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Arnold v. Aetna Life Insurance Co.

United States District Court, S.D. Mississippi, Western Division

June 17, 2015



DAVID BRAMLETTE, District Judge.

This cause is before the Court on Defendant's, Aetna Life Insurance Company, Motion for Judgment as a Matter of Law on Administrative Record, or Alternatively, for Summary Judgment [docket entry no. 15] and Plaintiff's, Jennifer Arnold, Motion for Summary Judgment [docket entry no. 17]. Having considered the motions and responses, applicable statutory and case law, and being otherwise informed in the premises, the Court finds as follows:

I. Factual and Procedural Background

Plaintiff Jennifer Arnold seeks a reversal of Defendant Aetna Life Insurance Company's ("Aetna") decision to deny her long-term disability benefits under an Employee Retirement Income Security Act ("ERISA") qualified plan.

Arnold began working as a physical therapist and rehabilitation director in March 2010 at Franklin County Memorial Hospital where she enrolled in a Group Life and Accident and Health Insurance Policy issued by Aetna. The policy included coverage for long term disability benefits. Arnold became eligible for those benefits under the plan on July 1, 2010. "Under the Plan, covered employees are eligible to receive [long term disability] benefits if the employee is disabled and unable to work because of an illness, an injury, or a disabling pregnancy-related condition as determined by AETNA." Mem. Supp. 5, ECF No. 16. The plan also contains a pre-existing condition exclusion to long term disability benefits. Under the plan, a pre-existing condition is one for which a covered employee has been diagnosed, received treatment, or taken medication during the three months before coverage became effective.

On January 25, 2012, Arnold submitted a claim for long term disability benefits. Her claim alleged that she became disabled effective July 22, 2011, because of a primary diagnosis of Lyme disease, a secondary diagnosis of babesiosis, and other diagnoses of bartonella, fibromyalgia, and chronic fatigue syndrome. Arnold's treating physician, Dr. James Forester, made these diagnoses. Dr. Forester further confirmed that Arnold had no ability to work because of her medical conditions. Dr. Forester stated that Arnold's disability was not permanent and that she could participate in a vocational rehabilitation program in one to two years. Arnold had also been treated by Karen Touchstone and Meredith Hayles, certified family nurse practitioners, and Dr. Joe Kim, a pain management specialist. Aetna reviewed Arnold's claim both through a phone interview with her and a review of her medical records.

On April 17, 2012, Aetna denied Arnold's claim because it found the claim was based on pre-existing conditions. Aetna found that in the three months prior to Arnold's eligibility for disability benefits, she "had been treated with Tramadol for pain and had been treated by Dr. Kim for chronic pain. Since [Arnold] claimed that her pain was a symptom of Lyme disease, and because [she] had been treated for pain, Aetna concluded that her conditions were pre-existing and excluded from coverage." Mem. Supp. 8, ECF No. 16. Arnold appealed. On appeal, the independent physicians determined that Arnold had not been treated for or diagnosed with Lyme disease or Fibromyalgia within the look back period. Therefore, Aetna informed Arnold that it was partially overturning its denial on December 28, 2012, "to determine if these diagnoses support a functional impairment that would prevent [Arnold] from performing the material duties of [her] own occupation." Mem. Supp. 9, ECF No. 16.

On February 7, 2013, Aetna again denied Arnold's claim. It based its second decision on a lack of objective evidence for either diagnosis in Arnold's medical records and a lack of evidence for a functional limitation. Arnold again appealed. On appeal, Dr. Tamara Bowman, an independent physician certified in internal medicine, reached the same conclusions that Aetna had on its second review of Arnold's claim. Dr. Bowman questioned the diagnosis of both babesiosis and Lyme disease and found that there were no clinical findings to support a disability related to either condition or any other malady. On April 30, 2013, Aetna notified Arnold that it had upheld its denial on appeal.

II. Analysis

A. Summary Judgment Standard

Summary judgment is appropriate "if the movant shows that there is no genuine dispute as to any material fact and the movant is entitled to judgment as a matter of law." Fed.R.Civ.P. 56(a). "A fact is material' if its resolution in favor of one party might affect the outcome of the lawsuit under governing law. An issue is genuine' if the evidence is sufficient for a reasonable jury to return a verdict for the non-moving party." Ginsberg 1985 Real Estate P'ship v. Cadle Co., 39 F.3d 528, 531 (5th Cir. 1994) (citations omitted). The moving party bears the initial responsibility of apprising the district court of the basis for its motion and the parts of the record which indicate the absence of a genuine issue of material fact. Celotex Corp. v. Catrett, 477 U.S. 317, 323 (1986).

"Once the moving party presents the district court with a properly supported summary judgment motion, the burden shifts to the non-moving party to show that summary judgment is inappropriate." Morris v. Covan World Wide Moving, Inc., 144 F.3d 377, 380 (5th Cir. 1998). "The evidence of the non-movant is to be believed, and all justifiable inferences are to be drawn in his favor." Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 255 (1986). But the nonmovant must meet his burden with more than metaphysical doubt, conclusory allegations, unsubstantiated assertions, or a mere scintilla of evidence. Little v. Liquid Air Corp., 37 F.3d 1069, 1075 (5th Cir. 1994). A party asserting a fact is "genuinely disputed must support the assertion by: (A) citing to particular parts of materials in the record, including depositions, documents, electronically stored information, affidavits or declarations, stipulations... admissions, interrogatory answers, or other materials...." Fed.R.Civ.P. 56(c)(1)(A).

Summary judgment must be rendered when the nonmovant "fails to make a showing sufficient to establish the existence of an element essential to that party's case, and on which that party will bear the ...

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