Billue v. AETNA Life Insurance Company et al
ORDER denying Plaintiff's motion for summary judgment, Doc. 21 , and granting Defendant's motion for summary judgment, Doc. 23 . Signed by Judge Nanette Laughrey on 6/5/2015. (Hatting, Elizabeth)
IN THE UNITED STATES DISTRICT COURT FOR THE
WESTERN DISTRICT OF MISSOURI
JOY M. BILLUE,
AETNA LIFE INSURANCE COMPANY,
Pending before the Court are the cross motions for summary judgment of Plaintiff
Joy Billue and Defendant Aetna Life Insurance Company. [Docs. 21 and 23]. For the
reasons set forth below, Defendant’s motion for summary judgment, Doc. 23, is granted.
Plaintiff’s motion for summary judgment, Doc. 21, is denied.
Billue’s Benefits and the Plan Document
Billue worked as a utility operator for Hubbell Power Systems in Centralia,
Missouri until May 26, 2011. [R. 335]. The job description for this position is as
Operator will be required to set-up, operate, and to adjust machines
and equipment in order to produce a good quality product.
Examples of machines and equipment are, but not limited to, crane,
forklift, hoist, spinner, tumbler, reclaimer, boiler, and other
Processes performed will be, but not limited to, inspecting, gauging,
counting, pickling, galvanizing, tumbling, drossing, reclaiming,
racking, stacking, loading, and unloading.
Operator must have the ability to interpret routing sheets and have
the ability to satisfactorily use measuring devises, and perform SPC
Operator may be required to make visual inspections, separate parts,
record production, record scrap, keep required production records,
and other operations as required.
Operator will be required to maintain acid concentration and
temperatures of liquids in accordance with company procedures.
Operator will be required to furnish own hand tools.
Operator will be required to maintain machines, equipment, and
work area in a clean and orderly manner.
Operator must ensure that any hazardous waste generated must be
properly packaged and labeled before removing from his/her area.
[R. 145]. In order to perform these job functions, Hubbell requires that utility operators
meet the following physical standards:
Ability to sit and/or stand and perform repetitive work for a
minimum of eight hours.
Ability to walk, hear, see, and have full use of both hands.
Ability to lift 50 lbs. from floor to waist and waist to floor.
Ability to lift in excess of 65 lbs.
Ability to pull 60 lbs. suspended by a crane into the proper position.
Ability to lift 30 lbs. and carry a distance of 4 feet at a height of 4
Ability to work off of a platform.
These physical requirements are generalities and work may
occasionally exceed the specified levels.
On June 13, 2011, Billue underwent a transvaginal hysterectomy. [R. 555-64].
She experienced complications with her surgery and in November 2011 underwent vein
surgery. [R. 790]. Subsequently, Billue requested long term disability (“LTD”) benefits
due to chronic phlebitis of saphenous vein. [R. 275, 533-34]. The effective date of her
LTD was November 27, 2011. [R. 369].
Aetna issued a determination that Billue was eligible to receive monthly benefits
for up to “24 months as long as you remain totally disabled from your own occupation.”
Id. In order to be considered disabled, Billue had to be unable “to perform the material
duties of [her] own occupation solely because of disease or injury; and [have] earnings
[of] 80% or less of [her] adjusted pre-disability earnings.” Id. “Own occupation” is
defined as “the occupation that you are routinely performing when your period of
disability begins.” [Policy 15]. Billue received $1888.18 in benefits per month. [R.
Under the Aetna policy, benefits terminate on “[t]he date Aetna finds you are no
longer disabled or the date you fail to furnish proof that you are disabled.” [Policy 5].
The policy also provides:
Your claim must give proof of the nature and extent of the loss.
Aetna may require copies of documents to support your claim,
including data about any other income benefits. You must also
provide Aetna with authorizations to allow it to investigate your
claim and your eligibility for and the amount of other income
You must furnish such true and correct information as Aetna may
[Policy 11]. In accordance with the policy, Billue signed an Authorization for Aetna to
Request Protected Health Information Necessary to Process a Disability Claim on
September 20, 2011.
That same day she provided a Supplemental
Information Questionnaire identifying Dr. William Bradley as her doctor and providing
his contact information, a list of her medications, and the name, address, and phone
number of her pharmacy. [R. 483-84].
The plan noted that Aetna is a fiduciary with complete authority to review claims
for denied benefits. [R. 68]. It provided that:
In exercising such fiduciary responsibility, Aetna shall have
discretionary authority to:
determine whether and to what extent employees and
beneficiaries are entitled to benefits; and
construe any disputed or doubtful terms of this policy.
Aetna shall be deemed to have properly exercised such authority
unless Aetna abuses its discretion by acting arbitrarily and
Id. The plan also noted that the fiduciaries operating the plan “have a duty to do so
prudently and in [the plan participant’s] interest and that of other plan participants and
beneficiaries.” [R. 29].
On March 12, 2012, Aetna sent Billue a letter regarding her continued eligibility
for LTD benefits. [R. 375-76]. The letter requested that Billue provide a completed
Attending Physician Statement from her disabling provider, completed Capabilities and
Limitations Worksheet from her disabling provider, completed Treating Physicians List,
completed Medications List, and completed Work History and Education Questionnaire.
Id. Aetna sent Billue a substantively identical letter on April 19, 2012, giving Billue until
May 3, 2012 to submit the information. [R. 388-89]. On May 29, 2012, Aetna sent a
third letter stating that they had not yet received the information and requesting it by June
12, 2012. [R. 401-02]. On June 14, 2012, Aetna sent a letter to Billue stating that her
benefits had been terminated effective the date of the letter because Aetna had not
received the requested information to evaluate Billue’s eligibility for benefits under the
plan provisions. [R. 414-15].
On June 22, 2012, Aetna informed Billue that it had received additional
information including a Medication List and an Attending Physician Statement, but stated
that it was not sufficient for her claim to be reversed. [R. 417]. Aetna informed Billue
that the Attending Physician Statement was not legible. Id.
On July 23, 2012, Aetna sent a letter to Billue indicating that it had received her
appeal request on July 19, 2012, and had begun its review on appeal. On July 29, 2012,
Billue signed a second Authorization for Aetna to Request Protected Health Information
Necessary to Process a Disability Claim form. [R. at 507-08]. That same day she
submitted a Disability Appeal Request Form indicating that she was appealing the claim
denial because “I was denied because they could not read my doctor’s handwriting. My
medical cond. have not changed.” [R. 620]. Billue indicated in her appeal that she had
veins clotting in her left leg, stomach and back problems, headaches, and was unable to
perform her job because she could not stand on her feet. [R. 621]. She noted on her form
that she did not intend to submit additional records for review on appeal. Id.
On August 14, 2012, Aetna sent Billue a follow up letter to her appeal, stating that
the most current office notes Aetna had were dated September 1, 2011, and most current
lab studies were dated December 15, 2011. [R. 425]. The letter indicated that Aetna left
messages for Billue on August 8, August 10, and August 13 which were not returned. Id.
The letter went on to state that “in order for [Billue] to qualify for continued disability
benefits, [she] must provide current medical data with objective findings to substantiate
[her] disability. Therefore, since [Aetna is] aware that additional documentation exists
which may support [Billue’s] claim for disability benefits, the appeal review is being
placed on hold until the additional materials are received.
Please submit all
documentation for review by September 12, 2012.” Id. Billue did not submit additional
documents for review.
In completing review of Billue’s appeal, Aetna sent Billue’s file for independent
medical review by an internist, Dr. Wendy Weinstein.
completed her report on October 10, 2012, which explained that she had been unable to
reach Dr. Bradley for additional information beyond what Billue had provided. [R. 50106]. Had she been able to speak with Dr. Bradley, she would have asked for examination
findings or complications from Billue’s phlebitis that would impact Billue’s ability to
return to work. Id. Dr. Weinstein noted that the records Aetna had did not show that
Billue had seen Dr. Bradley after January 6, 2012, and there was no documentation that
she continued to suffer from deep vein thrombosis or had any other complications that
would prevent her from working. [R. 504]. She found no documentation of actual
pulmonary embolism, respiratory distress, hypoxemia, or abnormal pulmonary function
studies. Id. Based on her review of Billue’s records, Dr. Weinstein concluded that Billue
had no functional impairments that would prevent her from performing her job. Id.
On November 2, 2012, Aetna informed Billue that the decision to terminate her
benefits had been upheld. [R. 431-33]. This letter recognized that a January 6, 2012
medical record from Billue’s appointment with Dr. Bradley referenced Billue being
anticoagulated with Lovenox. Id. It also noted that Dr. Bradley opined that Billue had a
history of venous thrombosis and that she was permanently disabled but was not a
candidate for surgery due to her blood disorder. Id. Senior Appeals Specialist Kay
Bryant found that there was insufficient medical evidence to support a functional
impairment which precluded her from performing the material duties of her own
occupation as of June 14, 2012, which resulted in her decision to uphold the termination
of Billue’s LTD benefits effective June 14, 2012. Id.
Both Billue and Aetna have filed motions for summary judgment in this matter,
contending that there are no genuine issues as to any material facts in the case and that
they are entitled to judgment as a matter of law. Fed. R. Civ. P. 56(a). As both parties
argue, there are no disputes as to any material facts. Therefore, the remaining question
before the Court is which party is entitled to judgment as a matter of law.
Review of Denial of Benefits Under ERISA
The plan and administration of benefits in this case are governed by the Employee
Retirement Income Security Act of 1974 (“ERISA”). In general, a court reviewing a plan
administrator’s decision to deny benefits applies a de novo standard of review. Firestone
Tire and Rubber Co. v. Brunch, 489 U.S. 101, 115 (1989). If the plan grants the claims
administrator discretionary authority, however, the administrator’s decision is reviewed
only for an abuse of discretion. Id. The Aetna policy provides that the administrator has
the discretionary authority both to determine whether employees are entitled to benefits
and construe the terms of the policy. [R. 68]. Therefore, the question is whether Aetna
abused its discretion when it terminated Billue’s LTD benefits.
Under the abuse of discretion standard, the Court may not vacate the plan
administrator’s decision simply because it disagrees with it. Instead, the Court must
affirm the plan administrator’s denial if it was supported by “substantial evidence.”
Carlson v. Standard Ins. Co., 920 F. Supp. 2d 1028, 1032 (W.D. Mo. 2013). A decision
is supported by substantial evidence if there is sufficient “relevant evidence as a
reasonable mind might accept as adequate to support a conclusion.” Id. (quoting McGee
v. Reliance Standard Life Ins. Co., 360 F.3d 921, 924 (8th Cir. 2004)); see also Lawyer v.
Hartford Life & Acc. Ins. Co., 100 F. Supp. 2d 1001, 1011 (W.D. Mo 2000) (describing
substantial evidence as “more than a scintilla but less than a preponderance” (quoting
Woo v. Delux Corp., 144 F.3d 1157, 1162 (8th Cir. 1998))).
In determining whether Aetna abused its discretion, the Court must account for the
inherent conflict of interest of the plan administrator. When an entity administering a
plan both determines benefits eligibility and pays benefits, a conflict of interest exists for
the administrator who owes a fiduciary obligation to the employee and also has a
corporate interest in avoiding paying out claims. Chronister v. Unum Life Ins. Co. of
America, 563 F.3d 773 (8th Cir. 2009) (citing Metropolitan Life Ins. Co. v. Glenn, 554
U.S. 105, 112 (2008)). The Supreme Court addressed how this conflict of interest is to be
weighed in Metropolitan Life Insurance Company v. Glenn and instructed that it should
be considered as a “factor” in evaluating the propriety of the administrator’s decision.
Glenn, 554 U.S. at 116-17.
The conflict of interest here . . . should prove more important
(perhaps of great importance) where circumstances suggest a higher
likelihood that it affected the benefits decision, including, but not
limited to, cases where an insurance company administrator has a
history of biased claims administration. It should prove less
important (perhaps to the vanishing point) where the administrator
has taken active steps to reduce potential bias and to promote
accuracy . . . .
Id. at 117.
The Court must also account for any “serious procedural irregularities” that arise
in the course of the plan administrator’s review of the claim. A “serious procedural
irregularity” is one which would be sufficient under the common law of trusts to cause
the application of a less deferential standard of review. Pralutsky v. Metropolitan Life
Ins. Co., 435 F.3d 833, 838 (8th Cir. 2006). The Eighth Circuit has acknowledged that a
serious procedural irregularity arises when an administrator makes a decision “‘without
knowledge of or inquiry into the relevant circumstances and merely as a result of [its]
arbitrary decision or whim.’” Id. (quoting Restatement (Second) of Trusts § 187 cmt. h
(1959)). For purposes of this order, the Court will assume that a serious procedural
irregularity should be treated in the same way as a conflict of interest. See Miller v.
American Airlines, Inc., 632 F.3d 837, 848 (3d Cir. 2011) (considering procedural
irregularity as “a significant factor to be weighed on arbitrary and capricious review”).
Aetna’s Termination of Billue’s Benefits Did Not Constitute an Abuse
Billue raises two issues that she argues rise to the level of “serious procedural
irregularities” in Aetna’s review of her claim. First, she argues that the administrator
improperly failed to consider the side effects of her medications in determining whether
she would be capable of performing her job. Second, she contends that Aetna failed to
adequately investigate Billue’s claim by failing to obtain her treatment records from Dr.
Bradley. Neither of these actions rises to the level of a serious procedural irregularity.
Furthermore, the evidence shows that Aetna completed a thorough and fair review of the
evidence in the case. Therefore, Aetna did not abuse its discretion in terminating Billue’s
benefits under the policy.
Aetna’s conduct prior to terminating Billue’s benefits makes clear that the
termination was not based on an attempt by Aetna to skirt its duties or prevent Billue
from obtaining benefits to which she is entitled. Aetna gave Billue every opportunity to
present medical evidence of her continuing disability in order to continue receiving her
LTD benefits. Billue’s repeated failure to furnish the requested information resulted in a
proper termination of her LTD benefits under the policy.
Billue had an obligation under the terms of the policy to provide ongoing proof of
disability to remain eligible for LTD benefits. Specifically, the policy stated that a
claimant’s LTD benefits would terminate “the day you fail to furnish proof that you are
disabled.” [Policy 5]. In providing proof of disability, the policy stated that the claimant
“must give proof of the nature and extent of the loss. . . . You must also provide Aetna
with authorizations to allow it to investigate your claim . . . . You must furnish such true
and correct information as Aetna may reasonably request.”
provisions clearly informed Billue that it was her obligation, not Aetna’s, to demonstrate
that she qualified for ongoing benefits.
On March 12, 2012, Aetna informed Billue that she needed to submit information
regarding her continued eligibility for LTD benefits. The letter requested a completed
Attending Physician Statement from her disabling provider, completed Capabilities and
Limitations Worksheet from her disabling provider, completed Treating Physicians List,
completed Medication List, and completed Work History and Education Questionnaire.
[R. 375, 388, 401]. The letter then explained that “[t]he above information is necessary
for us to determine whether you meet the above definition of disability, and determine
whether or not you are eligible for LTD benefits.” Id. Billue did not respond to this
letter. On April 19, 2012, Aetna sent Billue a substantively identical letter requesting the
information by May 3. [R. 388-89]. Billue once again did not respond and Aetna mailed
her a third letter on May 29 requesting the documentation by June 12. [R. 401-02]. On
June 14, 2012, three months after first requesting information from Billue and having
received no response to three separate letters requesting medical documentation, Aetna
terminated Billue’s LTD benefits. [R. 414-15].
The course of communication between Billue and Aetna even at this early stage of
the communications makes clear that Aetna was not attempting to wrongfully deprive
Billue of benefits to which she was entitled. Aetna provided Billue an extended period of
time to respond to its requests for documents and sent multiple letters asking for evidence
of continuing disability.
Soon after Aetna informed Billue that her benefits were being terminated, Billue
submitted two of the five documents requested by Aetna in its earlier communications: a
Medication List and an Attending Physician Statement.
Attending Physician Statement was not legible. Id. On June 22, Aetna sent Billue a
letter informing her that the statement was not legible and that the information she
submitted was not sufficient to warrant reversal of her claim. In this denial letter, Aetna
specifically noted that “we do not have any updated medical records, the last office visit
notes we have on file are date 7/24/2011 and 9/1/2011. The last testing results we have
on file are dated 12/8/2011 and 12/14/2011.” Id. Aetna’s denial letter from June 14 had
also informed Billue that she could submit additional evidence to be reviewed on appeal
including “physician’s prognosis including current course of treatment, frequency of
visits, office visit/treatment notes, specific medications prescribed; diagnostic studies
conducted during the above period, such as test results, X-rays, laboratory data, and
clinical findings.” [R. 414-15].
Despite having been informed that Aetna was not in possession of her medical
records after the dates listed and being told that she could submit additional records for
review on appeal, Billue never provided Aetna additional medical records or evidence of
her disability following this denial and Billue’s submission of her notice of appeal.
Billue contends that she did not submit her medical records at this point because while
Aetna informed Billue it was not in possession of the records, it never requested that
Billue send the records to the company. However, Aetna was not required to explicitly
state that Billue needed to send these records to the company for review.
requirement had already been communicated to Billue in the plan documents. The plan
placed the burden on Billue to present evidence of her continuing disability, not the
insurance company to inform Billue of every piece of evidence she needed to submit for
review. Moreover, any ambiguity in the letters about Aetna’s request for Billue to
provide it with the medical records was very slight, and a reasonable person would have
understood based on Aetna’s communications that she needed to submit medical
evidence and records to Aetna for review on appeal.
On August 14, 2012, Aetna mailed Billue another follow up letter indicating that a
representative from the insurance company had left messages for Billue on August 8,
August 10, and August 13. [R. 425]. None of these calls were returned. Id. However,
Aetna indicated that it was aware that additional documentation existed to support
Billue’s claim and stated that the review of Billue’s appeal was on hold until Aetna
received the additional materials. Id. This letter then stated that Billue should “submit
all documentation for review by September 12, 2012.” Id. Once again, Billue did not
respond to Aetna’s letter or submit any additional evidence of her disability.
Despite being given repeated opportunities to send Aetna evidence, Billue failed to
provide the company with requested documents, and failed to submit medical evidence to
support her claim. This course of communication does not suggest that Aetna was
behaving irregularly or attempting to exclude evidence of Billue’s disability from
consideration. See Braile v. Fort Dearborn Life Insurance Company, 2005 WL 2563185
(W.D. Mo. Oct. 11, 2005) (“where the failure to obtain records does not indicate an
attempt by the administrator to exclude unfavorable evidence, there is no procedural
irregularity”); see also Pralutsky, 435 F.3d at 838 (noting that a plan administrator may
not terminate a claimant’s benefits “‘without knowledge of or inquiry into the relevant
circumstances and merely as a result of [its] arbitrary decision or whim.’” (quoting
Restatement (Second) of Trusts § 187 cmt. h (1959)).
Even after Billue ignored Aetna’s requests for additional medical evidence
regarding her claim, Aetna continued to investigate the claim on appeal, sending Billue’s
file for independent review by Dr. Wendy Weinstein.
Dr. Weinstein reviewed the
entirety of Billue’s file and attempted to contact Billue’s doctor for additional
information regarding her claim. Dr. Bradley did not respond to Dr. Weinstein’s call.
[R. 501-06]. After Dr. Weinstein completed her report, Aetna sent the report to Dr.
Bradley for review and comment. [R. 430, 500]. After ten days, Aetna had received no
response or additional medical records from Dr. Bradley. [R. 348]. It was only after this
waiting period that Aetna issued its final decision on Billue’s appeal and upheld its
decision to terminate her benefits. [R. 431-33].
Aetna’s ongoing attempts to acquire medical documentation and review from
Billue and her doctor indicate that the termination of Billue’s benefits was based not on
procedural irregularities, but on Billue’s failure to furnish evidence of ongoing disability
in accordance with the policy. Contrary to the cases cited by Billue in support of her
arguments regarding procedural irregularities, there is no suggestion here that Aetna
intentionally disregarded medical records, inhibited Billue from presenting evidence of
ongoing disability, or attempted to twist Billue’s claim to prevent her from continuing to
receive LTD benefits.
C.f. Harrison v. Wells Fargo Bank, N.A.; Wells Fargo and
Company Disability Plan, 773 F.3d 15, 20 (4th Cir. 2014) (noting that the Plan
Administrator cannot be willfully blind to medical information that may support a
claimant’s disability theory); c.f. Harden v. American Express Financial Corp., 384 F.3d
498, 499-500 (8th Cir. 2004) (concluding that the plan administrator committed a serious
procedural irregularity by requesting some of claimant’s medical records but not Social
Security records that supported his claim, even though the plan required the claimant to
apply for Social Security benefits).
Billue contends that because Aetna required her to provide it with a release form
allowing it to independently request her medical records, Aetna committed a serious
procedural irregularity by failing to request the medical records and never notifying
Billue of her obligation to provide her medical records to the company. As discussed
above, the content of Aetna’s communications should have prompted Billue to submit
additional medical evidence, including relevant medical records.
requiring policy holders to provide release forms does not shift the burden from the
claimant to the plan administrator to acquire evidence of the claimant’s disability. The
plan was clear that claimants were required to both submit the signed release form and
provide evidence of their continuing disability. It never suggested that submitting the
release form altered the claimant’s obligation to furnish proof of disability.
Billue further argues that Aetna erred in not considering the side effects of her
medications in concluding that she could perform her job. However, there is no evidence
that Billue suffered from any of these side effects. C.f. Torres v. UNUM Life Ins. Co. of
America, 405 F.3d 670, 678 (8th Cir. 2005) (noting that the insurer’s failure to
acknowledge the side effects of the claimant’s prescription drugs was significant because
the claimant had explained that he suffered side effects). Billue’s medical records from
2007 indicated that she had a history of deep vein thrombosis with history of pulmonary
embolism. Her doctor commented in June 2012 that she had acute phlebitis of her leg
and was intolerant to medication, but there is no evidence of what, if any, side effects she
suffered as a result of this intolerance. Though her medical records from October 2011
indicated that she was incapacitated due to her condition, Billue has presented no
evidence of continuing incapacity any time in 2012. A single prothrombin time/inr test
indicating that Billue’s readings were high in relation to her Warfarin therapy is
insufficient for the Court to conclude that Aetna should have continued her LTD benefits
based on her medications.
Billue cites to a number of Federal District Court opinions considering the side
effects of prescription blood thinners in determining the claimant’s ability to work.
While these opinions all suggest that the side effects of blood thinners are relevant to a
claimant’s ability to work, the opinions all include recommendations from doctors that
the claimant restrict activities due to the prescription. Here, neither Billue herself nor her
doctor ever suggested that Billue’s activities needed to be limited due to her prescription
regimen. Without even the suggestion from a doctor that Billue was limited in her ability
to perform her job due to her prescriptions, Aetna’s failure to consider or recognize
limitations on Billue’s ability to work cannot constitute a procedural irregularity.
Billue also lists a number of other prescription medications she was talking in
2012, including Hydrocodone and Paroxetine. However, she presented no evidence that
she suffered from side effects in relation to these prescription medications. Therefore,
Aetna did not act improperly in terminating her benefits without accounting for potential
side effects of these drugs.
Finally, Billue has submitted no additional evidence to the Court beyond what was
provided to Aetna to suggest that her disability continues to prevent her from working.
She has not presented medical records to show what Aetna would have had available had
it obtained Billue’s records independently. Thus, this is not a case where the insurance
company is trying to avoid evidence that would be adverse to its decision.
For the reasons set forth above, Defendant’s motion for summary judgment, Doc.
Doc. 23, is granted. Plaintiff’s motion for summary judgment, Doc. 21, is denied.
/s/ Nanette K. Laughrey
NANETTE K. LAUGHREY
United States District Judge
Dated: June 5, 2015
Jefferson City, Missouri
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