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Arning v. Aetna Life Insurance Co.

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

July 18, 2019




         THIS MATTER is before the Court on “Defendant's Motion for Summary Judgment” (Doc. 16) and “Plaintiff's Motion for Summary Judgment” (Doc. 18) as well as the parties' associated briefs, affidavits, and exhibits. See Docs. 16, 17, 18, 19, 20, 21 and 22.

         The parties have consented to Magistrate Judge jurisdiction under 28 U.S.C. § 636(c), and this Motion is now ripe for the Court's determination.

         Having carefully considered the parties' arguments, the record, and the applicable authorities, the Court grants Defendant's Motion for Summary Judgment and denies Plaintiff's Motion for Summary Judgment as discussed below.


         This is an action for declaratory and injunctive relief as well as payment of long term disability (LTD) benefits under to the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. § 1001. The Court has jurisdiction over the controversy pursuant to 29 U.S.C. § 1132(e)(1). Plaintiff alleges a physical and mental disability. Taking the facts in the light most favorable to Plaintiff, he was employed as President of Arndt & Herman Building Products Division (Arndt & Herman) of ECMD, Inc.

         Plaintiff was a full-time employee of ECMD, Inc. and at all times was a covered beneficiary under its Long Term Disability Executives Plan (Plan). The Plan plainly states with respect to “Long Term Disability Benefit Eligibility: ‘You will be considered disabled while covered under this . . . Plan on the first day that you are disabled as a direct result of a significant change in your physical or mental conditions and you meet all of the following requirements:' “(1) be covered by the Plan; (2) be under a physician's regular care; and (3) be disabled by illness or injury” as determined by Aetna's Test of Disability.” (AR 272). The Test for Disability states, “You meet the test of disability on any day that: You cannot perform the material duties of your own occupation solely because of an illness, injury, or disabling pregnancy-related condition;. . ..” Own occupation means “[t]he occupation you are routinely performing when disability begins, and is “viewed as it is normally performed in the national economy rather than for specific employers.” (AR 288). Aetna has “discretionary authority to determine whether and to what extent eligible employees and beneficiaries are entitled to benefits and to construe any disputed or doubtful terms under this Policy, the Certificate or any other document incorporated.” (AR 1501).

         On September 15, 2015 ECMD, Inc. admonished Plaintiff for failure to adhere to business hours and/or to adequately apprise his employer of his whereabouts and activities outside the office. (AR 674). Plaintiff received a memo on September 21, 2015 regarding issues with his work performance and the overall financial performance of the division. Prior to Plaintiff's termination Arndt & Herman was not performing well financially. (AR 675). On January 4, 2016, Plaintiff was terminated for poor performance.

         Prior to his termination, Plaintiff underwent a series of medical procedures from 1973 to 2013 including inguinal hernia repair, left total hip replacement, right total knee replacement, right rotator cuff repair, right pectoralis tendon repair, and resection of left first rib secondary to a benign tumor, laminectomy of the lumbosacral spine to address left leg pain in 2008, and a laminectomy to address left leg and right hip pain in 2013. He continues to experience back, leg, and hip pain, pain and stiffness in his hands and wrists, and inguinal neuralgia. None of Plaintiff's injuries or medical procedures are work related. Following the laminectomy in 2013, Plaintiff experienced increased pain in his groin area. He was diagnosed by his treating physician, Dr. Hans Hansen, with lumbar degenerative disc disease (primary), inguinal neuralgia (secondary), and peripheral neuropathy (other). (AR 1412). The diagnosis indicated that Plaintiff was capable of light work, defined as “[e]xerting up to 20 pounds of force occasionally and/or up to 10 pounds of force frequently.” (AR 1413). A Capabilities and Limitations Worksheet from Dr. Hansen indicated Plaintiff could frequently lift up to twenty pounds.

         On January 5, 2016, one day following his termination from ECMD, Inc., Plaintiff filed an application for LTD with Aetna. Neither party to this action raises an issue with Plaintiff filing for benefits after termination from his employment. At no point during his employment did Plaintiff apply for disability benefits. Plaintiff was notified by Aetna on January 8, 2016 that he was not eligible to file for LTD because he had not satisfied the ninety-day elimination period. Plaintiff became eligible to file for benefits on April 4, 2016. On March 28, 2016 Aetna requested a thirty-day extension to review Plaintiff's request. On May 10, 2016, Aetna issued a letter to Plaintiff denying his disability benefits. The letter stated, “[t]here is no support for impairment that would prevent you from performing the material duties of your occupation” as President as viewed in the national economy. Plaintiff timely appealed the initial decision. Aetna assigned Dr. Rajesh Kannon, a specialist in Occupational Medicine, to review the appeal. Dr. Kannon's findings were based upon a complete review of the record including supplemented materials provided by Plaintiff on appeal. Aetna also conducted a two-day period of video surveillance of Plaintiff which revealed his ability to sit at a ninety-degree angle for thirty minutes. This observation conflicts with the treating physician's finding that Plaintiff could not sit at a ninety degree angle. Dr. Kannon stated:

There is no credible evidence to restrict [Plaintiff's] sitting based on medical risk, however, taking into consideration of his consistent reports of pain and demonstrated ability while on surveillance the following restriction to sitting is reasonable and very permissive. Sitting restricted on frequent basis, with change of position for [five] 5 minutes every [thirty] 30 minutes for standing and walking.

         A final administrative denial of Plaintiff's claim was issued on June 22, 2017.


         A. Summary Judgment

         Federal Rule of Civil Procedure 56(a) provides:

A party may move for summary judgment, identifying each claim or defense-or the part of each claim or defense-on which summary judgment is sought. The court shall grant summary judgment if the movant shows that there is no genuine dispute as to any material fact and the movant is entitled to judgment as a matter of law. The court should state on the record the reasons for granting or denying the motion.

Fed.R.Civ.P. 56(a). The Rule provides procedures for establishing the presence or absence of any genuine dispute as to any material fact:

(c) Procedures.
(1) Supporting Factual Positions. A party asserting that a fact cannot be or is genuinely disputed must ...

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