012. 

Aetna submitted only some of Mendez’s medical records to Dr. 

Martin Mendelssohn, a retired orthopedic surgeon, for a file review. 

(See Dkt. 19-3 at 105-07.) Aetna did not request an in-person 

examination of Mendez. Dr. Mendelssohn concluded that there were 

insufficient objective findings that Mendez could not work at least 

twenty-five hours per week (id. at 107), so Aetna denied Mendez’s longterm Total Disability claim. (Dkt. 19-2 at 4.) Aetna did not address the 

Social Security Administration’s decision to grant Mendez disability 

benefits, even though Aetna had been offsetting Mendez’s Occupational 

Disability benefits since he had begun receiving SSDI. 

Mendez appealed the decision to the Aetna Appeal Review 

Committee. Aetna again submitted Mendez’s medical and other records 

to physicians for a file review, but still did not request an in-person 

examination. (Dkt. 19-3 at 108-17.) Dr. James Wallquist, an orthopedic 

surgeon, concluded that there was insufficient objective medical 

evidence to show that Mendez could not work at least twenty-five hours 

per week. (Id. at 110-12.) Dr. John P. Shallcross, a neuropsychologist, 

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concluded the same, finding that there was no documentation of 

Mendez’s “mental and nervous condition from 5/3/13 forward,” and “no 

assessment of [Mendez]’s psychiatric state sufficient to diagnose an 

Adjustment Disorder.” (Id. at 115-17.) Thus, in March 2015, the 

Review Committee upheld the denial of Mendez’s Total Disability claim. 

(Dkt. 19-1 at 2-4.) 

The Review Committee addressed the Social Security 

Administration’s award of SSDI as follows: 

The Committee noted your client has received a disability 

determination from the Social Security Administration. 

However, the criteria utilized by the Social Security 

Administration for the determination of Social Security 

disability awards are different from the definition for Total 

Disability set forth in the Plan, and that [sic] the Committee 

has a duty to follow the terms of the Plan. 

It is recognized your client was awarded Social Security 

Disability Benefits in May 2013; however Aetna has received 

more recent documentation from your client’s providers 

which we have taken into consideration in making our 

determination. 

(Id. at 4.) 

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II. Standard 

Summary judgment in an ERISA case requires the Court to 

conduct “a de novo review based solely upon the administrative record, 

and render findings of fact and conclusions of law accordingly.” Wilkins 

v. Baptist Healthcare System, Inc., 150 F.3d 609, 619 (6th Cir. 1998) 

(“Because this court’s precedents preclude an ERISA action from being 

heard by the district court as a regular bench trial, it makes little sense 

to deal with such an action by engaging a procedure designed solely to 

determine whether there is a genuine issue for trial.”). Here, however, 

the review is whether the plan administrator’s decision was arbitrary 

and capricious, because the administrator had “discretionary authority 

to determine eligibility for benefits or to construe the terms of the plan.” 

Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989). 

Under the arbitrary and capricious standard, this Court upholds 

the administrator’s decision “if it is the result of a deliberate, principled 

reasoning process and if it is supported by substantial evidence.” Glenn 

v. MetLife, 461 F.3d 660, 666 (6th Cir. 2006) (internal quotation marks 

omitted). The Court considers the quality and quantity of the medical 

evidence; the existence of any conflicts of interest; whether the 

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administrator considered any disability finding by the Social Security 

Administration; and whether the administrator contracted with 

physicians to conduct a file review as opposed to a physical examination 

of the claimant. Bennett v. Kemper Nat’l Servs., Inc., 514 F.3d 547, 552-

53 (6th Cir. 2008); see Fura v. Fed. Express Corp. Long Term Disability 

Plan, 534 F. App’x 340, 342 (6th Cir. 2013). 

III. Analysis 

The Aetna Appeal Review Committee affirmed the initial decision 

to deny Mendez’s claim for long-term disability benefits under the Total 

Disability definition of the Plan. Several issues during the process 

show that Aetna’s decision was arbitrary and capricious. 

First, Aetna conducted no in-person evaluation at any level, 

instead relying on file reviews. “[T]here is nothing inherently improper 

with relying on a file review, even one that disagrees with 

the conclusions of a treating physician.” Calvert v. Firstar Fin. Inc., 409 

F.3d 286, 297 n.6 (6th Cir. 2005). But the Sixth Circuit has held that 

“the failure to conduct a physical examination, whe[n] the Plan 

document gave the plan administrator the right to do so, ‘raise[s] 

questions about the thoroughness and accuracy of the benefits 

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determination.’” Shaw v. AT&T Umbrella Benefit Plan No. 1, 795 F.3d 

538, 550 (6th Cir. 2015) (quoting Helfman v. GE Grp. Life Assurance 

Co., 573 F.3d 383, 393 (6th Cir. 2009)). This is especially troubling 

given that the physicians Aetna hired to conduct a file review here 

noted and then disregarded the extensive complaints of severe pain 

recognized by Mendez’s treating physicians. (Dkt. 19-3 at 106, 111-12); 

see Shaw, 795 F.3d at 550 (quoting Judge v. Metro. Life Ins. Co., 710 

F.3d 651, 663 (6th Cir. 2013)). 

This included evidence from a September 11, 2014 visit with 

Natasha Smith in physical medicine and rehabilitation at Wayne State 

University Physician Group, when Mendez “reported chronic daily pain 

in the pelvis, right leg[,] and shoulders”; “numbness over the left lateral 

femoral cutaneous and . . . continued . . . pain in the right and left 

groin”; “tenderness to palpation over the bilateral sacroiliac (SI) joints 

and right acromioclavicular (AC) joint”; and “decreased sensation in 

both lower extremities at L5-S1 and in bilateral lateral femoral 

cutaneous nerves.” (Dkt. 19-1 at 3.) And at a December 18, 2014 visit 

with Dr. Jay Maythaler, for “follow up of traumatic brain injury, neck 

pain, back pain, headaches, leg pain[,] and pelvic pain,” Mendez 

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reported “increased chronic daily pain in the pelvis, right leg[,] and 

shoulders,” “frequent muscle spasms in his back that lasted for several 

days,” and “burning pain in his left thigh.” (Id.) 

Remarkably, without having conducted an in-person medical 

evaluation, the Review Committee notes the objective medical evidence 

that Mendez “has sustained a fractured pelvis, acetabular fractures, is 

status post open reduction and internal fixation, has a diagnosis of 

traumatic brain injury and late effects of traumatic brain injury, right 

AC joint separation, left first rib fracture, neuropathic pain of the 

bilateral lower extremities, chronic back pain and insomnia,” yet 

concludes that “there are no significant objective findings to support an 

inability to perform a sedentary job for a minimum of twenty five hours 

per week.” (Id. at 4; see, e.g., Dkt. 19-3 at 111(Dr. Wallquist noting an 

MRI that “apparently revealed the L5 area was ‘compromised’”)). 

And in any case, Aetna could not ignore Mendez’s extensive 

complaints of pain, even if they were “subjective.” “Complaints of pain 

necessarily are subjective as they are specific to the patient and are 

reported by the patient.” James v. Liberty Life Assurance Co., 582 F. 

App’x 581, 589 (6th Cir. 2014). Implicit in the Review Committee’s 

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decision is a determination that Mendez’s subjective complaints of 

severe pain lacked credibility. But “without ever examining [Mendez], 

the Plan should not have made a credibility determination about [hi]s 

continuous reports of pain.” See Shaw, 795 F.3d at 550; see, e.g., 

Godmar v. Hewlett-Packard Co., 631 F. App’x 397, 407 (6th Cir. 2015) 

(“[The administrator] decided that [plaintiff]’s pain was subjective 

without examining him, and that failure weighs in favor of a 

determination that the denial of his claim was arbitrary and 

capricious.”). 

Second, and relatedly, Aetna’s reviewing physicians were repeat 

players that have a material, if not necessarily disabling, conflict of 

interest. “[P]hysicians repeatedly retained by benefits plans may have 

an incentive to make a finding of ‘not disabled’ in order to save their 

employers money and to preserve their own consulting arrangement.” 

Shaw, 795 F.3d at 550-51 (quoting Elliott v. Metro. Life Ins. Co., 473 

F.3d 613, 620 (6th Cir. 2006)). Dr. Martin Mendelssohn,1 Dr. James 

 

1 See, e.g., Mendelblatt v. Aetna Life Ins. Co., No. 14-cv-12140, 2016 U.S. Dist. 

LEXIS 21400, at *24-25 (E.D. Mich. Feb. 22, 2016); Morris v. Am. Elec. Power Sys. 

Long-Term Disability Plan, No. 2:07-cv-183, 2008 U.S. Dist. LEXIS 82829, at *30-31 

(S.D. Ohio Sep. 30, 2008); Cox v. UPS Health & Welfare Package, No. 1:06-cv-401, 

2007 U.S. Dist. LEXIS 69316, at *5-6 (S.D. Ohio Sep. 19, 2007); Davis v. Broadspire 

Servs., No. 04-CV-74792-DT, 2006 U.S. Dist. LEXIS 72018, at *21-23 (E.D. Mich. 

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Wallquist,2 and Dr. John P. Shallcross3 are all repeat players among 

ERISA benefit plan administrators. This does not automatically render 

Aetna’s decision arbitrary and capricious, but it is a factor that weighs 

against Aetna. See Bennett, 514 F.3d at 552-53. 

Third, Aetna did not adequately explain why the Social Security 

Administration’s decision to award Mendez SSDI benefits should be 

distinguished. As noted above, the first-level reviewer did not mention 

the Social Security Administration’s decision. And when it was 

addressed by the Review Committee on appeal, Aetna provided only 

conclusory observations that “the criteria utilized by the Social Security 

Administration for the determination of Social Security disability 

 

Mar. 23, 2006); Stano v. Lumbermens Mut. Cas. Co., No. 06-CV-10842-DT, 2007 

U.S. Dist. LEXIS 3535, at *9 (E.D. Mich. Jan. 18, 2007); Jones-Stott v. Kemper 

Lumbermans Mut. Cas. Co., No. 04-CV-40263-FL, 2007 U.S. Dist. LEXIS 15294, at 

*11-12 (E.D. Mich. Jan. 12, 2007). 

2 See, e.g., Fura v. Fed. Express Corp. Long Term Disability Plan, 534 F. App’x 340, 

341 (6th Cir. 2013) (holding that reliance on Dr. Wallquist file review, among 

others, arbitrary and capricious in light of records from treating physicians); 

Shedrick v. Marriott Int’l, Inc., No. 11-820, 2012 U.S. Dist. LEXIS 22635, at *13-14 

(E.D. La. Feb. 22, 2012; Wooden v. Alcoa, Inc., No. 3:11 CV 525, 2012 U.S. Dist. 

LEXIS 11407, at *5 (N.D. Ohio Jan. 31, 2012); Harper v. Aetna Life Ins. Co., No. 10-

1459, 2011 U.S. Dist. LEXIS 34848, at *7 (E.D. Pa. Mar. 31, 2011); Farler v. Henry 

Ford Health Sys., No. 04-74368, 2005 U.S. Dist. LEXIS 13313, at *20 n.10 (E.D. 

Mich. July 5, 2005); Hufford v. Harris Corp., 322 F. Supp. 2d 1345, 1351-52 (M.D. 

Fla. 2004). 

3 See, e.g., Gardner v. Metro. Life Ins. Co., 8 F. Supp. 3d 677, 683 (E.D. Pa. 2014); 

Kushner v. Lehigh Cement Co., 572 F. Supp. 2d 1182, 1186 (C.D. Cal. 2008); Moore 

v. Can. Life Assur. Co., No. 1:02-cv-102, 2003 U.S. Dist. LEXIS 14069, at *4-5 (E.D. 

Tenn. May 16, 2003); Gough v. Metro. Life Ins. Co., No. 3:03-0158, 2003 U.S. Dist. 

LEXIS 25252, at *18-19 (M.D. Tenn. Nov. 21, 2003). 

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awards are different from the definition for Total Disability set forth in 

the Plan,” and “more recent documentation from [Mendez]’s providers 

[were] taken into consideration.” 

Aetna’s discussion of the Social Security Administration decision 

is not sufficient to meet the requirement that the administrator’s 

decision be supported by substantial evidence and “the result of a 

deliberate, principled reasoning process.” Glenn, 461 F.3d at 666. The 

Review Committee should have explained why a different 

determination should result from the difference in the disability 

definitions or the “more recent” documentation. Bennett, 514 F.3d at 

554 (“[I]f the plan administrator (1) encourages the applicant to apply 

for Social Security disability payments; (2) financially benefits from the 

applicant’s receipt of Social Security; and then (3) fails to explain why it 

is taking a position different from the SSA on the question of disability, 

the reviewing court should weigh this in favor of a finding that the 

decision was arbitrary or capricious.”) (emphasis added). 

“A casual mention of a disability determination is insufficient to 

constitute an ‘explanation’ in accordance with Bennett.” Wooden v. 

Alcoa, Inc., 511 F. App’x 477, 484 (6th Cir. 2013) (noting there, like 

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here, the Plan required LTD applicants to apply for SSDI and benefited 

financially because of the offset). Aetna’s “cavalier treatment of 

[Mendez]’s SSA determination weighs in favor of finding [Aetna]’s 

denial of benefits to be arbitrary and capricious.” See id. at 485. 

The Aetna Appeal Review Committee did not conduct an in-person 

medical examination of Mendez. Rather, the Review Committee relied 

on file reviewers who are repeat hires among ERISA plan 

administrators to discount extensive medical documentation of chronic 

pain, among other ailments, from Mendez’s treating physicians. And 

the Review Committee did not explain why the difference in the 

disability definitions or the “more recent” medical documentation 

should result in different disability determinations. For these reasons, 

the Review Committee’s decision to deny Mendez’s claim for long-term 

disability benefits under the Total Disability definition was arbitrary 

and capricious. 

When “the problem is with the integrity of the plan’s decisionmaking process, rather than that a claimant was denied benefits to 

which he was clearly entitled, the appropriate remedy generally is 

remand to the plan administrator.” Shaw, 795 F.3d at 551. But when 

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remand “would be a useless formality,” i.e., when the objective medical 

evidence clearly establishes that the claimant “was denied benefits to 

which he is entitled,” the Court may “award[] benefits without 

remanding.” Id. at 551-52. 

As noted by the Review Committee, Mendez was treated as late as 

December 2014 for “traumatic brain injury, neck pain, back pain, 

headaches, leg pain[,] and pelvic pain.” (Dkt. 19-1 at 3.) An “MRI of his 

back” had revealed that his “L5 is ‘compromised.’” (Dkt. 19-2 at 170; 

Dkt. 19-3 at 111.) His treating physician noted that he “clearly cannot 

stand for more than [thirty] minutes or sit more than [one] hour,” “had 

severe derangement of the pelvic musculature, hip joints[,] and sacral 

iliac joints,” suffers from a “TBI,” has “balance problems, walks with 

assistive devices,” and “has limited ambulation endurance.” (Dkt. 19-2 

at 212; see Dkt. 19-1 at 3.) He is on Percocet for “frequent muscle 

spasms in his back that last for several days.” (Dkt. 19-2 at 210; see 

Dkt. 19-1 at 3.) He is on gabapentin for “burning pain in his left thigh.” 

(Dkt. 19-2 at 210; see Dkt. 19-1 at 3.) He has “[h]ip arthritis,” and 

suffers from “[i]njury of lumbar, sacral[,] and pelvic sympathetic 

nerves.” (Dkt. 19-2 at 210.) 

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In addition to the Percocet and gabapentin noted above, he is also 

on Prilosec, Neurontin, Maxalt, and Ibuprofen for his pain and Robaxim 

for his muscle spasms. (Id. at 212.) The Review Committee itself 

summarizes the objective medical evidence by noting that Mendez “has 

sustained a fractured pelvis, acetabular fractures, is status post open 

reduction and internal fixation, has a diagnosis of traumatic brain 

injury and late effects of traumatic brain injury, right AC joint 

separation, left first rib fracture, neuropathic pain of the bilateral lower 

extremities, chronic back pain[,] and insomnia.” (Dkt. 19-1 at 3.); see 

Koning v. United of Omaha Life Ins. Co., 627 F. App’x 425, 437-38 (6th 

Cir. 2015) (noting that “MRIs, records of [] physical examinations, chart 

notes, lab and other test results, and physician diagnoses, all . . . qualify 

as objective medical evidence”). 

Mendez was denied benefits to which he is clearly entitled. Thus, 

rather than remanding, Aetna is ordered to pay Mendez the long-term 

disability benefits for which he is qualified under the Total Disability 

definition of the Plan. See, e.g., Shaw, 795 F.3d at 551-52 (ordering 

award of benefits rather than remanding when claimant could not sit or 

stand for more than thirty minutes and suffered from back and neck 

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spasms and limited range of motion, among other things) (citing Caesar 

v. Hartford Life & Accident Ins. Co., 464 F. App’x 431, 436 (6th Cir. 

2012); Cooper v. Life Ins. Co. of N. Am., 486 F.3d 157, 171 (6th Cir. 

2007); Brooking v. Hartford Life & Accident Ins. Co., 167 F. App’x 544, 

550 (6th Cir. 2006); Kalish v. Liberty Mut./Liberty Life Assurance Co., 

419 F.3d 501, 512-13 (6th Cir. 2005)). 

IV. Conclusion 

Plaintiff Mendez’s motion for summary judgment (Dkt. 17) is 

GRANTED. Defendants FedEx Express’s and Aetna’s motion for 

summary judgment (Dkt. 20) is DENIED. 

Plaintiff must submit briefing regarding back-due benefits, 

applicable interest, and any other costs and fees that are appropriate by 

September 30, 2016. Defendants may respond within two weeks after 

plaintiff files such brief, and plaintiff may reply to defendants’ response 

within one week if defendants file such response. 

IT IS SO ORDERED. 

Dated: August 22, 2016 s/Judith E. Levy 

Ann Arbor, Michigan JUDITH E. LEVY 

United States District Judge 

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CERTIFICATE OF SERVICE

The undersigned certifies that the foregoing document was served 

upon counsel of record and any unrepresented parties via the Court’s 

ECF System to their respective email or First Class U.S. mail addresses 

disclosed on the Notice of Electronic Filing on August 22, 2016. 

s/Kelly Winslow for 

FELICIA M. MOSES 

Case Manager 

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