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Robbins v. Aetna Life Insurance Co.

September 8, 2006

JANICE J. ROBBINS, PLAINTIFF,
v.
AETNA LIFE INSURANCE COMPANY, DEFENDANT.



The opinion of the court was delivered by: Garaufis, United States District Judge

MEMORANDUM & ORDER

In this suit, Janice Robbins ("Robbins" or "Plaintiff"), who was a registered nurse employed by the North Shore-Long Island Jewish Health System ("North Shore LIJ") brings suit against Aetna Life Insurance Company ("Aetna" or "Defendant") under the Employee Retirement Income Security Act of 1974, 29 U.S.C. § 1001, et seq. ("ERISA"). At this time, the court considers Plaintiff's and Defendant's cross-motions for summary judgment pursuant to Rule 56 of the Federal Rules of Civil Procedure. For the reasons set forth below, the Defendant's motion is DENIED and Plaintiff's motion is GRANTED to the extent that this matter is REMANDED to Defendant to issue a new determination as set forth in this Memorandum and Order.

I. Facts

The following facts are not in dispute.*fn1 Robbins worked at North Shore LIJ as an operating room nurse. (Plaintiff's Rule 56.1 Statement ("Pl. 56.1 Stmt.") ¶ 1.)*fn2 Aetna is the claims administrator of the long-term disability benefit policy for North Shore LIJ employees. (Pl. 56.1 Stmt. ¶¶ 2-3; Defendant's Local Rule 56.1 Statement ("Def. 56.1 Stmt.") ¶ 2.) By 2002, Robbins had been working as an operating room nurse for over a decade. (Pl. 56.1 Stmt. ¶ 7.) In February 2002, Robbins participated in the Flex Benefits Program ("the Plan") and was covered under the group long term disability insurance policy ("the Policy"). (Pl. 56.1 Stmt. ¶¶ 2, 8.) The Policy states that it shall pay a monthly benefit for "a period of total disability caused by a disease or accidental bodily injury." (Pl. 56.1 Stmt. ¶ 5; Def. Mem. Supp. Mot., Ex. ("Def. Ex.") 1, at 353.) The Policy defines "total disability" as follows:

You are deemed totally disabled while either of the following applies to you: During the period which ends right after the first 24 months benefits are payable in a period of total disability: You are not able, solely because of injury or disease, to perform the material duties of your own occupation; except that if you start work at a reasonable occupation you will no longer be deemed totally disabled.

Thereafter during such period of total disability: You are not able, solely because of injury or disease, to work at any reasonable occupation.

You will not be deemed to be performing the material duties of your own occupation or working at a reasonable occupation on any day if: you are performing at least one, but not all, of the material duties of your own occupation or you are working at any occupation (full-time or part-time); and solely due to disease or injury, your income from either is 80% or less of your adjusted predisability earnings.

(emphasis in original).

While Plaintiff submitted a responsive 56.1 statement, Defendant did not. All material facts set forth by the moving party in its statement of material facts that are not controverted by the opposing party in its own statement of material facts are deemed admitted.

E.D.N.Y. Civ. R. 56.1(c). I shall therefore deem Plaintiff's statements in her 56.1 statement not addressed in Defendant's 56.1 statement to be admitted by Defendant. Id.

(Pl. 56.1 Stmt. ¶ 5; Def. Ex. 1, at 353.) The Policy defines "reasonable occupation" as "any gainful activity for which you are, or may reasonably become, fitted by education, training or experience."

(Pl. 56.1 Stmt. ¶ 5; Def. Ex. 1, at 353.) Beginning in 1999, Plaintiff sought medical care for muscle spasms and pain in her neck. (Pl. 56.1 Stmt. ¶ 10.) In February 2002, Robbins stopped working and made a claim for short-term disability benefits. Aetna approved the claim and provided Robbins with about five months of benefits. (Id. ¶ 11-12; Def. Ex. 1, at 264, 274.) During this period, Dr. Daniel Reinharth, her primary physician, provided Aetna with two completed forms regarding Robbins's short-term disability application. (Pl. 56.1 Stmt. ¶ 19; Def. Ex. 1, at 264, 274.) The first, dated April 3, 2002, states that Robbins was unable to work because of back pain and a tender neck caused by straining on the job, and that she was unable to return to work. (Def. Ex. 1, at 274.) The second, dated May 15 2002, repeats the above opinion, but adds that "she has improved, but not fully, and remains at risk for re-injury." (Def. Ex. 1, at 190, 264.)

Robbins did not return to work, and claimed long-term disability benefits. (Def. 56.1 Stmt. ¶ 4.) On June 11, 2002, Aetna work records indicate that Aetna communicated the following message to Robbins:

We . . . will only pay . . . [long-term disability] if she is disabled from performing the duties of all nursing jobs for which she is qualified by experience and/or education. Advised that since she is certain she is not able to do her own job, she needs to start looking at other type[s] of jobs such as case management positions for hospitals and private insurance companies, etc. [Employee] . . . states she is in too much pain now. Advised of the [long-term disability] review process, and that we do have to collect all of her . . . medical info. (Pl. 56.1 Stmt. ¶ 22; Def. Ex. 1, at 27.) On July 24, 2002, Robbins contacted Aetna and informed it that her primary doctor was Dr. Daniel Reinharth, that she had a primary condition of chronic neck and back pain and a secondary hip condition, in addition to Fibromyalgia, and that she could not return to her past position. (Pl. 56.1 Stmt. ¶ 14-16; Def. Ex. 1, at 2.)

By letter dated September 12, 2002, Aetna denied Robbins's claim for long-term disability on the basis that "there is no proof that you are totally disabled from performing the material duties of your own occupation." (Def. 56.1 Stmt ¶ 6; Piotrowski Aff. ¶ 8; Def. Ex. 1, at 153-55; Def. Ex. 4.) Specifically, Aetna stated:

We have reviewed the medical information provided to us by Dr. Liptez, Dr. Rokito, Dr. Rengarth, and Sports Therapy and Rehabilitation Services. Dr. Lipetz and Dr. Rokito did not indicate in their records that your complaints were preventing you from performing the duties of your own occupation as a nurse. Dr. Renharth did not provide us with objective medical evidence that supports the restrictions that he provided, and the physical therapy notes do not provide objective evidence nor document impairment from the duties of your occupation, thus your proof of disability has not been satisfied. (Def. Ex. 4, at 1.) The denial letter further stated that in an administrative appeal of the decision, the Plaintiff should furnish medical evidence to Aetna, including a narrative report from treating physicians, diagnostic studies, and information about Robbins's medical condition. (Id. at 2.)

Plaintiff appealed that decision by letter dated October 24, 2002. (Pl. 56.1 Stmt. ¶ 5; Def. Ex. 1, at 141-42.) Robbins in her appeal letter stated that at North Shore LIJ, she had a twelve hour shift with mandatory overtime of three hours with few or no breaks, often for up to three consecutive days, and her position as an operating room nurse was stressful and required the movement of heavy equipment with quick physical movements. (Def. Ex. 1, at 141.) She alleged that she first developed muscle spasms and neck pain in September 1999 and again in December 2001, which were successfully treated by Dr. Reinharth and physical therapy such that she could return to her position at North Shore LIJ, but that treatment for her current condition did not allow her "to return to perform the material duties of my occupation." (Id.) Lastly, she alleged (and Defendant has not denied) that the following medical evidence supports her long-term disability claim:

(a) Dr. Reinharth, her primary care physician, completed two Aetna forms on August 22 and September 23, 2002, and one form (attached by Robbins) states that Robbins "is currently disabled from her job as a nurse, because her nursing functions include physical activities which can (and have) reaggravate[d] her neck and back pain" (id. at 142-43);

(b) Jason S. Lipetz, M.D., the Director of Spine Rehabilitation at North Shore LIJ recommended that she not return to perform her duties as an operating room nurse (id. at 142);

(c) she performed physical therapy two days per week from March 2002 until September 6, 2002, after which the rehabilitation center provided her a note (which Robbins attached) stating "[a]s per patient[']s complaints of pain, the patient would most likely not tolerate ...


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