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Reeder v. Aetna Life insurance Co.

United States District Court, M.D. Pennsylvania

June 9, 2015

SHARON REEDER, Plaintiff
v.
AETNA LIFE INSURANCE CO., Defendant.

MEMORANDUM

Matthew W. Brann United States District Judge

Pending before this Court are two motions for summary judgment on the complaint, one filed by Plaintiff Sharon Reeder and the other filed by Defendant Aetna Life Insurance Co. Plaintiff’s complaint seeks a reversal of a decision by the Defendant to terminate her long term disability benefits, pursuant to § 501(a)(1)(B) of the Employee Retirement Income Security Act, 29 U.S.C. § 1001, et seq. (hereinafter “ERISA”). Both parties assert that they are entitled to judgment as a matter of law on the claim set forth in the complaint. The matter has been fully briefed and is now ripe for disposition. In accordance with the following reasoning, Defendant’s motion for summary judgment is granted and Plaintiff’s motion for summary judgment is denied. Plaintiff’s claim for long term disability benefits under ERISA § 1001, et seq., is dismissed.

I. BACKGROUND

The relevant facts are as follows. Plaintiff Sharon Reeder was employed by Community Health Systems (hereinafter “CHS”) as an Assistant Chief Nurse Officer assigned to Lock Haven Hospital, where she was an eligible participant in the CHS Long Term Disability Plan (hereinafter the “Plan”). Def’s Statement of Facts ¶ 1-2, September 17, 2014, ECF No. 19 (hereinafter “Def’s SOF”); Pl.’s Statement of Facts ¶ 2, September 16, 2014, ECF No. 16 (hereinafter “Pl.’s SOF”). The Plan was funded through a Group Policy issued by Defendant Aetna Life Insurance Company. Def’s SOF ¶ 3; Pl.’s SOF ¶ 1, 3. Under the Plan, the test for disability provides:

In the first 24 months of any period of disability, you will be deemed disabled on any day if
- you are not able to perform the material duties of your own occupation solely because of: disease or injury; and
- your work earnings are 80% or less of your adjusted predisability earnings.
After the first 24 months of a period of disability, you will be deemed to be disabled on any day if you are not able to work at any reasonable occupation solely because of
- disease; or
- injury.

Def’s SOF ¶ 8; Pl.’s SOF ¶ 4-6. Beginning on June 13, 2007, Plaintiff was approved for short term disability benefits for a period of 26 weeks based on an initial co-morbid diagnosis of diabetes mellitus, hypertension, hyperdermia, depression, and severe anxiety. Def’s SOF ¶ 11-12; Pl.’s SOF ¶ 7. She was later approved for long term disability benefits beginning September 11, 2007, which benefits were renewed once again in June 2009. Def.’s SOF ¶ 13, 14; Pl.’s SOF ¶ 7, 9.

Sometime between July and August 2009, Plaintiff began to work part-time at light duty capacity as a clinical instructor at the Pennsylvania College of Technology. Def.’s SOF ¶ 15; Pl.’s SOF ¶ 10. Aetna conducted an analysis of this job description, which summarized the position as “responsible for education leadership, student instruction, and/or clinic supervision on a part-time basis in the Nursing/Practical Nursing Programs” and listed some physical requirements of the position including standing or walking for extended periods of time, having full range of motion for multiple physical positioning as well as motor dexterity. Def.’s SOF ¶ 18. Though Plaintiff does not dispute that this summary is consistent with the written description of Plaintiff’s part-time position, she maintains that she did not exercise many of these responsibilities because she was not physically capable of doing so; rather, the nursing division was aware of her capabilities and accommodated her physical limitations. Pl.’s Counter Statement of Facts ¶ 18, October 21, 2014, ECF No. 26 (hereinafter “Pl.’s Counter SOF”).

On March 17, 2010, Plaintiff’s treating physician, Dr. Adroja, completed a Capabilities and Limitations Worksheet (hereinafter “CLW”) which certified Plaintiff’s ability to frequently lift no more than ten pounds, occasionally climb, lift, forward reach, and carry. Def.’s SOF ¶ 21. She was also certified to frequently engage in hand grasping, fine and gross manipulation, repetitive motion, sitting, standing, and walking. Id. However, Dr. Adroja stated that she could never crawl, kneel, pull, push, reach above the shoulder, bend, twist, or stoop. Pl.’s Counter SOF ¶ 21. Dr. Adroja further opined that Plaintiff was only capable of working part-time. Def.’s SOF ¶ 21.

Several months later, on June 23, 2010, Plaintiff underwent a left rotator cuff repair by her orthopedic surgeon, Dr. Ronald DiSimone. Def.’s SOF ¶ 22; Pl.’s SOF ¶ 11; 27. Following this surgery, Plaintiff was unable to work at all due to pain and decreased range of motion in her shoulder, until her surgeon released her to limited[1] duty, right-hand work, with restrictions on lifting, pulling, and pushing. Pl’s SOF ¶ 28-31; Def.’s SOF ¶ 23; Pl.’s Counter SOF ¶ 23. She returned to work on a part-time basis in January 2011. Def.’s SOF ¶ 23; Pl.’s SOF ¶ 12. Nevertheless, Defendant continued to review updated medical records from Plaintiff’s treating physician, Dr. Adroja, and Plaintiff’s surgeon, Dr. DiSimone (together, Plaintiff’s “treating physicians”), and found that the records supported functional impairment precluding full-time sedentary work due to limited range of motion of left arm which required further physical therapy. Def.’s SOF ¶ 24. An Attending Physician Statement and CLW from Dr. Adroja dated May 2, 2011 reiterated his belief that Plaintiff could work only at a part-time level due to shoulder pain. Def.’s SOF ¶ 25-26. However, after an internal clinical review of Plaintiff’s medical records from March through May 2011, the clinician found that the records provided insufficient quantifiable clinical findings to support Plaintiff’s subjective complaints of chronic pain; the clinician therefore recommended an independent occupational medical review and peer outreach to Plaintiff’s two treating physicians. Def.’s SOF ¶ 27.

On June 13, 2011, Dr. Donald T. Lee, board certified in preventative and occupational medicine, conducted an independent review of Plaintiff’s medical records from December 10, 2009 through May 17, 2011. Def.’s SOF ¶ 28; Pl.’s SOF ¶ 13. He attempted to speak with Dr. DiSimone; however, the record is unclear as to whether he was ever able to do so. Def.’s SOF ¶ 29. He did speak with Dr. Adroja, who stated his continued belief that Plaintiff was functionally impaired due to limited range of motion of her shoulder and lifting restrictions and therefore was only capable of working on a part time basis. Def.’s SOF ¶ 30; Pl.’s SOF ¶ 35. Dr. Lee ultimately found that Plaintiff had functional impairment and was restricted in certain ways; however, he concluded that the medical documentation supported an ability to do light duty work on a full time basis. Def.’s SOF ¶ 31; Pl.’s SOF ¶ 36. After reading Dr. Lee’s report, Dr. DiSimone responded to inform Aetna that he did not believe Plaintiff was capable of working light duty on a full-time basis but rather opined that she could perform at a sedentary level on a full-time basis. Def’s SOF ¶ 33; Pl.’s SOF ¶ 37.

On April 25, 2012, Defendant determined that a Functional Capacity Examination (hereinafter “FCE”) would be appropriate to clarify Plaintiffs functionality and to reconcile the competing opinions of the three physicians. [2] Def’s SOF ¶ 36; Pl.’s SOF ¶ 16. The examiner at Plaintiffs FCE found that Plaintiff did not meet the requirement of sedentary strength work duty due to her inability to lift, carry, push, pull with two hands or sit for greater than ten minutes. Pl.’s SOF ¶ 16; Def’s SOF ¶ 37. However, the examiner also concluded that Plaintiff had provided “inconsistent effort during functional testing” and repeated the phrase “I know I look good on the outside.” Def’s Counter Statement of Facts ¶ 16, October 10, 2014, ECF No. 23 (hereinafter “Def’s Counter SOF”). Moreover, the examiner determined that Plaintiffs subjective pain rating was not consistent with her demeanor because she never provided a pain rating greater than 5 out of 10 even though she had significant difficulty lifting an unweighted box. Id. Defendant determined that the FCE results were invalid because of Plaintiff s inconsistent effort and refusal to perform material handling using the left hand. Def’s SOF ¶ 38.

Following the FCE, Defendant scheduled an Independent Medical Exam (hereinafter “IME”) for September 28, 2012 with Dr. Gregory Billy, a physical medicine and rehabilitation physician. Pl.’s SOF ¶ 19; Def’s SOF ¶ 39. Dr. Billy reviewed various medical records of Plaintiff s and also conducted a physical examination. Def’s SOF ¶ 40. Dr. Billy found that Plaintiff was capable of working full time at a sedentary capacity. Def’s SOF ¶ 42; Pl.’s ¶ 19. Dr. Adroja disagreed with Dr. Billy’s findings and once again reiterated his belief that Plaintiff was incapable of full-time work due to the limited range of motion in her shoulder. Def’s SOF ¶ 43; Pl.’s SOF ¶ 20.

Finally, Defendant requested a Transferable Skills and Labor Market Analysis (hereinafter “TSA/LMA”) be conducted. Def’s SOF ¶45; Pl.’s SOF ¶ 21. That assessment explained that the Dictionary of Occupational Titles identified Plaintiffs current part-time position as a clinical instructor as “light duty.” Def’s SOF ¶47. It therefore named four occupations, each accepting the “no reaching restriction, ” each paying more than ...


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