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Vanessa Pearson-Rhoads v. Aetna Life Insurance Company

October 28, 2011

VANESSA PEARSON-RHOADS
v.
AETNA LIFE INSURANCE COMPANY



The opinion of the court was delivered by: Legrome D. Davis, J.

MEMORANDUM

This is an action for judicial review of an administrator's denial of disability insurance benefits under the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. §§ 1001-1461; see Sections 502(a)(1)(B) and 503 of ERISA, 29 U.S.C. §§ 1132(a)(1)(B), 1133. The case was removed from state court on federal question jurisdiction. 29 U.S.C. § 1132(e); 28 U.S.C. § 1331.

Plaintiff, Vanessa Pearson-Rhoads, a former employee of Quest Diagnostics, Inc., moves for summary judgment to recover long-term disability benefits under a group disability insurance policy issued by Defendant Aetna Life Insurance Company to Quest Diagnostics. Doc. No. 22. The policy is an employee welfare benefit plan governed by ERISA, 29 U.S.C. § 1002(1). Aetna cross-moves for summary judgment, submitting that it properly determined that Plaintiff was not entitled to disability benefits. Doc. No. 23. Because Aetna's refusal of benefits was reasonable and not an abuse of its discretion as plan administrator, Plaintiff's motion will be denied and Defendant's motion will be granted.

I. PROCEDURAL AND FACTUAL BACKGROUND

Plaintiff, who is now 44 years old, was injured in a motor vehicle accident on January 12, 2007. At that time, Quest Diagnostics employed Plaintiff as an internal account service representative, a sedentary position. She described her duties as "update contracts, enter data in computer, answer phone calls, contact clients, educate clients, fax, mailing." Administrative Record ("R.")*fn1 369, 630; R. 1173 (Quest Diagnostics on-line career description).

On June 26, 2007, Plaintiff applied to Aetna for long-term disability insurance benefits, asserting that as of the day of the accident, she stopped working because of "slow thought process, inability to multi-task, dizziness, inability to sit or stand for long periods of time, tremors, shaking/movement disorder, numbness hand/feet." R. 630-43, 638. She was unable to perform any work because of "tremors, dizziness, headaches, neck and back pain, fatigue, shaking/movement disorder, pain, lack of concentration, headaches, facial pain." Id. On November 14, 2007, Aetna denied the claim. R. 941-47. On February 1, 2008, Plaintiff initiated an administrative appeal, and on June 24, 2009, Aetna upheld the original denial of benefits.

Pl.'s 2/1/08 letter, R. 954; Def.'s 6/24/09 letter, R. 1634-40.

On February 8, 2010, having exhausted her administrative remedies, Plaintiff filed a complaint in the Philadelphia County Court of Common Pleas, which Aetna removed to this Court on March 11, 2010. On February 15, 2011, the parties filed cross-motions for summary judgment, presenting the sole issue of whether Aetna's determination that Plaintiff was not disabled under the Policy,*fn2 based on the administrative record, was arbitrary and capricious.

II. ADMINISTRATIVE RECORD

Plaintiff, as an employee of Quest Diagnostics, participated in her employer's group long- term disability benefit plan. The plan was funded by a Group Long Term Disability Insurance Policy, number GP-699840-A, issued by Aetna to Quest Diagnostics. Aetna, as plan fiduciary and administrator, was given "complete authority to review all denied claims for benefits under this policy" and had "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." R. 57-58. Here, Aetna found that Plaintiff was able to perform the material duties of her own occupation, and therefore, she was not disabled as defined by the Policy. Policy, R. 75; Def.'s 6/24/09 letter, R. 1634.

The medical evidence of record, as developed by Aetna's claims administration department, reflects that after the January 2007 accident, Plaintiff was treated by 15 physicians and health care providers. Diagnostic tests were performed, most of which produced normal findings: January 15, 2007 MRI of the cervical spine (R. 776); January 23, 2007 MRI of the brain (R. 770); March 6, 2007 MRI of the cervical spine (R. 773-74). A January 10, 2008 MRI reported "mild discogenic disease and facet anthropathy of lower lumbar spine" (R. 1193-99). The objective tests did not explain the reported extent and severity of Plaintiff's symptoms.

On January 15, 2007, Plaintiff began treatment with her primary care physician, Dr. Carol Henwood, D.O. R. 617. On January 17, 2007, she also consulted a dentist, Thomas P. Sollecito, DMD "because she ha[d] noted some alteration in her bite and . . . significant pain and some numbness on the right side of her face." R. 645. Dr. Sollecito noted that Plaintiff reported pain, but her "occlusion looked grossly intact" and she "probably ha[d] an efflusion in her temporomandibular joint ["TMJ"]." Id. He recommended that she see a neurologist and a physiatrist, Larry H. Chou, M.D. Id. As reflected in a January 31, 2007 progress note, Dr. Henwood found that Plaintiff "sounds significantly improved," "voice not shaky," "tremors significantly improved," and "Xanax helped symptoms." R. 755, 750-757.

On February 1, 2007, Plaintiff consulted Dr. Chou. He found Plaintiff had a "tremor of unknown etiology," "neck pain and headache. . . ," and "numbness and tingling in her right more than her left arm." R. 652-54. Chou noted that Plaintiff denied "having a sense of anxiety," "a startle response," and "playing the accident over in her head," but admitted to "non-restorative sleep pattern." R. 653. Chou referred Plaintiff to a neurologist, Allan A Weber, M.D.

In early February 2007, Plaintiff consulted Dr. Weber about her complaints of tremor in the upper right arm, neck, and head. R. 614-16. Weber observed "the obviously disabling tremor," but was not able to reach a diagnosis. Id. He referred her to Norman Leopold, D.O., a movement disorder specialist. On March 5, 2007, Dr. Leopold evaluated Plaintiff and reported his "impression" to Weber, commenting that her "history and examination is most compatible with the diagnosis of psychogenic tremor."*fn3 R. 743-45. Leopold found: "There is no significant consistency to her tremor, either in frequency, direction, or amplitude. With distraction, the tremor can be briefly suppressed. The patient cannot perform . . . alternating movements, even with her tongue, without changing the character of her tremor." R. 745. He suggested psychiatric or psychological counseling. Id.

In progress notes dated March 14, 2007, Plaintiff's dentist, Dr. Sollecito recorded "[o]verall improvement of jaw ache. . . . Reports no pain just jaw discomfort." R. 822-24. He diagnosed "sprain of neck" and "spasm of muscle." R. 823.

In a follow-up office visit on March 15, 2007, Dr. Chou noted Plaintiff's "tremors are dramatically improved . . . , but it is still there." R. 677-78. He noted that she was scheduled for neuropsychiatric testing, finding this "appropriate in the absence of significant structural abnormalities identified on an MRI." R. 678.

On April 3, 2007, Dr. Weber again examined Plaintiff and reported his and Dr. Leopold's findings to Dr. Henwood. R. 612-13. Weber noted that Plaintiff "can have several hours at a time where tremor is not present" and "is able to function as far as dressing herself and keeping up with her hygiene and putting in her earrings." Id. "However, she finds that the tremors are exhausting and limits how much activity she can do in a day. She also finds the mental exertion and focusing on objects induces or worsens her headaches." Id.

On April 16, 2007, Tracey Gemzik, PA-C, a physician's assistant in Dr. Henwood's office, submitted to Aetna a Disability Attending Physician's Statement ("AP Statement"), listing Plaintiff's diagnosis as: "movement disorder, psychogenic tremor." R. 617. Gemzik noted that Plaintiff's subjective symptoms were: "headache, neck pain, tremor, fatigue, decreased concentration," but that the results of a CT scan of the head, an MRI of the brain and cervical spine, and an x-ray of the lumbar spine were "normal." Id. Plaintiff's prognosis was noted as "fair" and her "maximum medical improvement" would be reached in six-nine months. Her "limitations (physical and/or mental)" were noted as "unable to perform job of any kind" and her "restrictions" were noted as "no driving, no working." R. 620. Gemzik noted Plaintiff was not a viable candidate for vocational rehabilitation, because she "needs psychiatric evaluation." Id.

In a follow-up office visit on May 10, 2007, Dr. Chou noted Plaintiff's tremors were "overall . . . improving." R. 679-80. She reported "having a lot of pain in her back and upper back with a burning sensation down her back, into her hands and in her feet." R. 679. However, Chou found that an MRI of her cervical spine revealed "no evidence of significant cord impingement or cord signal change" or "anything that would explain the burning sensation" and the MRI of her brain was "likewise unrevealing." Id. Chou recommended an EMG of the upper limbs "simply to rule out any evidence of underlying neural pathology," although he "suspect[ed] this will be normal." Id. An EMG performed on May 30, 2007 produced test results within normal limits. R. 692.

On May 22, 2007, Ms. Gemzik submitted to Aetna another AP Statement for Plaintiff, noting the diagnosis of psychogenic tremor and most of the same subjective reports of symptoms as noted in January 2007. R. 625-26. In May 2007, Plaintiff was no longer under the care of Dr. Henwood's office for this condition; however, it was noted that Plaintiff was "able to perform all ADLs [activities of daily living], but "is unable to work at this time. . . . no work." Id.

Plaintiff continued to see Dr. Weber. On April 17, 2007, Dr. Weber reported to Aetna's claims representative that Plaintiff had been diagnosed with a psychogenic tremor, which "does not have a primary neurologic etiology and I would have to defer your questions of prognosis and work capacity to a mental health specialist." R. 622 (also noting her "high amplitude tremor would likely be very distracting in a work environment"). After another office visit on June 4, 2007, Weber noted that she reported "her headache frequency and severity has decreased substantially" and the tremors "are slowly resolving." R. 873-74. Weber submitted to Aetna a July 9, 2007 AP Statement, noting that Plaintiff's "disability from her primary diagnosis (psychogenic tremor) requires treatment from mental health specialists (psychiatry, psychotherapy, psychology) which she has yet to initiate." R. 949. On July 9, 2007, Weber examined Plaintiff and noted "improvement" and "near resolution of her external tremors." R. 871-72. However, he noted her new complaints of "anxiety, possibly anxiety attacks and migrainous quality headaches." Id. He suggested occipital nerve blocks and psychiatric care. Id.

In June and July 2007, Plaintiff participated in therapy at AquaSport Physical Therapy. On July 11, 2007, AquaSport noted that her tremors were the "primary complication," which were "slowly improving." R. 667. It was also noted that she reported "ongoing cervical and upper back pain," "continued headaches as well as radicular symptoms," and "tingling and burning." Id. According to AquaSport, the "subjective and objective findings appear[ed] to be consistent with neurological involvement," but her "rehabilitation potential [wa]s good." R. 668.

At Dr. Chou's suggestion, Plaintiff consulted Andrea LaBorde, M.D., a physical medicine and rehabilitation specialist, to assess potential traumatic brain injury. In a July 19, 2007 letter to Chou, LaBorde detailed Plaintiff's subjective reports of symptoms, including pain, headaches, dizziness, changes in mood and personality, difficulty hearing and seeing, tingling in her legs and feet, slowed responses, problems sleeping, and fatigue. R. 1852-54. However, LaBorde noted: Plaintiff was "[p]leasant, cooperative, well groomed, dressed appropriately for the weather, [and] arrive[d] to her appointment early"; she had nausea with a maneuver used to diagnose vertigo, but no dizziness; she had "a constant resting tremor of her upper extremities and her head and neck." R. 1853. In LaBorde's opinion, "the patient has probable craniocerebral trauma but diagnostic input is limited at this time. . . . There is a possibility the patient could also have symptoms related to post-traumatic stress disorder." Id. LaBorde did not render a diagnosis, choosing to wait for the results of a neuropsychological evaluation and sleep study. R. 1854.

Dr. Weber continued to follow Plaintiff's neurologic condition, reporting his findings to Dr. Henwood's office by letters dated August 21 and October 2, 2007. R 869-70, 867-68. In August 2007, Weber made no notations regarding tremor; he noted that Plaintiff reported "headaches consistent with occipital neuralgia" and she had consulted a psychiatrist. R. 869. In October 2007, Weber noted that Plaintiff reported follow-up visits with her psychiatrist and "for the first time since her accident she has had several good days. She has ...


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