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Law v. Aetna Life Insurance Co.

United States District Court, N.D. Alabama, Southern Division

January 21, 2015

SIDNEY LAW, Plaintiff,


JAMES H. HANCOCK, Senior District Judge.

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 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 evidence[2] (Doc. #16) 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 evidence[3] (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 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 booklet-certificate. (Admin. Rec. at CL000186.) The booklet states as follows regarding "pre-existing conditions":

A pre-existing condition is an illness, injury or pregnancy-related 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 CL000270-71.)

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 spondylosis[4] with stenosis in the lumbar region." (Id.) Dr. Clark ordered a lumbar and cervical myelogram[5] 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 ...

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