Sixth Circuit Reverses District Court Ruling Affirming a Partial Denial of ERISA Long-Term Disability Benefits

Aug 24, 2015 - Articles by

Melissa McKenna worked as an Administrative Assistant at Dow Corning Corporation where she received Long-Term Disability (LTD) group coverage provided by Aetna Life Insurance Company (Aetna). Ms. McKenna suffered from low back pain for many years, with a bulging disc first revealed in a 2010 MRI. Even with a bulging disc, Ms. McKinna continued to work until March 2012, when she was admitted to the hospital with a high pain level. Ms. McKinna was admitted again in April 2012 and began a treatment regimen with a pain management clinic, surgical injections, physical therapy, and treatment with a neurosurgeon, rheumatologist, physical medicine and rehabilitation doctor.

The Aetna LTD plan covering Dow Corning Corporation employees includes an “own occupation” disability standard for the first twenty-four months of LTD benefits, followed by an “any occupation” disability standard. Following the 180-day elimination period in the Aetna LTD policy, Ms. McKenna submitted her claim for LTD benefits. Aetna denied Ms. McKenna’s claim in October 2012 “based on a reviewing nurse’s opinion that the medical records would not support an inability to sit, stand, walk, bend, use upper or lower extremities, etc. to perform work duties.” McKenna v. Aetna Life Ins. Co., No. 14-2445, 2015 WL 4880042, at *3 (6th Cir. Aug. 14, 2015) (Internal quotation marks omitted). While continuing to receive treatment, including additional MRI, discogram, and CT scans, in March 2013 Ms. McKenna submitted her appeal of Aetna’s October 2012 denial of her LTD benefits, including the additional test results and medical records. As Aetna reviewed Ms. McKenna’s appeal, she continued treatment with her Neurosurgeon. In May 2013, Aetna approved Ms. McKenna’s benefits through February 2013 and denied benefits beyond February 2013, based on the conclusions of Aetna’s physician, Dr. Stuart Rubin, who performed a file review of Ms. McKenna’s medical records.

Following Aetna’s denial of Ms. McKenna’s LTD benefits, she filed suit in the Eastern District of Michigan, alleging Aetna and Dow Corning breached the terms of the LTD Plan when Aetna denied disability benefits beyond February 2013. The district court affirmed the denial of benefits and Ms. McKenna appealed to the United States Court of Appeals for the Sixth Circuit. Both the district court and circuit court determined that Aetna’s denial of benefits was to be reviewed de novo, as the benefit plan did not give the plan administrator discretionary authority to determine eligibility for benefits. A de novo review requires the court to determine “whether Aetna properly interpreted the Plan and whether [Ms. McKenna] was entitled to benefits under the Plan.” Id., at *5.

First, the circuit court determined that the district court did not do a proper de novo review when it upheld the Aetna’s denial of benefits. Second, after its own review, the Sixth Circuit found that Ms. McKenna was entitled to benefits through February 2013 based upon the medical records, and Aetna was to determine the scope of her entitlement to benefits beyond that point. In determining that Ms. McKenna was entitled to benefits through February 2013, the court was critical of the file review performed by Aetna’s physician, noting:

Dr. Rubin fails to explain the basis for his opinion that [Ms. McKenna]’s condition and symptoms—which he agreed both prevented her from performing the material duties of her occupation and had exhibited a chronic pattern—would continue only through [February 2013].

Id., at *6. The court recognized that Ms. McKenna’s neurosurgeon gave a return to work date of February 2013 in his initial evaluation of her, but on subsequent examination and testing, determined Ms. McKenna still suffered from a number of conditions and that a return to work could cause permanent nerve damage or paralysis. This led the court to remark that:

For this reason, and because Dr. Rubin neither conducted his own physical examination of [Ms. McKenna] nor offered any other explanation as to why he believed [her] condition and symptoms would continue only through [February 2013], we give little weight to his opinion that her abnormal findings would be expected to continue only through that date.

Id. Finally, in finding for Ms. McKenna, the Sixth Circuit concluded that she “unquestionably” met her burden to prove that she was entitled to LTD benefits when she proved “that her condition resulted in functional impairments that prevented her from performing the material duties of her own occupation through” February 2013. Id. at *7. Therefore, the circuit court determined Ms. McKenna was entitled to benefits beyond February 2013 and sent the case back to Aetna to determine the proper amount of benefits she was entitled to receive.