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Cline v. Aetna Life Insurance Co.

United States District Court, W.D. North Carolina, Statesville Division

November 15, 2017

LARRY CLINE, Plaintiff,
v.
AETNA LIFE INSURANCE COMPANY, Defendant.

          ORDER

          Richard L. Voorhees United States District Judge

         THIS MATTER IS BEFORE THE COURT on cross motions for summary judgment, each supported by an accompanying brief. Each party responded to the other's motion, and replied to the other's response. These cross-motions are thus ripe for consideration.

         I. PROCEDURAL HISTORY

         On July 28, 2015, Plaintiff filed suit against Defendant in this Court. [Doc. 1]. On September 28, 2015, Defendant filed an Answer to Plaintiff's Complaint. [Doc. 4]. On April 5, 2016, Plaintiff filed its motion for summary judgment (“Plaintiff's Motion”) and an accompanying brief in support. [Doc. 8, 9]. On the same day, Defendant filed its motion for summary judgment (“Defendant's Motion”) and an accompanying brief in support. [Doc. 11, 11-1]. On April 22, 2016, Plaintiff filed a response in opposition to Defendant's Motion. [Doc. 12]. On the same day, Defendant filed a response in opposition to Plaintiff's Motion. [Doc. 13]. On May 2, 2016, Defendant filed a reply brief in support of Defendant's Motion. [Doc. 14]. On the same day, Plaintiff filed a reply brief in support of Plaintiff's Motion. [Doc. 15].

         II. JURISDICTION AND VENUE

         This Court has jurisdiction over this matter pursuant to the Employee Retirement Income Security Act of 1974 (“ERISA”), and in particular 29 U.S.C. § 1132(e) and 1132(f) contained therein, which give District Courts jurisdiction to hear civil actions involving benefit claims arising under Employment Welfare Plans such as the one at issue in this action. 28 U.S.C. § 1331 gives District Courts jurisdiction to hear cases involving actions arising under the laws of the United States.

         Plaintiff is a citizen and resident of Lincoln County, North Carolina, and was employed full-time by Netjets, Inc. (“Netjets”) as a commercial pilot. [Doc. 1] at 1-2. Defendant is the claims administrator for the Netjects's Long-Term Disability Plan (the “Plan”), and also insures the benefits under the Plan. [Doc. 1] at 1-2; [Doc. 4] at 1. Venue in the Western District of North Carolina, Statesville Division, is appropriate by virtue of Plaintiff s residence and Defendant's presence and doing business in this district.

         III. STATEMENT OF FACTS

         At all times relevant to this action, Plaintiff has been a covered beneficiary under the Netjets, Inc. Long-Term Disability Plan (the “Plan”), which provides group long-term disability (“LTD”) benefits to eligible employees. [Doc. 1] at 2; [Doc. 4] at 2.

         The Plan provides LTD benefits when a claimant meets the “test of disability, ” which is defined as:

Test of Disability
From the date that you first become disabled and until Monthly Benefits are payable for 24 months, you will be deemed to be disabled on any day if:
• you are not able to perform the material duties of your own occupation solely because of: disease or injury; and
• your work earnings are 80% or less of your adjusted predisability earnings.
. . . .
If your own occupation requires a professional or occupational license or certification of any kind, you will not be deemed to be disabled solely because of the loss of that license or certification.

Record (AR 7010004)

         The Plan defines “Material Duties” as duties that:

• are normally required for the performance of your own occupation; and
• cannot be reasonably: omitted or modified. However, to be at work in excess of 40 hours per week is not a material duty.

Record (AR 7010017)

         The Plan defines “Own Occupation” as:

This is the occupation that you are routinely performing when your period of disability begins. Your occupation will be viewed as it is normally performed in the national economy instead of how it is performed:
• for your specific employer; or
• at your location or work site; and
without regard to your specific reporting relationship.

Id.

         One of the overriding job functions for a Netjets pilot is to “[b]”e able to meet physical demands as outlined in the Physical Demands Summary of this Essential Job Functions form.” [Doc. 8-1] at 1. Among other requirements, and most relevant to Plaintiffs claim, the Physical Demands Summary lists the following tasks which a Netjets pilot must be able to perform:

Ascending or descending ladders, stairs, scaffolding, ramps, poles and the like, using feet and legs and/or hands and arms. Body agility is emphasized. This factor is important if the amount and kind of climbing required exceeds that required for ordinary locomotion: Climb or descend steep or narrow passageways such as stairways to aircraft; climbing on wings, to put engine covers on, up and down aircraft stairs.
. . . .
Balancing. Maintaining body equilibrium to prevent falling and walking, standing or crouching on narrow, slippery, or erratically moving surfaces. This factor is important if the amount of balancing exceeds that needed for ordinary locomotion and maintenance of body equilibrium.
. . . .
Crouching. Bending the body downward and forward by bending leg and spine.
. . . .
Standing. Particularly for sustained periods of time.
. . . .
Walking. Moving about on foot to accomplish tasks, particularly for long distances or moving from one work site to another: Sometimes may be required to run while carrying or pulling suitcase, kitbags, etc.
. . . .
Response to emergency situations. Must be able to override jammed or manually operative flight controls; operate and reset emergency exit handles; Ability to evacuate the airplane in an emergency from available exits effectively utilizing appropriate emergency equipment such as slides, rafts and other flotation devices; Ability to open window and evacuate cockpit via a rope in an emergency. Must be able to lift, turn and otherwise manipulate objects weighing up to 65 [pounds] during emergency procedures including emergency exit doors, and life-rafts. Must be able to apply at a minimum the following forces: pitch and roll (arm) control, two hands available 50-75 [pounds] of force; pitch and roll (arm) control, one hand available 25-50 [pounds] of force; yaw (leg) control exerting 150 [pounds] of force.

Id. at 1-3 (original emphasis omitted) (emphasis added).

         On May 11, 2012, Plaintiff underwent decompression surgery for lumbar stenosis, which was performed under the auspices of Dr. Timothy Adamson.[1] (AR 7000064)[2]. Following Plaintiff's general recovery, he returned to work on April 26, 2013. Id. On November 6, 2013, Plaintiff stopped working, alleging he suffered from disability, including lumbosacral spondylosis, tarsal tunnel syndrome, and significant leg weakness, and could no longer safely and reliably perform some of the essential job functions for a Netjets pilot. [Doc. 1] at 3; [Doc. 4] at 2. Plaintiff reported that his inability to depend on leg strength and stability precluded him from performing any duty listed on the capabilities worksheet that require use of his leg. (AR 7000212). More specifically, Plaintiff reported that “his right leg has weakness and will ‘give out' on him intermittently.” Record (AR 7000089). At Plaintiff's November 6, 2013, appointment, Dr. Adamson recommended a right L5-S1 epidural injection, referred Plaintiff to physical therapy, and noted that “[d]ue to the type of work that Mr. Cline does, we will have him remain out of work until his next office appointment.” (AR 7000271). Plaintiff underwent physical therapy from December 31, 2013 to February 24, 2014. Id. at AR 7000276. On February 26, 2014, Plaintiff followed-up with Dr. Adamson, who noted that “as part of his job duties [Plaintiff] does need to strengthen the lower extremities, since the right leg continues to give out from time to time we will have him remain out of work at this point.” Id. at AR 7000268.

         On or about May 5, 2014, the end of the elimination period and at least 180 days after the onset of his asserted disability, Plaintiff applied for LTD benefits. [Doc. 1] at 3; [Doc. 4] at 3. On May 24, 2014, Dr. Adamson ordered a right lower extremity electromyography (“EMG”) nerve conduction study, which was performed on June 5, 2014 by Dr. John Welshofer. (AR 7000234); (AR 7000234). Dr. Welshofer reported that the EMG revealed “[m]ild prolongation of the conduction velocity of the peroneal nerve around the fibular head, ” “a mild peroneal neuropathy at the fibular head, ” and “mild prolongation of the [right] medial and lateral plantar mixed sensory responses suggestive of a mild [right] tarsal tunnel compressive neuropathy, ” but no “electrodiagnostic evidence to diagnose a lumbar radiculopathy” or “other significant electrodiagnostic abnormalities.” (AR 7000237). Dr. John Lesher then ordered an ultrasound, which was performed on July 8, 2014. (AR 7000227); (AR 7000221). After reviewing the ultrasound, Dr. Lesher reported that he thought Plaintiff's symptoms are “related to chronic right S1 radiculitis given his sensory involvement affecting the lateral aspect of his foot and diminished right Achilles reflex.” (AR 7000223).

         On May 16, 2014, while Plaintiff underwent the evaluations described above, Defendant sent a letter to Dr. Adamson, asking him to confirm that Plaintiff was able to perform “Light Work.” Id. at AR 7000256-7000257. The letter defined “Light Work” as:

Light work involves lifting, carrying, pushing, or pulling 20 pounds occasionally, up to 10 pounds frequently, or negligible amount constantly. May include walking and/or standing frequently even though weight is negligible. May include pushing and/or pulling of arm and/or leg controls while sitting most of the time.

Id. Dr. Adamson signed the letter, confirming that Plaintiff could perform light work, subject to the caveat that “[t]here is concern he will not be able to use foot pedal effectively. He may work light duty if it does not involve flying.” Id. (emphasis added).

         On July 25, 2014, Defendant denied Plaintiff's LTD benefit claim, asserting that “[t]he medical information does not support your inability to perform the material duties of your own occupation based on the information currently noting no evidence of neuromotor loss of the lower extremities in particular the lower leg, ankle, foot that would result in ongoing functional loss of the right foot. Record (AR 7000166).

         On November 14, 2014, Plaintiff appealed Defendant's decision in the form of a letter and supporting correspondence from Dr. Adamson, Dr. Welshofer, and Dr. Allen Edwards, Plaintiff's Aviation Medical Examiner. Id. at AR7000212-7000218. Plaintiff's narrative states that, after his leg began collapsing at random times, he realized that “if [his] leg were to give out as it has and continues to do, that could result in injury to me and/or passengers ...


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