Law v. Aetna Life Insurance Company
MEMORANDUM OF DECISION. Signed by Judge James H Hancock on 1/21/2015. (JLC)
2015 Jan-21 AM 11:04
U.S. DISTRICT COURT
N.D. OF ALABAMA
IN THE UNITED STATES DISTRICT COURT
NORTHERN DISTRICT OF ALABAMA
AETNA LIFE INSURANCE CO.,
MEMORANDUM OF DECISION
The court has before it Cross-Motions for Judgment on the Administrative
Record (Docs. # 14 & 15).1 Pursuant to the court’s November 17, 2014 order (Doc.
#17), the motions were deemed submitted, without oral argument, on December 10,
2014. After thorough review of the briefs and administrative record, the court
concludes that summary judgment is due to be granted in favor of Defendant Aetna
Life Insurance Company for the reasons explained below.
I. Procedural History
Plaintiff Sidney Law commenced this action on December 17, 2013 by filing
The court also has before it Plaintiff’s Motion (Doc. # 18) to Strike. Because the court
concludes that Aetna’s decision was correct and does not have to consider the objectionable
evidence, the Motion (Doc. #18) to Strike is MOOT.
a Complaint (Doc. #1) in this court against Defendant Aetna Life Insurance
Company. Plaintiff’s Complaint set forth only one cause of action: wrongful denial
of disability benefits in violation of the Employee Retirement Income Security Act
of 1974, as amended, (ERISA), 29 U.S.C. §§ 1001, et seq. Defendant responded with
an Answer (Doc. #4) on February 14, 2014. On October 31, 2014, the Cross-Motions
for Judgment on the Administrative Record (Docs. # 14 & 15) were filed.
Defendant’s Motion (Doc. #15) for Judgment asserts that the Aetna’s determination
that the plan at issue excluded coverage for Plaintiff’s alleged disability that was
contributed to by a pre-existing condition was correct, and, even if incorrect, it was
not arbitrary and capricious. Plaintiff’s Motion (Doc. #14), however, contends that
Aetna’s “denial of his disability claim was de novo wrong and arbitrary and
capricious, and that he is entitled to disability benefits in the amount of $2,283.93 per
month from April 27, 2013 for the first 24 months under the plan, and that Aetna must
place Mr. Law on disability status at least until the 24 months disability definition
ends.” (Doc. #14 at 1.)
Both parties have filed briefs and submitted evidence in support of their
respective positions. Plaintiff submitted a brief (Doc. #14) and evidence2 (Doc. #16)
Plaintiff submitted the following evidence under seal in support of his Motion: medical
records; long term disability plan at issue; short term disability plan payment records; Aetna
claim file records; Aetna letter dated 4/4/2013; Aetna letter dated 5/17/2013; Law letter dated
in support of his motion on October 31, 2014. On December 3, 2014, Defendant filed
a brief (Doc. # 23) in opposition to Plaintiff’s Motion, and on December 10, 2014,
Plaintiff filed a brief (Doc. #24) in reply. On October 31, 2014, Defendant submitted
a brief and evidence3 (Doc. # 15) in support of its own Motion for Judgment on the
Administrative Record. On December 3, 2014, Plaintiff filed a brief (Doc. # 22) in
opposition to Defendant’s Motion, and on December 10, 2014, Defendant filed a brief
(Doc. # 25) in reply to Plaintiff’s opposition.
II. Findings of Fact
A. The Plan
Long term disability (LTD) benefits under the Plan are funded by Group Policy
No. GP-511745-GI (“the Group Policy”) which was issued by Aetna to Walpole, Inc.
(Def. Exh. 2). Plaintiff was employed by Walpole, Inc. as a truck driver and was a
participant in the Plan. (Admin. Rec. at CL000246, 258, 296.) The Group Policy
confers Aetna with discretionary authority to determine whether and to what extent
6/10/2013; Aetna letter dated 7/24/2011; physician review report by Kathryn Ko, MD, contract
between MES Solutions and Aetna and statement of payments to MES Solutions for 203;
physician review report by Wendy Weinstein, MD, contract between Wendy Weinstein and
Aetna, and statement payment to Wendy Weinstein for 2013; information packets supplied to Dr.
Ko and Dr. Weinstein by Aetna; Aetna letter dated 8/15/2013; letter from counsel for Law to
Aetna dated 9/6/2013; Aetna letter dated 10/24/2013; Aetna LTD Pre-Existing Conditions P & P
manual; answers to interrogatories and document request by Aetna.
Defendant submitted the following evidence in support of its Motion: affidavit of Debra
Comar with exhibits; the Group Policy; and the administrative record.
eligible employees and beneficiaries are entitled to benefits and to construe any
disputed or doubtful terms under this Policy, the Certificate or any other documents
incorporated therein.” (Def. Ex. 2 at GP000016.) LTD benefits are payable under the
Plan to eligible participants who are “disabled” as defined by the Plan bookletcertificate. (Admin. Rec. at CL000186.) The booklet states as follows regarding
A pre-existing condition is an illness, injury or pregnancyrelated condition for which, during the 12 months before
your coverage or increase in coverage became effective:
You were diagnosed or treated; or
You received diagnostic or treatment services; or
You took drugs that were prescribed or
recommended by a physician.
The Plan does not pay benefits for a disability that is
caused, or contributed to, by a pre-existing condition, if the
disability starts within the first 24 months after your
coverage goes into effect.
(Id. at CL000189.)
B. Plaintiff’s Medical History, Spine Surgery and Short Term Disability Claim
Plaintiff has a long history of problems with back pain. On July 12, 2011,
Plaintiff saw Dr. Katherine Moore. (Id. at CL000305.) Plaintiff reported to Dr.
Moore that he had chronic back pain, which required pain medication three or four
times per year, and brought Lortab pills with him that were dated 2009. (Id.) Dr.
Moore prescribed Plaintiff Lortab for “arthritis.” (Id.) Plaintiff filled prescriptions
for hydrocodone and methocarbamol in July, August and October 2011. (Id. at
On December 4, 2011, Plaintiff went to see Dr. Dallas C. Wilcox, Jr. due to a
cut on his arm and requested a tetanus shot. (Id. at CL000278-79.) Plaintiff reported
to Dr. Wilcox that he fell and injured his back. (Id.) Dr. Wilcox noted “[m]oderate
spasm of the lumbar area,” and he gave Plaintiff a prescription for Robaxin. (Id.)
On September 17, 2012, Plaintiff saw Dr. Charles H. Clark III for pain in his
back. (Id. at CL000137-38.) Dr. Clark noted Plaintiff’s “long history of back pain.”
(Id. at CL000153.)
Dr. Clark stated that the pain “radiate[s] to both hips
intermittently. Activity and weightbearing exacerbates the pain.” (Id.) Past
treatment included “epidural blocks” which “have provided temporary relief.” (Id.)
Plaintiff also complained of chronic neck pain and right shoulder discomfort, but “no
clearcut radicular symptoms.” (Id.) Dr. Clark also noted that Plaintiff had been
prescribed Robaxin and Lortab by another physician. (Id.) Dr. Clark diagnosed
Plaintiff with “[c]ervical and lumbar spondylosis4 with stenosis in the lumbar region.”
“Spondylosis refers to degeneration of the spine. . . . Most often, the term spondylosis
is used to describe osteoarthritis of the spine, but it is also commonly used to describe any
manner of spinal degeneration.” Spine-health,
(last visited January 16, 2015).
(Id.) Dr. Clark ordered a lumbar and cervical myelogram5 and post myelogram CT
scans. (Id. at CL000138.) Dr. Clark’s notes stated that the tests revealed as follows:
bilateral pars defects at L5 with grade 1 spondylosis. HE
also has severe foraminal stenosis bilaterally at L5-S1. I
feel this explains his bilateral hip pain. There is also disc
degeneration at C5-6 on the cervical study. No cervical
stenosis is noted. The lower back symptoms are worse.
(Id. at CL000153.)
After review of the tests and “[d]ue to long-standing pain unresponsive to
conservative treatment,” Dr. Clark recommended the “possibility of posterior
interbody fusion with pedicle screws and lateral mass fusion L5-S1.” (Id.) Dr. Clark
discussed the procedure with Plaintiff, including the risks and benefits, and Plaintiff
wanted to go ahead with the surgery. (Id.)
Plaintiff’s last day of work was on October 29, 2012, and, on October 31, 2012,
he underwent a lumbar interbody fusion procedure. (Id. at CL 000150-53, 311.)
Following the surgery, Plaintiff submitted a claim for short term disability (STD)
benefits. (Id. at CL000329-43.) The claim was based on a diagnosis of lumbar
spondylosis resulting in “severe [lower back pain] that radiates both hips
“A myelogram is a diagnostic imaging procedure done by a radiologist. It uses a
contrast dye and X-rays or computed tomography (CT) to look for problems in the spinal canal,
including the spinal cord, nerve roots, and other tissues.” Johns Hopkins Medicine,
70/ (last visited January 16, 2015).
intermittently.” (Id.) Plaintiff’s anticipated return to work was 3 to 12 weeks postsurgery. (Id.) Plaintiff was initially approved for 91 days of STD benefits, beginning
October 29, 2012. (Id. at CL000402.)
In a January 16, 2013 letter, Dr. Clark stated that Plaintiff was “under his care
and [would] be out of work until further notice.” (Id. at CL000237.) Handwritten
diagnoses of “lumbar spondylosis” and “cervical spondylosis” were included in the
About a month later, and approximately three and a half months after surgery,
on February 15, 2013, Plaintiff saw Dr. Clark again and stated that although his “[l]eft
leg pain ha[d] improved from the preoperative status,” Plaintiff continued to have
“significant lower back pain intermittently extending to his hip and lateral thigh.”
(Id. at CL000157.) Dr. Clark ordered a lumbar CT scan, and it showed the following:
(1) “sclerosis along the inferior endplate of free L5, overlying the anterior part of the
disc spacer bilaterally”; (2) spondylosthesis at the L5-S1 disc level that remained
“unchanged”; (3) a bulging disc at L4-L5; and (4) “a mild degree of bony canal
stenosis” at the L3-L4 level. (Id. at CL000158-59.)
On March 7, 2013, Dr. Clark noted that Plaintiff continued to have “left hip
and lateral thigh pain” and that there “appears to be a small osteophyte in the left L5S1 neural foramen encroaching on the L5 nerve root.” (Id. at CL000160.) Dr. Clark
stated that he would refer Plaintiff for a transformational block at L5-S1 on the left,
and if that did not provide relief, he would “see him again for consideration of
foraminotomy6 at L5-S1 on the left.” (Id.) On March 20, 2013, Plaintiff underwent
a left L4-L5 transforaminal epidural steroid injection.7 (Id. at CL000161.)
Plaintiff returned to Dr. Clark on April 22, 2013, and he noted that Plaintiff
was “improved after lumbar epidural block,” that there was no significant hip and leg
pain, and that Plaintiff’s primary complaint was “posterior cervical pain.” (Id. at
CL000163.) Dr. Clark reviewed Plaintiff’s cervical myelogram done on September
27, 2012, which showed C5-6 spondylosis and degenerative disc disease, and
suggested a “cervical epidural block at C5-6 since this [was] now the main symptom.”
(Id.) In a form written the next day, Dr. Clark stated that Plaintiff was “still in [the]
recovery phase of lumbar fusion surgery on 10/31/12,” diagnosed Plaintiff with “post
op lumbar fusion/continued pain,” and estimated Plaintiff’s return to work date as
May 31, 2013. (Id. at CL000288.)
“A foraminotomy is a decompression surgery that is performed to enlarge the
passageway where a spinal nerve root exits the spinal canal. The term foraminotomy is derived
from the medical term for a hollow passageway—foramen. The latter half of the term
foraminotomy—otomy—means to open.” Spineuniverse,
(last visited January 16, 2015).
Based on all of the above, Plaintiff’s STD benefits were extended four times. (Admin.
Rec. at CL000402, 407, 413, 417.) Plaintiff exhausted his STD benefits on May 5, 2013. (Id. at
C. Plaintiff’s Long Term Disability Claim, Denial and Appeal
On March 21, 2013, anticipating the exhaustion of his STD benefits, Aetna
notified Plaintiff that it was going to evaluate his eligibility for LTD benefits. (Id. at
CL000074.) During a telephone interview on March 28, 2013, Plaintiff stated that
his back condition was not related to any injury and “his symptoms started developing
over the years.” (Id. at CL000029.) Plaintiff reported to Aetna that he had a bone
spur that was aggravating and causing nerve pain, and although he continued to have
back pain, it was getting better every day. (Id.)
On March 25, 2013 and again on April 2, 2013, Aetna wrote to Plaintiff’s
employer, Walpole, Inc., seeking confirmation of several dates, including Plaintiff’s
last scheduled day of work, his first date of absence from work, and that date he was
eligible to enroll for LTD under the Plan. (Id. at CL000308.) Walpole replied on
April 4, 2013, and stated that Plaintiff enrolled for LTD coverage on February 1,
2012.8 (Id. at CL000307.)
After receiving that information, on April 4, 2013, Aetna sent Plaintiff a letter
regarding his LTD claim. (Id. at CL000106.) Aetna stated that it was conducting a
pre-existing condition investigation since his claim was asserted within 24 months
Plaintiff was actually eligible to enroll for LTD coverage in February 2009, but he did
not enroll until February 1, 2012. (Admin. Rec. at CL000307.)
of his effective date of LTD coverage. (Id.) Aetna reviewed all the medical
documents discussed in Section II. B. during this review.
By letter dated May 17, 2013, Aetna informed Plaintiff that his LTD claim was
denied under the pre-existing condition exclusion in the Plan. (Id. at CL000250-51.)
Aetna determined that (1) Plaintiff’s disability was contributed to by a pre-existing
condition for which he was diagnosed or treated, or for which he received diagnostic
or treatment services, or for which he took prescription drugs in the 12 months before
his LTD coverage became effective, and (2) his disability started within 24 months
after his LTD coverage went into effect. (Id.) Aetna noted that Plaintiff’s LTD
coverage became effective February 1, 2012, and Plaintiff became disabled on
October 29, 2012. (Id.) Therefore, the “look-back” period for Plaintiff’s LTD claim
was February 1, 2011 through January 31, 2012. (Id.)
In explaining its denial decision, Aetna cited the medical records from Drs.
Moore and Wilcox, noting that Plaintiff reported back pain and back spasms in July
2011 and December 2011, and that both doctors prescribed medicine to treat the
condition. (Id.) Aetna also cited pharmacy records, emphasizing that Plaintiff was
prescribed Robaxin and hydrocodone in July and October 2011. (Id.) Based on this
information, Aetna concluded that the condition for which Plaintiff was claiming
disability – lumbar spondylosis with subsequent lumbar fusion surgery – was
contributed to by his pre-existing condition of chronic back pain. (Id.)
Plaintiff appealed the denial decision by letter dated June 10, 2013, and argued
that the visits to Dr. Moore and Dr. Wilcox were unrelated to the back condition for
which he had undergone surgery. (Id. at CL000268-69.) Plaintiff admitted to seeing
Dr. Moore with “a history of back pain that began earlier in  and had been
going on for about 4 months” after he “stepp[ed] out of the truck and into a hole and”
fell. (Id.) Plaintiff said that after that incident, he “experienced lower back pain
whenever [he] stood for a long period of time, usually over 30 minutes.” (Id.)
Plaintiff explained that Dr. Moore referred him to an orthopedist, Dr. William
Burkhalter, who “took x-rays and ordered an MRI which revealed a fracture in
[Plaintiff’s] spine.” (Id.) Plaintiff further stated that Dr. Burkhalter “immediately
removed [Plaintiff] from work and had [him] fitted for a brace,” and eventually
released Plaintiff to work in October 2011. (Id.)
As for his visit to Dr. Wilcox in December 2011, Plaintiff stated that the visit
was for “a slip, not a fall, while working on [his] house,” which resulted in a cut on
his arm and a pulled muscle in his “upper back and shoulder area.” (Id.) Plaintiff
insisted that it was “complete[ly] unrelated to the lower back lumbar fusion surgery
in October 2012. (Id.) Plaintiff admitted that Dr. Wilcox prescribed “muscle
relaxers,” but contended they were for “stiffness” in the upper back and shoulder area.
According to Plaintiff, the condition resulting in his surgery began in the
“summer of 2012" when he “began experiencing a radiating pain from [his] hip which
at times prevented motion and severely limited [his] ability to walk.” (Id.) Plaintiff
said this pain is what prompted him to seek treatment from Dr. Clark, who
“performed tests and discovered the nerves were agitated due to the condition which
resulted in the need for the lower back lumbar fusion surgery.” (Id.)
After receiving this appeal, Aetna began the review process of its denial.
Aetna submitted Plaintiff’s medical records for independent review by two physicians
– Dr. Wendy Weinstein, a board-certified internal medicine doctor, and Dr. Kathryn
Ko, a board-certified neurological surgeon. (See id. at CL000216-19, CL000222-27.)
Dr. Weinstein concluded that during the look-back period of February 1, 2011
through January 31, 2012, Plaintiff (1) was diagnosed and treated for chronic back
pain by Dr. Moore and Dr. Wilcox, (2) received diagnostic and treatment services by
the same two doctors, and (3) was prescribed medications for chronic pain and muscle
spasms (Lortab and methocarbamol). (Id. at CL000225-26.)
Similarly, Dr. Ko concluded that during the look-back period, Plaintiff was
diagnosed and treated for lumbar spondylosis, received treatment services for lumbar
spondylosis, and was prescribed pain medicine (hydrocodone) and a muscle relaxer
(methocarbamol). (Id. at CL000218.) More specifically, Dr. Ko explained as
The claimant has a history of low back pain. Trauma in the
form of lumbar fracture can be contributory to future spine
degenerative conditions and lead to surgical intervention
such as spine fusion. . . . Based on these records [and the
prescriptions], and in the absence of clarification by the
claimant’s own spine surgeon9 it appears that the claimant
had treatment for lumbar derangements from 2/1/11 and
On August 13, 2013, Aetna informed Plaintiff that its LTD benefits decision
was upheld on appeal. (Id. at CL000128.) Aetna reiterated the contents of Plaintiff’s
treatment records with Dr. Moore and Dr. Wilcox, as well as the pharmacy records,
and emphasized the conclusions of the two independent physicians who reviewed the
documents during the appeal process. (Id.) Aetna concluded that Plaintiff’s
“disability of lumbar spondylosis was caused or contributed to by a pre-existing
condition” and informed Plaintiff that he had exhausted his appeals under the Plan.
Dr. Ko’s review was sent to Dr. Clark on August 7, 2013, and his input was solicited.
(Admin. Rec. at CL000213.) Specifically, Dr. Clark was asked to let Aetna know if he disagreed
with the conclusions of Dr. Ko, but he did not respond. (Id.; Id. at CL000128.) Additionally, Dr.
Ko attempted to discuss Plaintiff’s condition with Dr. Clark on August 13, 2013, but was
informed that Dr. Clark did not conduct peer-to-peer conferences for disability claims. (Id. at
On September 13, 2013, Plaintiff’s attorney wrote a letter to Aetna stated that
he represented Plaintiff in connection with the appeal and submitted additional
records from Dr. Clark and records from Dr. Burkhalter.10 (Id. at CL000169-173.)
Although Plaintiff’s right to appeal was already exhausted, Aetna reviewed the new
information. (Id. at CL000069.) Its decision did not change. (Id.) By letter dated
October 24, 2013, Aetna informed Plaintiff’s counsel of the affirmance of the
decision and reiterated the grounds for the denial. (Id. at CL000132.)
III. Standard of Review
ERISA “permits a person denied benefits under an employee benefit plan to
challenge that denial in federal court.” Metro. Life Ins. Co. v. Glenn, 554 U.S. 105,
108 (2008) (citing 29 U.S.C. § 1132(a)(1)(B)). ERISA itself does not provide a
standard for courts reviewing benefits decisions made by plan administrators or
fiduciaries. Blankenship v. Metro. Life Ins. Co., 644 F.3d 1350, 1354 (11th Cir.
2011) (citing Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 109 (1989)), but
the Eleventh Circuit has “established a multi-step framework to guide courts in
reviewing an ERISA plan administrator’s benefits decisions” in light of recent
decisions of the Supreme Court Id. The steps are as follows:
A medical record from Dr. Burkhalter dated June 1, 2012, indicated that Plaintiff
presented with right arm pain and shoulder pain, was assessed with a “partial rotator cuff tear”,
and prescribed anti-inflammatories. (Admin. Rec. at CL000173.)
(1) Apply the de novo standard to determine whether the
claim administrator’s benefits-denial decision is “wrong”
(i.e., the court disagrees with the administrator's decision);
if it is not, then end the inquiry and affirm the decision.
(2) If the administrator’s decision in fact is “de novo
wrong,” then determine whether he was vested with
discretion in reviewing claims; if not, end judicial inquiry
and reverse the decision.
(3) If the administrator’s decision is “de novo wrong” and
he was vested with discretion in reviewing claims, then
determine whether “reasonable” grounds supported it
(hence, review his decision under the more deferential
arbitrary and capricious standard).
(4) If no reasonable grounds exist, then end the inquiry and
reverse the administrator’s decision; if reasonable grounds
do exist, then determine if he operated under a conflict of
(5) If there is no conflict, then end the inquiry and affirm
(6) If there is a conflict, the conflict should merely be a
factor for the court to take into account when determining
whether an administrator's decision was arbitrary and
Wayton v. United Mine Workers of America Health and Retirement Funds, 2014 WL
2566092 *3 (11th Cir. 2014). This court’s review of Aetna’s decision is limited to
“consideration of the material available to the administrator at the time of the
decision.” Blankenship, 644 F.3d at 1354 (citing Jett v. Blue Cross & Blue Shield,
890 F.2d 1137, 1140 (11th Cir. 1989)).
The claimant has the burden of proving entitlement to ERISA benefits. Glazer
v. Reliance Std. Life Ins. Co., 524 F.3d 1241, 1248 (11th Cir. 2008). Plaintiff “bears
the burden of proving that [Aetna’s] decision is wrong.” Id. at 1247. If Plaintiff
satisfies this burden, he “then must demonstrate that [Aetna’s] decision to deny [his]
LTD benefits was arbitrary and capricious; that is, he must show that no reasonable
grounds support [Aetna’s] decision.”11 Id.
As discussed in detail above, Aetna denied Plaintiff’s LTD claim because it
concluded that Plaintiff’s disability was contributed to by a pre-existing condition.
First, the court must decide whether Aetna’s decision was correct. If it was, the
inquiry ends. If it was incorrect, the court must then go on to the next steps int eh
ERISA analysis and ultimately decide whether the decision was arbitrary and
A. Aetna’s Decision Denying Benefits Was Correct
The court “looks to the plain language of Defendant’s policy” for the definition
The parties dispute whether the Plan granted Aetna discretionary authority in reviewing
claims - Plaintiff contends that it did not and Defendant contends that it did. It is clear from the
Plan documents before the court, including both the Group Policy and the Plan bookletcertificate, that the Plan granted Aetna discretionary authority in reviewing claims.
of pre-existing condition and for when it applies to a LTD claim. See Fath v. Unum
Life Ins. Co. of Am., 982 F.Supp 1147, 1151 (M.D. Fla. 1996). The Plan here
provides a specific definition of a pre-existing condition as “an illness, injury or
pregnancy-related condition for which, during the 12 months before . . . coverage .
. . became effective” one of the following three things have occurred: (1) claimant
was diagnosed or treated for the condition; (2) claimant received diagnostic or
treatment services for the condition; or (3) claimant took drugs that were prescribed
or recommended by a physician for the condition. (Admin. Rec. at CL000189.)
Further, the Plan states that it “does not pay benefits for a disability that is caused, or
contributed to, by a pre-existing condition, if the disability starts within the first 24
months after your coverage goes into effect.” (Id.)
“Next, the court reviews Plaintiff’s medical history, . . . medical notes and
studies” to determine if he was diagnosed with, received treatment for, or took drugs
prescribed by a physician for the disabling condition during the relevant period. Fath,
928 F. Supp. at 1151. It is undisputed that Plaintiff’s date of disability was October
29, 2012, which was within the 24 months after coverage was effective, and the date
of effective coverage was February 1, 2012. Therefore, the 12-moth look-back period
was from February 1, 2011 through January 31, 2012.
The evidence in the administrative record before the court is crystal clear that
Plaintiff’s disabling condition was caused by, or was contributed to, by a pre-existing
condition under the terms of the Plan. Plaintiff claims to be disabled due to back pain
from degenerative spinal problems, diagnosed as spondylosis. In the relevant medical
records, Dr. Clark repeatedly notes Plaintiff’s “long history or back pain, and on
October 31, 2012, due to this “long-standing pain unresponsive to conservative
treatment,” Plaintiff underwent a posterior lumbar interbody fusion. Before the
surgery, Dr. Clark reviewed a lumbar MRI from a year earlier, indicating “moderate
L4-5 stenosis and possible spondylosis.”
In July 2011, Plaintiff reported to Dr. Moore that he had chronic back pain that
required pain medication three or four times a year, and Dr. Moore prescribed Lortab
for “arthritis.” In December 2011, Plaintiff told Dr. Wilcox that he injured his back.
Dr. Wilcox noted “[m]oderate spasm of [the] lumbar area” and prescribed Robaxin.
Plaintiff was also treated by Dr. Burkhalter in the summer of 2011 for back pain, and
he reportedly ordered an MRI showing a fracture of Plaintiff’s spine.
From these medical records, it is clear that Plaintiff was diagnosed and treated
for chronic back pain and “lumbar derangements,” received diagnostic and treatment
services for the condition, and was prescribed pain medication for back pain and back
spasms during the look-back period. Each of those, separately and in combination,
qualified under the Plan to exclude Plaintiff’s disabling condition under the pre18
existing conditions provision.
Plaintiff’s explanations for his visits to Dr. Moore and Dr. Wilcox are not
supported by the medical records.
Moreover, his argument that these earlier
treatments for his chronic back pain are somehow separate and apart from his
disabling condition have no merit. The court refuses to separate the two when the
medical evidence clearly does not. There is no evidence in the record to show that
the disabling pain was not caused by, or contributed to, these older complaints of
back pain.12 See Griswell v. Reliance Standard Life Ins. Co., 209 Fed. Appx. 888
(11th Cir. 206) (affirming district court’s decision that “because [plaintiff] was treated
for the same conditions and symptoms [chronic back pain and degenerative spinal
issues] both during the . . . ‘look back’ period and as part of his treatment in
connection with his disability claim, the plain and unambiguous terms of the ‘preexisting condition’ provision excluded [plaintiff] from coverage).
Plaintiff has not met his burden of proving that Aetna’s determination that the preexisting condition provision precludes his claim for benefits is wrong. Therefore, the
decision must be affirmed.
The court rejects Plaintiff’s argument that “Aetna mischaracterized the evidence by
translating back pain and chronic back pain to lower back pain.” (Doc. # 14 at 20.) The welldocumented degenerative lumbar condition and the long history of back pain leads to the logical
conclusion that the back pain and spasms described to Dr. Moore and Dr. Wilcox, for which he
took prescription pain medication, and for which ultimately required spinal surgery, are
B. There are Reasonable Grounds for Aetna’s Decision
Under the multi-step ERISA framework, the court’s inquiry ends after the court
determines that Aetna’s decision was correct. Blankenship, 644 F.3d at 1355.
However, alternatively and additionally, the court concludes, consistent with the
discussion above, that even if Aetna’s decision was wrong (and to be clear, the court
finds that it was not), there were “reasonable” grounds in the record which support
Aetna’s decision. Because reasonable grounds exist to support the denial decision,
it is unnecessary for the court to determine if Aetna operated under a conflict of
interest. Therefore, this court’s consideration of Plaintiff’s ERISA claim is at its end.
Aetna’s decision is due to be affirmed. A separate order will be entered
dismissing this case with prejudice.
DONE this the
day of January, 2015.
SENIOR UNITED STATES DISTRICT JUDGE
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