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Kochanek v. Aetna Life Insurance Co.

United States District Court, E.D. Arkansas, Western Division

August 27, 2018

KATHERINE KOCHANEK, on behalf of herself and all others similarly situated PLAINTIFF
v.
AETNA LIFE INSURANCE CO. and HOME DEPOT U.S.A., INC. DEFENDANTS

          ORDER

         Plaintiff Katherine Kochanek appeals the termination of her short-term disability (“STD”) benefits under the Employee Retirement Income Security Act (“ERISA”). Defendant Aetna Life Insurance Company's (“Aetna”) decision to terminate Kochanek's benefits is affirmed, judgment is entered for Aetna and defendant Home Depot U.S.A., Inc. (“Home Depot”), and this case is dismissed with prejudice.[1]

         I. BACKGROUND

         Katherine Kochanek is a former employee of Home Depot who received insurance coverage through the Home Depot Welfare Benefits Plan. Administrative Record (“AR”) at 69, 81, 83, 85, 384-91, 501, 737-39, 747, Doc. No. 17. The plan includes STD benefits insured through Aetna under a group policy issued to Home Depot. See Id. It defines the eligibility requirements for STD benefits and designates Aetna to serve as the claims administrator. Id. at 89, 385-86, 501. This means that Aetna has the sole authority to determine whether and to what extent an insured is entitled to receive STD benefits. See Id. at 79, 391, 471, 499, 501. The plan permits Aetna to interpret its terms and decide all claims and appeals, and it confers broad discretion on Aetna in making all of these determinations. Id. at 79, 391, 471, 499.

         The plan defines a “disability” as an illness, injury, or pregnancy-related condition that precludes an individual from performing the material duties of her job. Id. at 89. An individual is not performing the material duties of her job if (1) she is only performing some of the material duties of her job; and (2) her income is 80% or less of her predisability earnings solely because of an illness, injury, or a disabling pregnancy-related condition. Id. The plan defines “illness” as a “[a] pathological condition of the body that presents a group of clinical signs and symptoms and laboratory findings peculiar to it and that sets the condition apart as an abnormal entity differing from other normal or pathological body states.” Id.

         Kochanek applied for STD benefits on April 29, 2014, id. at 517, because she was being treated for splenomegaly, an abnormal enlargement of the spleen, and for Epstein-Barr virus (“EBV”). Id. at 727-28. Kochanek provided authorization to Aetna to obtain her medical information so that it could evaluate her claim. Id. at 530-31. Aetna requested that her primary care physician, Dr. Derek Bryant, complete a statement concerning Kochanek's health and send supporting records and other medical documentation. Id. at 525-35, 537-41. Dr. Bryant sent Aetna a statement indicating that Kochanek had splenomegaly and EBV; that Kochanek reported abdominal swelling, fever, and fatigue beginning around January 30, 2014; and that she had “[n]o ability to work” between April 24, 2014, to July 1, 2014. Id. at 727-28. Dr. Bryant, however, did not submit any supporting medical records or physical examination findings-he simply stated that Kochanek was awaiting an appointment with a gastroenterologist. Id.

         At this point, Aetna suspended its claims investigation and informed Kochanek that Dr. Bryant's statement was insufficient to support her claim. Id. at 542. It advised her that it would need medical notes with objective physical examination findings that demonstrate that Kochanek would be unable to perform core elements of her job. Id. On May 20, 2014, Dr. Bryant sent the following medical documentation to Aetna: (1) a CT scan from February 28, 2014, showing “[m]ild fatty infiltration of the liver and mild splenomegaly, ” (2) an Anti-Nuclear ABS test, which detected elevated EBV levels, (3) records from a visit on April 7, 2014, in which Kochanek complained about an enlarged spleen, EBV, diabetes, fatigue, stomach pain, diarrhea, and general pain; and (4) records from a visit on April 24, 2014, in which Kochanek complained about heart palpitations, nausea, bloating, stomach acid, EBV, and generally feeling unwell. Id. at 706-08, 712-13, 714-19. It appears that Dr. Byrant referred Kochanek to a gastroenterologist, Dr. Angelo Coppola, and prescribed Valtrex, Carafate, Prilosec, and Zantac. Id. at 706.

         After reviewing these records, Aetna's staff recommended denying Kochanek's claim after finding that “the medical data received does not support a functional impairment. We did not find specific physical examination findings which would preclude the associate from performing the core elements of her own job.” Id. at 628, 769. Aetna, however, ultimately approved the claim through June 5, 2014, following a consultation with Dr. Coppola and further review of Kochanek's job requirements. Id. at 773-75. It informed Kochanek that her benefits would not be extended past June 5, 2014, without additional medical information supporting her claim. Id. at 543.

         Aetna then sought additional documentation from Dr. Bryant, who forwarded a report from Dr. Coppola dated June 5, 2014, concerning an esophagogastroduodenoscopy procedure. Id. at 702. Dr. Coppola found that Kochanek had antral gastritis, which he treated with increased doses of previously prescribed proton pump inhibitor drugs. Id. Based on this report, Dr. Bryant reported that Kochanek would not be able to return to work until August 1, 2014, because of nausea and weakness. Id. at 703. When asked about specific restrictions, Dr. Bryant responded that he was waiting for further results, but he did not identify any specific limitations on Kochanek's daily activities. Id. Kochanek also reported that she had appointments with her doctors on June 9, 2014, and July 2, 2014, for a repeat CT scan and a colonoscopy. Id. at 609.

         On June 13, 2014, Aetna decided to continue paying STD benefits to Kochanek through July 6, 2014, but it informed her that continued benefits past that date were contingent on the submission of objective evidence supporting her disability claim. Id. at 552. Because Kochanek was still waiting for the results of diagnostic testing, it again agreed to continue her benefits until August 4, 2014. Id. at 574.

         On August 19, 2014, Aetna denied Kochanek's claim for benefits, effective August 5, 2014. Id. at 583. It did so after receiving documentation from Drs. Bryant and Coppola which, according to Aetna, failed to support her disability claim past August 5, 2014. Id. at 673-89. In particular, Dr. Coppola released Kochanek to return to work as early as July 3, 2014, and reported that she was able to perform “[h]eavy work activity” without restrictions or limitations. Id. at 675, 687. Although Dr. Bryant submitted a contrary opinion, he was unable to identify any specific restrictions or limitations that would prevent Kochanek from returning to work. Id. at 689. Further, he did not send any medical documentation supporting his opinion. Id.

         Kochanek appealed Aetna's denial of her STD benefits through its internal appeals process. Id. at 585. Aetna referred her file to Dr. Edward Klotz, an internal medicine physician, for review. See Id. at 836. Dr. Klotz found no functional impairment and concluded that Kochanek was not disabled. Id. at 651-52. Following a conversation with Dr. Bryant, who reported that there were no objective findings supporting his opinion and the he did not know whether Kochanek's conditions affected her daily living activities, Klotz reaffirmed his conclusion. Id. at 640-41. It appears that Aetna denied Kochanek's appeal on this basis. Kochanek then filed this lawsuit, pursuant to 29 U.S.C. section 1132(a)(1)(B), to reinstate her benefits. Class Action Compl. ¶¶ 6-8, Doc. No. 2.

         II. DISCUSSION

         A. Standard of Review

         The parties dispute the applicable standard of review. When an ERISA benefits plan gives an administrator “discretionary authority to determine eligibility for benefits, ” the administrator's decision is reviewed for an abuse of discretion. Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989). Here, various plan documents indisputably confer broad discretionary authority on Aetna to determine whether and to what extent claimants ...


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