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Maria A. Kuntz v. Aetna Inc.

May 17, 2013

MARIA A. KUNTZ PLAINTIFF,
v.
AETNA INC. DEFENDANT.



The opinion of the court was delivered by: Tucker, C.J.

MEMORANDUM

Maria A. Kuntz brings this action against Aetna, Inc. ("Aetna") for a denial of long term disability benefits under an Aetna-sponsored welfare benefit plan. After exhausting Aetna's internal administrative review process, Kuntz filed this action pursuant to 29 U.S.C. § 1132(a)(1)(B) of the Employee Retirement Income Security Act ("ERISA"). Currently before me are the parties' cross motions for summary judgment under Rule 56 of the Federal Rules of Civil Procedure. For the reasons set forth below, I will grant Kuntz's motion for summary judgment; accordingly, Aetna's motion for summary judgment will be denied.

I. FACTS AND PROCEDURAL HISTORY

Kuntz worked as a claims processor for Aetna for fifteen years, beginning in July of 1993.

(R. at 502.) As an Aetna employee, she was eligible to participate in an ERISA-governed, employer-sponsored, self-insured welfare benefit plan (the "Plan"), administered by Aetna Life Insurance Company ("ALIC"). (Def. Aetna Inc.'s Resp. in Opp'n to Pl.'s Mot. Summ. J. 2.) The Plan included a long term disability ("LTD") benefit plan. (Id.)

In early 2007, Kuntz gave birth to her second child. After taking maternity leave, she returned to work in June 2007. (R. at 549.) Approximately one month later, Kuntz began experiencing anxiety that she claims impacted her ability to perform the functions and duties of her job. (Id.) Toward the end of July, she sought medical attention from her primary care provider to address her anxiety and fatigue. (Id.) Her lab results did not show any medical reason for her symptoms. (Id.) Nevertheless, Kuntz continued to seek treatment from her primary care provider through the remainder of 2007. On November 29, 2007, Kuntz left Aetna on short term disability ("STD") leave. (Id. at 362, 549.)

On December 21, 2007, Kuntz visited The Mitchell Psychiatric Center in Emmaus, Pennsylvania, where John F. Mitchell, M.D., a board-certified psychiatrist, performed an initial evaluation, including a mental status examination ("MSE"). (R. at 527.) The record of the initial evaluation states that Kuntz's thought content and perception were "logical," her memory was "OK," her attention and concentration were "fair," her insight and judgment were both "good," and that she was alert with normal motor activity. (Id. at 528.) Mitchell assigned her a current Global Assessment of Functioning ("GAF") score of "40-70."*fn1 (Id.) He also stated that her mood appeared sad and hypervigilant, and noted sleep disturbance. (Id.) Mitchell's diagnosis stated social anxiety, performance anxiety, and panic disorder. (Id.)

Kuntz continued to see Mitchell approximately once a month throughout her STD leave.

(Id. at 529-30.) On March 3, 2008, Kuntz returned to her position as a senior claims processor for Aetna. (Id. at 298.) Upon return, Kuntz's supervisor informed her that she would need to increase her work week from twenty-five hours to forty hours per week. (Id.) On March 5, Kuntz met with Mitchell and reported that since returning to work her depression and sadness were "clearing," and although she did not feel agitated, she was anxious and panicky. (Id. at 529.) Then, on March 7, Kuntz called Mitchell and explained that she was not doing well at work because she was feeling panicky and tearful, and as a result was going to pursue a medical leave of absence. (Id.)

Kuntz resumed her STD leave on March 8, 2008. In addition to seeing Mitchell, she also began to meet with Robin Rooth-Fogel, a licensed clinical social worker employed at The Mitchell Psychiatric Center. (Id. at 516-17.) Kuntz visited Rooth-Fogel weekly for several months following her initial visit in early April. (Id. at 516-17, 594.) By the end of summer 2008, the visit intervals were lengthened to approximately once every three weeks. (Id. at 594.)

On April 28, 2008, ALIC wrote to Kuntz and informed her that her STD benefits would terminate on May 28, 2008. (Id. at 494.) ALIC advised Kuntz that if she wished to seek LTD benefits she needed to provide specific information and documentation concerning her disability within thirty days, or her file would be closed. (Id.) Kuntz promptly submitted her request for LTD benefits to ALIC. (Id. at 392.) On May 7, 2008, ALIC again wrote Kuntz and asked for additional information in order to make a decision on her claim. (Id. at 498.) Specifically, ALIC requested the following: copies of Mitchell's office visit notes; test results that would medically support a claim on an ongoing basis from November 1, 2007, until the present day; the initial evaluation; and any documentation from other counselors in his office. (Id.) Additionally, ALIC requested that Kuntz sign an "Authorization for Aetna to Request Protected Health Information" form, and asked that Mitchell complete an "Attending Physician Behavioral Health Statement" ("APS"), along with the last office visit note from the disabling provider. (Id. at 499.)

On June 27, 2008, after reviewing the requested information, including additional information provided by Rooth-Fogel at ALIC's request, ALIC denied Kuntz's request for LTD benefits. (Id. at 543-45.) Susan Dunn, a senior disability analyst for ALIC, stated that ALIC's medical staff reviewed the information submitted by Kuntz, Mitchell, and Rooth-Fogel, and determined that the file showed "limited and inconsistent findings" with respect to Kuntz's diagnosis of agoraphobia and panic disorder. (Id. at 544.) Furthermore, Dunn stated that RoothFogel "did not provide sufficient exam findings of [Kuntz's] emotional impairment and the symptoms specified did not meet the impairment determination protocol for panic disorder." (Id.) Finally, ALIC found that the information provided did not explain how Kuntz's impairment in emotional and cognitive functioning would preclude her from performing as a claims processor. (Id.)

Pursuant to her rights under the Plan, Kuntz appealed the denial of LTD benefits. In support of her appeal, she submitted two letters to ALIC that further explained the severity of her symptoms and addressed the discrepancies in ALIC's review of her file. (Id. at 549-61.) RoothFogel also submitted a letter on Kuntz's behalf, asking for further consideration of her LTD claim and providing a description of her symptoms, with an explanation as to how they would limit her ability to work. (Id. at 546.) Additionally, Mitchell provided a response to a follow-up questionnaire pertaining to Kuntz's symptoms, treatment regimen, prognosis, and barriers to improvement-a response that ALIC had requested for its initial review. (Id. at 542.)

On August 29, 2008, after a review of the record by ALIC's appeals committee, which included a review by Dr. Ivy E. Sohn, an independent consulting peer physician board certified in psychiatry, ALIC denied Kuntz's appeal for LTD benefits. (Id. at 576.) Sohn, noted that RoothFogel's psychotherapy notes did not contain any MSEs or descriptions of symptom frequency, severity, or duration. (Id. at 577.) Additionally, there was no explanation as to how the symptoms prevented Kuntz from performing her occupation. (Id. at 578.) Sohn stated that the symptoms described were not consistent with the requirements for a diagnosis of panic attacks according to the Diagnostic and Statistical Manual of Mental Disorders ("DSM-IV (TR)"), noting that losing color in one's face and headaches were not included in the enumerated symptomatolgy. (Id.) She also noticed a lack of MSEs and objective tests of cognitive functioning in Mitchell's treatment notes. (Id.) Additionally, Sohn deemed some of Mitchell's findings to be inconsistent where, for instance, he would note observed improvement but yet conclude an impairment in Kuntz's occupational functioning. (Id.)

On October 2, 2008, Kuntz requested reconsideration of the denial of her appeal. (Id. at 581.) Again, she submitted a letter further explaining what she believed were discrepancies in the denial of her appeal. (Id. at 581-85.) Rooth-Fogel submitted another letter describing Kuntz's panic attack and agoraphobia symptoms, situations that triggered her symptoms, and the impact such symptoms would have on her ability to function as a claims processor. (Id. at 586.) Mitchell submitted a one-paragraph letter clarifying that what he had described as "job interviews" in his office visit notes were actually visits to survey possible venues for Kuntz's son's birthday party. (Id. at 587.)

ALIC reviewed the file in its entirety, including the information submitted subsequent to the denial of the appeal. (Id. at 592.) In addition, Dr. Marcus J. Goldman, a new independent peer physician board certified in psychiatry, also reviewed the file. (Id.) On November 19, 2008, based on ALIC's findings and Goldman's assessment of the record, ALIC denied Kuntz's claim with finality. (Id.) Subsequent to that decision, Kuntz filed a complaint against Aetna in the Court of Common Pleas for Northampton County challenging ALIC's denial of LTD benefits. Aetna timely removed the action to the Eastern District of Pennsylvania.

II. STANDARD OF REVIEW

Summary judgment is appropriate when "the movant shows that there is no genuine issue of material fact and the movant is entitled to judgment as a matter of law." Fed. R. Civ. P. 56(a). Notwithstanding, "Where the decision [of an ERISA-governed plan] to grant or deny benefits is reviewed for abuse of discretion, a motion for summary judgment is merely the conduit to bring the legal question before the district court and the usual tests for summary judgment, such as whether a genuine dispute of material fact exists, do not apply." Davis v. Broadspire Servs., Inc., No. 05-5829, 2006 WL 3486464, at *1 (E.D. Pa. Dec. 1, 2006) (quoting Bendixen v. Standard Ins. Co., 185 F.3d 939, 942 (9th Cir. 1999)) (internal quotation marks omitted).

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). "[A] denial of benefits challenged under § 1132(a)(1)(B) is to be reviewed under a de novo standard unless the benefit plan gives the administrator or fiduciary discretionary authority to determine eligibility for benefits or to construe the terms of the plan." Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989). When a plan confers such discretionary authority on an administrator or fiduciary, however, the district court reviews the administrator's denial of benefits under an "arbitrary and capricious," or abuse of discretion, standard. See id.; Miller v. Am. Airlines, Inc., 632 F.3d 837, 844-45 (3d Cir. 2011). "An administrator's decision is arbitrary and capricious 'if it is without reason, unsupported by substantial evidence or erroneous as a matter of law.'"*fn2 Miller, 632 F.3d at 845 (quoting Abnathya v. Hoffman-La Roche, Inc., 2 F.3d 40, 45 (3d Cir. 1993)) (internal quotation marks omitted). "This scope of review is narrow, and 'the court is not free to substitute its own judgment for that of the defendants in determining the eligibility for plan benefits.'" Abnathya, 2 F.3d at 45 (quoting Lucash v. Strick Corp., 602 F. Supp. 430, 434 (E.D. Pa. 1984)). Nevertheless, while "the arbitrary and capricious standard is extremely deferential, '[i]t is not . . . without some teeth. Deferential review is not no review, and deference need not be abject.'" Moskalski v. Bayer Corp., No. 6-cv-568, 2008 WL 2096892, at *4 (W.D. Pa. May 16, 2008) (quoting McDonald v. Western-Southern Life Ins. Co., 347 F.3d 161, 172 (6th Cir. 2003)).

Here, the Plan language is clear that ALIC holds the discretionary authority to determine eligibility for Plan benefits. Furthermore, the parties agree that the proper standard of review is the arbitrary and capricious standard. The only question that remains with respect to the standard of review is whether a conflict of interest exists in Aetna's administration of the plan such that it should be considered as a ...


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