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Lee v. Aetna Life and Casaly Insurance Co.

May 24, 2007

DEBRA A. LEE, PLAINTIFF,
v.
AETNA LIFE AND CASALY INSURANCE CO. DEFENDANT,



The opinion of the court was delivered by: Honorable Paul A. Crotty, United States District Judge

OPINION AND ORDER

Plaintiff Debra A. Lee ("Lee") seeks a declaratory judgment against Defendant Aetna Life and Casualty Insurance Company ("Aetna") that she is disabled and entitled to benefits pursuant to a long term group disability income policy ("the Plan") issued to Lee's prior employer, Accenture, LLP ("Accenture"). The Employee Retirement Income Security Act of 1974 ("ERISA") governs this action. 29 U.S.C. § 1001 et seq. On February 13, 2006, the Court denied Lee's motion to apply a de novo standard of review to Aetna's denial of benefits to Lee, and affirmed that the appropriate standard was "arbitrary and capricious" review. Aetna now moves for summary judgment dismissing Lee's claim.*fn1

RELEVANT FACTS*fn2

I. Terms of the Plan

The Accenture Plan requires that the claimant be "totally disabled" before long term disability benefits can be paid. Total disability occurs when a worker is "not able, solely because of injury or disease, to work at [her] occupation." Affidavit of Maryanne M. Barry ("Barry Aff."), Exhibit A at LEE000042. Inability to work at one's occupation requires only an inability to perform all the material duties of the occupation. A period of total disability ends on, inter alia, "the date [she ceases] to be under the care of a physician." Id. at LEE000043 (emphasis in original). Claims under the Plan "must give proof of the nature and extent of the loss." Id. at LEE000050.

II. Aetna's Review

Ms. Lee commenced working as a consulting manager for Accenture on January 7, 2002. On February 7, 2003, Lee went on a part-time schedule as a result of her claimed disability. On or about June 2, 2003, Lee submitted an application for long term disability benefits with supporting medical documentation from her treating rheumatologist, Efstathia Chiopelas, M.D. ("Dr. Chiopelas") and her psychiatrist Stanley Portnow, M.D., claiming to suffer from paresthesia, arthralgia and anxiety.*fn3 Aetna approved the application, and Lee received partial benefits from May 31, 2003 to August 8, 2003,*fn4 on or about which date she was terminated by Accenture. After her termination, Lee received full long term disability benefits through March 10, 2004.

In September 2003, Lee advised Aetna that she was no longer being treated by a psychiatrist for any psychological condition, and did not rely on such a condition as a basis for her disability claim. Dr. Chiopelas sent updated statements on Lee's condition in August and September 2003, and on October 13, 2003, Aetna retained Profile Consultants, Inc. to conduct a personal interview with Lee. On or about January 2004, Lee's medical and claim file was forwarded for review to Aetna's in-house Nurse Consultant, Karen Mazza, R.N. ("Nurse Mazza"). The listed "Question" asked whether Lee could return to work in her own occupation, and whether there was "sufficient objective medical documentation to support her inability to [return to work] full time." Barry Aff., Exhibit B, LEE001039. After receiving Nurse Mazza's evaluation, Aetna terminated Lee's benefits by a letter of March 11, 2004.

Lee appealed the termination in a letter dated August 5, 2004, submitting in support a letter by Bruce Solitar, M.D. ("Dr. Solitar") a new rheumatologist treating Lee. In or around October 2004, Lee's medical and claim records were sent for review to Oyebode Taiwo, M.D. ("Dr. Taiwo"), a consulting Medical Director for Aetna, board certified in internal medicine and occupational medicine. The "Referral Question" included requests to comment on whether the included lab results "would support specific disease process," and whether "there are limitations and restrictions supported by the medical information." Id. at LEE000480. The Referral Question also stated: "It does not appear there is specific information to support functional limitations. Please review for functional limitations." Id. On November 3, 2004, Aetna rejected Lee's appeal. This lawsuit followed.

III. Relevant Evidence of Disability Provided to Aetna

Lee claims long term disability benefits based on her symptoms of pain, paresthesia, fatigue, arthralgia, sleep disorder, hysteria, and anxiety. In reviewing her claim, Aetna considered all of Lee's submissions, including, inter alia: (1) an interview with Dr. Chiopelas and various reports and records prepared by her; (2) records from Dr. Harold Weinberg, M.D. ("Dr. Weinberg"), her neurologist; and (3) a letter from Dr. Solitar. Aetna also considered the evaluations of this evidence by Nurse Mazza and Dr. Taiwo.

Dr. Chiopelas's Findings

In her May 30, 2003 APS, Dr. Chiopelas noted Lee's reported symptoms of "upper and lower extremity paresthesias, arthralgias, anxiety," that "any stress.will cause anxiety and paresthesias to worsen," and that Lee "require[d] rest periods to avoid worsening of symptoms." Id. at LEE000753-54. Dr. Chiopelas's clinical findings were normal, and diagnostic results, including MRI reports of her brain and lumbar spine, were within normal limits, except for a positive blood test for "anti-cardiolipin antibodies." Id. at LEE000753. The latter were treated with aspirin. Dr. Chiopelas continued to treat Lee and after visits on August 14, 2003 and September 10, 2003, again noted Lee's symptoms and confirmed that her clinical and diagnostic findings were normal except for positive anti-cardiolipin antibodies, which continued to be treated with aspirin. The August 14 report also noted that Lee's was an "unclear diagnosis." id. at LEE000703, but that she was "unable to work with these symptoms." Id.

In a January 22, 2004 interview with an Aetna case manager, Dr. Chiopelas stated that Lee's symptoms had no clear etiology, or cause,*fn5 and no "identifiable triggers," except that stress worsened the symptoms. Id. at LEE000580-81. Dr. Chiopelas also stated that the abnormal anti-cardiolipin antibodies findings could be consistent with lupus or multiple sclerosis, but that Lee had no family history of such ailments. Dr. Chiopelas also opined that Lee's physical symptoms should not ...


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