United States District Court, D. Connecticut
RULING ON MOTION FOR SUMMARY JUDGMENT
Warren W. Eginton, Senior U.S. District Judge.
In her complaint, plaintiff Nancy Mirto alleges that defendants Aetna Life Insurance Company and Yale New Haven Health System Long Term Disability Plan erroneously terminated her Long Term Disability benefits under an employee benefits plan governed by the Employee Retirement Income Security Act ("ERISA").
The parties have filed cross motions for summary judgment. Defendants have also filed a motion to dismiss a claim in the newly amended complaint. For the following reasons, the Court will deny defendants’ motion for summary judgment and grant plaintiff’s motion for summary judgment to the extent that the matter will be remanded to Aetna. The motion to dismiss will be granted.
The parties have submitted statements of facts with supporting citations to the administrative record.
Defendant Yale New Haven Health System Long Term Disability Plan is a long-term disability plan (the “Plan”) underwritten by a group insurance policy between Aetna and Yale New Haven Health Systems (the “Group Insurance Policy”). The Summary Plan Description identifies Yale-New Haven Hospital as the plan administrator and Aetna as the claims fiduciary to the Plan. At page two, the Plan document states: “This Plan is underwritten by the Aetna Life Insurance Company, of Hartford, Connecticut (called Aetna). The benefits and main points of the group contract for persons covered under this Plan are set forth in this Booklet.” At page thirteen, the Plan document states: “This document describes the main features of this Plan. Additional provisions are described elsewhere in the group contract. If you have any questions about the terms of this Plan or about the proper payment of benefits, you may obtain more information from your Employer or, if you prefer, from the Home Office of Aetna.”
The Group Insurance Policy designates Aetna as the ERISA claim fiduciary with “complete authority to review all denied claims for benefits, ” and it provides that “Aetna shall be deemed to have properly exercised such authority unless Aetna abused its discretion by acting arbitrarily and capriciously.”
Relevant to long term disability (“LTD”) benefits, the Plan provided that a participant who was “unable to perform the material duties of [her] own occupation” would receive monthly benefits for 36 months after the date of becoming disabled. After the first 36 months, the participant would receive a monthly benefit payable during a period of disability if she was “not able to work at any reasonable occupation solely because of: disease; or injury.” The Plan defines “own occupation” as “the occupation that you are routinely performing when your period of disability begins.” It defines “reasonable occupation” as “any gainful activity for which you are; or may reasonably become; fitted by: education; training; or experience; and which results in; or can be expected to result in; an income of more than 80% of your adjusted predisability earnings.”
Plaintiff commenced employment at Yale-New Haven Hospital in July 1980. Plaintiff holds an Associate’s Degree in nursing. At the time relevant to this action, she held the position of Clinical Nurse II SVC, which required medium physical demands of lifting, pushing, pulling and significant standing. Plaintiff was also required to assess patients; draw blood; administer IVs and medication; and collaborate with the medical team to facilitate patient care.
On August 22, 2009, plaintiff fractured her left rib and twisted her right knee. Plaintiff did not return to work until September 9, 2009. However, she ceased working on September 14, 2009. Plaintiff received short term disability benefits through January 25, 2010.
Plaintiff was first eligible to receive LTD benefits on February 27, 2010. In a letter dated March 5, 2010, Aetna informed plaintiff that it had determined her to be “totally disabled from her own occupation.” She was eligible to receive monthly LTD benefits “effective February 27, 2010, and continuing for up to 36 months as long as you remain disabled from your own occupation.” Plaintiff was also informed that after February 27, 2013, she would need to provide “objective medical evidence” that she met the “any reasonable occupation” definition of disability in order to receive LTD benefits.
On April 5, 2011, plaintiff underwent bilateral simultaneous total knee replacements.
In June 2011, plaintiff was awarded social security disability insurance effective March 1, 2010, in the amount of $1, 937 per month. Aetna did not receive the Social Security Administration’s determination or the relevant administrative record.
In July 2011, three months after plaintiff had undergone knee surgery, plaintiff’s physician, Dr. David Gibson, an orthopedic surgeon, noted that plaintiff was “making slow progress, although, indeed, making progress.” He stated that she had “mild restriction in flexion” in both knees; that her range of pain was ”2-4 out of 10;” and her left hip was “tender” with a normal range of motion. He concluded that her knees were “doing well” and that her “aberrant gait” had resulted in “trochanteric bursitis.” In his attending physician statement dated July 6, 2011, he indicated that her diagnosis was “degenerative joint disease, bilateral knees” and that her treatment plan was “surgery, physical therapy, [and] home exercise program.”
Office visit notes dated September 14, 2011, signed by Dr. Gibson, stated that plaintiff had “ongoing anterior knee pain that is exacerbated with certain activities, ” although range of motion for both knees was “near normal.” An office visit note dated December 2, 2011, provided that plaintiff “walks without external support and appears in no acute distress” and that her knees had “near normal” range of motion.
An office visit note dated March 7, 2012 indicated that plaintiff’s knees “are making slow progress” with some anterior knee discomfort” and “near normal” range of motion. Plaintiff appeared to be “in no acute distress.” The note also stated that plaintiff was experiencing “ongoing lumbar discomfort” and to a “lesser extent” left shoulder discomfort. Dr. Gibson reported that plaintiff was “not quite ready for work” because she was unable to stand for a “protracted period of time” or “sit for time” due to discomfort. In a Capabilities and Limitations Worksheet dated March 7, 2012, Dr. Gibson indicated that plaintiff was “totally disabled.”
Dr. Gibson’s office visit note dated June 1, 2012, provided that plaintiff was “doing reasonably well” even though she had knee discomfort, and difficulty negotiating stairs and getting up from a seated position. He found that she was “not quite ready” for work as a full duty nurse.
In a letter dated July 20, 2012, plaintiff was informed by Aetna that the “own occupation” definition of disability would end on February 26, 2013, and that she would be eligible for LTD benefits only if she was determined to be disabled from “performing any gainful occupation.” She was informed that she should notify Aetna if she had “any medical ...