Opinion ID: 51197
Heading Depth: 2
Heading Rank: 1

Heading: STD Benefits Claim

Text: In determining whether Aetna was de novo wrong and unreasonable in terminating Helms’s STD benefits, we begin with the plan itself, since an ERISA plan administrator must “discharge his duties with respect to a plan . . . in accordance with the documents and instruments governing the plan insofar as such documents and instruments are consistent with the provisions of [ERISA].” 29 U.S.C. § 1104(a)(1)(D). Under Aetna’s plan section labeled “Medical Proof of Disability,” Helms was required to provide information from his physician that verified and explained the nature and extent of his disability. Helms argues that he has met Aetna’s STD requirements and that not only was Aetna’s procedural handling of his STD claim flawed, but that Aetna’s substantive reasoning for the denial of his STD claim was faulty. For the following reasons, we agree. 16 1. Aetna’s Procedural Handling of Helms’s STD Claim Aetna never subjected the medical evidence provided by Dr. Epperson to peer review, nor did Aetna ever subject Helms to an independent medical exam (“IME”). We have been critical of a nurse’s review when a meaningful review dictated assessment of specialized tests beyond a nurse’s training. See Levinson v. Reliance Standard Life Ins. Co., 245 F.3d 1321, 1326-27 (11th Cir. 2001). Here, while no reviews of specialized tests were necessarily required, the STD benefits hinged on a diagnosis that even Nurse Blackmer admitted was subjective. Aetna was presented with no evidence that suggested that Helms was a malingerer; conversely, the record was replete with numerous office visit notes and narratives from Dr. Epperson expressing worry over Helms’s condition and crediting his complaints of debilitating chronic headaches. In Godfrey v. Bellsouth Telecommunications, Inc., a nurse practitioner never bothered to gather the treating doctor’s notes and test results. 89 F.3d 755, 758-59 (11th Cir. 1996). Here, Aetna’s notes concluded that Aetna should request the office visit notes from both Drs. Thornbury and Epperson. Similar to the facts in Godfrey, Aetna’s records do not reflect that Aetna ever followed through on its notation that it “[was] necessary” to gather all of Dr. Thornbury’s 17 office notes and test results. See id.1 Given the circumstances, Aetna’s reliance on a registered nurse’s review of an admittedly subjective diagnosis without so much as a peer review or an IME was wrong and unreasonable. See Godfrey, 89 F.3d at 758-759 (holding that the record supported the district court’s finding that defendant’s physicians arbitrarily rejected clear medical evidence that plaintiff submitted and ignored the medication that claimant had to take on a daily basis without examining her themselves or seeking the treatment notes of her doctors); see also Kunin v. Benefit Trust Life Ins. Co., 910 F.2d 534, 538 (9th Cir. 1990) (holding that an ERISA administrator’s inadequate investigation and reliance on non-experts in the field failed to provide a reasonable basis for the administrator’s determination).2 Like our sister circuit, we believe that “[a]lthough in some contexts it may not be arbitrary and capricious to require clinical evidence of the etiology of the allegedly disabling symptoms in order to verify that there is no 1 Admittedly, Dr. Thornbury treated Helms’s for his rotator cuff injury, not his headaches. Nevertheless, the record fails to indicate that Aetna followed through on its own suggested course of action laid out in its internal notes. Although not directly related to Helms’s headaches, the complete orthopedic records could have indicated whether Dr. Thornbury noted any signs of malingering. 2 We are not espousing a rule that qualified nurses can never review claims, but in circumstances such as these, with highly subjective determinations, a peer review or an IME was warranted. 18 malingering, we conclude that it was arbitrary and capricious to require such evidence in the context of this [p]lan” and Helms’s case. See Mitchell v. Eastman Kodak Co., 113 F.3d 433, 442-43 (3d Cir. 1997). Aetna’s own procedures set forth two appeals levels Helms needed to exhaust before bringing suit in either state or federal court. At appeal “Level 1,” Aetna’s “decision w[ould] be forwarded to [the claimant] in writing and w[ould] include the specific reasons and plan references on which the decision is based.” R1, 29-5 at 29. At appeal “Level 2,” Aetna’s procedures state that it would notify a claimant of Aetna’s decision within 45 days of Aetna’s receipt of the request for a Level 2 review. If Aetna needed additional time, it would notify the claimant “during that 45-day period of why additional time is needed.” Id. Aetna was wrong in failing to communicate sufficiently its justifications for both the various initial denials Helms received and the extension Aetna granted itself in ultimately denying Helms’s Level 2 Appeal. The three identical, initial denial letters lack the required specificity. Aetna’s letters from 13 and 30 October 2003 and 19 November 2003 all stated that Aetna “c[ould ]not certify [Helms’s] disability because [they] ha[d] not received medical information to show that [Helms] remain[ed] disabled.” R1, 29-4 at 7, 10, 15. Internally, however, even before the 13 October 2003 denial, Aetna’s reviewer concluded 19 that Helms lacked “enough objective medical information” to support continuing his STD benefits, R1, 29-13 at 3, and that Helms failed to present sufficient (or any) restrictions and limitations.3 Nowhere in Aetna’s first three denial letters did Aetna explain its conclusion regarding objective evidence. Furthermore, Aetna failed to identify any specific examples of objective evidence that Helms could have submitted in support of his STD claim, despite Aetna’s own policy that stated that denied claimants would receive “[a] description of additional material or information [they] could provide to support the claim -- and the reasons why that information [wa]s necessary.” R1, 29-5 at 28.4 In fact, on Aetna’s own APS form under the question that asks for “Objective findings that substantiate 3 Aetna’s internal notes vacillated between the conclusion that the restrictions and limitations presented were insufficient and the conclusion that Helms failed to present any restrictions and limitations. Compare R1, 29-13 at 3 (noting “R&Ls MD advises no work due to chronic headaches”) with R1, 29-14 at 2 (concluding “[b]ased on no R&Ls, given the fact that [Helms] is able to drive, do machinery, etc. medical continues to not support impairment”). 4 Given that Aetna has discretion in terms of what it considers adequate “proof” of disability, we cannot say that it is always unreasonable for Aetna to demand objective evidence. Accord Wangenstein v. Equifax, Inc., 191 Fed. Appx. 905, 913-14 (11th Cir. 2006) (unpublished) (“[G]iven that KNS has discretion in terms of what it considers adequate ‘proof’ of continuing disability, we cannot say that it is unreasonable for KNS to demand objective evidence.”). We note, however, that this case is distinguishable from Wangenstein on its facts. As an initial matter, the plan administrator in Wangenstein had four doctors conduct five independent paper peer review consultations and a neurologist conduct an IME, neither of which was performed here. Id. at -4. There, the neurologists recommended specific additional documentation and procedures that would be helpful. Id. at . Here, in contrast, Aetna repeatedly gave no indication to Helms as to what it needed, even as it internally noted that it lacked objective evidence and sufficient restrictions and limitations. 20 impairment,” Aetna gives examples that include “current laboratory, physical and/or mental status examination, and other testing.” See, e.g., R1, 29-6 at 12 (emphasis added). Not only did Aetna repeatedly neglect to inform Helms that it required “objective” evidence, but, based on its own forms, Dr. Epperson’s examinations of Helms should have qualified as “objective findings.” Nor do the three initial denial letters specifically reference a need to provide or clarify Helms’s restrictions and limitations. Under the plain language of its plan, Aetna was wrong to send Helms these terse letters. See Mitchell, 113 F.3d at 442 (“The Administrator’s denial letters are terse, and we are not altogether certain of their meaning.”). No reasonable interpretation of Aetna’s plan documents permitted Aetna to send boilerplate letters that did not sufficiently disclose Aetna’s reasons for the denial of Helms’s STD claim. At appeal “Level 2,” Aetna’s procedures stated that it would notify claimants of Aetna’s decision within 45 days of Aetna’s receipt of the request for a Level 2 review. Aetna promised that all extension notices for reviewing disability claims would explain: “- The standards used in determining whether a participant is entitled to a benefit, - The unresolved issues that prevent a decision on the claim, and - The additional information needed to resolve those issues.” R1, 29-5 at 28. With regard to Level 2 appeals specifically, Aetna claimed that if 21 it needed additional time, it would notify the claimant “during that 45-day period of why additional time is needed.” Id. at 29. Aetna’s letter notifying Helms that Aetna was extending the appeal deadline failed to give any reason as to why the additional time was needed to reach a conclusion. No reasonable interpretation of the plan allows Aetna simply to ignore the substance of its own notification requirement. 2. Aetna’s Analysis of Helms’s STD Claim In addition to asserting that Aetna’s claims procedures were inadequate, Helms also argues that Aetna’s substantive analysis of his STD claim was flawed. We agree. In reviewing the record as a whole and taking the evidence in the light most favorable to Aetna, we find no sufficiently contradictory evidence from Dr. Epperson regarding Helms’s impairment. Aetna and the dissent try to paint Dr. Epperson’s opinions as inconsistent, but we find that the portions of the medical evidence that cast Helms as improving are qualified by the undisputed fact that his improvement was dependent on medication that left him sedated and interfered with his daily functions. It is true that Dr. Epperson recorded an improvement in Helms’s headaches in his office visit notes of 3 September 2003, but Dr. Epperson’s notes from that day also recommended that Helms continue his medications and suggested that he could decrease his medication dosage at his 22 own discretion.5 Dr. Epperson’s later APS, and his letters of 14 October 2003 and 25 November 2003, further clarified and contextualized his office visit note from 3 September 2003. Stated simply, Helms’s condition “improved” only through medication that controlled the severity of the headaches but left Helms sedated and interfered with his ability to work and drive. R1, 29-7 at 19. At no point did Dr. Epperson vacillate regarding his ultimate conclusion that Helms qualified for disability benefits. Aetna essentially pulled two positive sentences out of Dr. Epperson’s 3 September 2003 notes and discredited or ignored the undisputed evidence consisting of the neurologists’ numerous office visit notes, APSs, and narratives that stated that Helms’s condition did not continue to improve unless on sedating medication and that Helms was unable to work in his condition. A doctor’s treatment records will often note improving and deteriorating conditions, especially in situations such as these, wherein a doctor has tried different combinations of medicines with various results. Under the dissent’s logic, any noted improvement, however excised from the context of the unrefuted medical conclusion that Helms warranted disability, must result in a triable question of fact. Viewing the evidence in the light most favorable to 5 Aetna’s records reflect that Helms notified Aetna that he had not, in fact, reduced his medication after the 3 September 2003 visit with Dr. Epperson. 23 Aetna still leaves Aetna unable to refute the fact that Helms’s improved status at the time was a result of a regiment of drugs that left him sedated and, in the opinion of the only doctor involved in Helms’s review, unable to work. If Aetna believed that there was a contradiction in the Dr. Epperson’s notes, it could have had conducted a peer review of Helms’s file and it could have ordered an IME to gain additional perspective, especially since Nurse Blackmer herself admitted that “[m]igraine is a subjective diagnosis.” R2, 44-2 at 85.6 To conclude, as Aetna did, that Helms provided insufficient restrictions or limitations, or even no restrictions and limitations at all, is wrong because it is contrary to the undisputed evidence. In light of its own forms, Aetna unreasonably construed what qualified as “restrictions and limitations.” While Aetna was not satisfied with Dr. Epperson’s restrictions and limitations, Aetna’s APS form only gives pithy examples of restrictions and limitations, suggesting: “Activities of Daily Living, Driving, Lifting, Pulling, Pushing, and Amounts, etc.” R1, 29-6 at 12. Dr. Epperson stated that Helms had difficulty driving and 6 Furthermore, Aetna’s argument on appeal that Dr. Epperson merely stated that Helms’s medication could “cause mild sedation” but did not claim that the medication actually caused Helms sedation is not only post hoc reasoning, but also wrong. See R1, 29-7 at 26. Dr. Epperson noted in a 25 November 2003 letter submitted with Helms’s appeal that the medications “cause[d] sedation interfering with his ability to work or drive a vehicle and numerous other daily activities.” R1, 29-7 at 19. Even Aetna’s own notes acknowledge that “[m]eds leave him in a sedated state, can’t drive, and has trouble focusing/concentrating.” R1, 29-13 at 2. 24 working. Aetna’s 18 August 2003 notes confirmed that Helms had restrictions regarding driving and working with machinery. R1, 29-12 at 2; 29-13 at 2. Also, Helms presented evidence, such as his questionnaire, wherein Helms indicated that he had trouble driving, among other things, and frequently needed to lay down and rest throughout the day.7 Aetna’s appeal denial letter admitted that Helms’s questionnaire “provide[d] insight [into] the activities of Mr. Helms may be able to do or not do within the course of the day.” R1, 29-7 at 12. In the very next line, however, Aetna then concluded that the questionnaire “d[id] not inquire about restrictions and limitations” that prevented Helms from returning to work. Id. It is baffling how Aetna could concede that Helms had difficulty driving and needed to lay down occasionally and then go on to conclude in the very next line that Helms failed to submit any restrictions and limitations. Aetna’s reliance on Black & Decker Disability Plan v. Nord, 538 U.S. 822, 123 S. Ct. 1965 (2003), is unconvincing. Nord instructs us that we may not impose on plan administrators “a discrete burden of explanation when they credit 7 The dissent asserts that the fact that Helms performed his work throughout the period of treatment is evidence that allows a reasonable inference that Helms’s headaches did not render him disabled. We have considered similar arguments in prior cases and noted doubt that an applicant’s status as a full-time employee constitutes evidence that he was able to perform the material duties of his occupation on a full-time basis. Levinson, 245 F.3d at 1327 n.6 (“[Applicant] ‘gave it a go’ and her attempt to work does not forever bar her collection of sickness disability benefits.’” (citing Marecek v. BellSouth Telecomms., Inc., 49 F.3d 702, 706 (11th Cir. 1995)). 25 reliable evidence that conflicts with a treating physician’s evaluation,” 538 U.S. at 834, 123 S. Ct. at 1972, but here there was no evidence other than that of Helms’s treating physician Dr. Epperson and Helms himself. Put another way, this is not a case wherein the plan administrator refused to credit the opinions of doctors that supported disability but instead accorded greater weight to conflicting opinions of doctors that did not support disability. See, e.g., Wangenstein, 191 Fed. Appx. at 912-13 (upholding a plan administrator’s weighing of multiple neurologists’ examinations and reviews but ultimately crediting neurologists that did not support a finding of disability). With only Dr. Epperson’s medical evaluation in the form of his office notes, test results, APSs, and narratives, Aetna excised narrow snippets of Dr. Epperson’s notes, while it discredited or ignored whole tracts of his medical evaluation that supported Helms’s STD claim, all without a peer review or an IME. Aetna’s review in this case was malignant at worst, and arbitrary at best. See Nord, 538 U.S. at 834, 123 S. Ct. at 1972 (“plan administrators . . . may not arbitrarily refuse to credit a claimant’s reliable evidence, including the opinions of a treating physician.”). Here, Aetna possessed only a scintilla of evidence pulled out of context against the extensive documentation of Helms’s chronic headaches and powerful medication. While Aetna seized a line in Dr. Epperson’s September 2003 records 26 that noted Helms’s condition greatly improved, that evidence alone does not create a triable issue of fact when it is undisputed that the remark was written in the context of the drugs Helms continued to take--drugs that left him mildly sedated and interfered with numerous daily activities.8 In a letter dated October 2003, Dr. Epperson clarified that while Helms’s condition had improved, it was still his opinion that Helms warranted disability benefits as a result of his decreased functionality due to present medications and lingering headaches.9 If Aetna was dissatisfied with the evidence of disability and restrictions and limitations submitted by Helms and Dr. Epperson, it was entitled to require Helms undergo an IME or to submit Helms’s file to a peer review. Had Aetna done so, Aetna would have been entitled to discount Dr. Epperson’s opinion in favor of a contrary opinion produced by an IME or a peer review. See House v. Paul Revere Life Ins. Co., 241 F.3d 1045, 1048 (8th Cir. 2001) (“If Paul Revere was 8 The dissent’s suggestion that “[t]hings changed only after Helms underwent surgery to repair a torn rotator cuff on July 8” is simply a mischaracterization of the record. Helms had sought treatment for headaches since February 2003 and in May 2003 Dr. Epperson wrote, with regard to Helms’s headaches: “Consider short-term disability and he may need long-term disability.” R1, 29-6 at 24. 9 Furthermore, any intimation by Aetna or the dissent that Dr. Epperson somehow improperly “promise[d]” that he would support Helms in violation of his ethical duties as a physician is completely unsupported in the record. See Scotto v. Almenas, 143 F.3d 105, 114 (2d Cir. 1998) (holding that the party opposing summary judgment “may not rely on conclusory allegations or unsubstantiated speculation”). 27 dissatisfied with the medical evidence submitted by Nolewajka, it was entitled to require House to submit to an [IME]. Had it done so, Paul Revere would have been entitled to discount Nolewajka’s opinion entirely in favor of a contrary opinion produced by the independent examiner.”). We find it is unreasonable, and therefore arbitrary and capricious, for Aetna to have repeatedly sheathed its true justifications in boilerplate language in its first three denial letters to Helms. Aetna was also unreasonable to have ignored submitted restrictions and limitations and excised only snippets of Dr. Epperson’s evaluations without the context of the sedating medications in discrediting or ignoring overwhelming portions of Dr. Epperson’s medical evidence that supported Helms’s STD claim. Finally, Aetna was unreasonable when it failed to initiate a peer review or an IME that could have provided additional perspective on this admittedly subjective diagnosis. To be clear, we are not holding that Aetna must always have a doctor perform a claims review or even that a failure to perform an IME is necessarily arbitrary and capricious. Rather, we find that, in this case, Aetna’s myopic and flawed reasoning and its procedural failures to properly inform Helms of the specific reasons for his denial in a timely fashion, coupled with the lack of an IME of an admittedly subjective condition, is arbitrary and capricious. Similar to the conclusion reached by the district court in 28 Levinson, “there was absolutely no justification for [Aetna’s] denial of [Helms’s] benefits claim. [Aetna] did not have a doctor review [Helms’s] condition and presented no evidence to [support] its findings that [Helms] was not entitled to benefits. In essence, there was no disputed material issue of fact in [Aetna’s] determination, which is why summary judgment [for Helms is] appropriate.” See Levinson v. Reliance Standard Life Ins. Co., 2000 WL 193623, at  (S.D. Fla. Jan. 5, 2000) (unpublished), affirmed, 245 F.3d at 1331.10