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Wilcox v. Aetna Life Insurance Co.

United States District Court, E.D. Wisconsin

August 26, 2019

CHRISTOPHER WILCOX, Plaintiff,
v.
AETNA LIFE INSURANCE COMPANY, Defendant.

          DECISION AND ORDER

          WILLIAM C. GRIESBACH, CHIEF JUDGE

         Plaintiff Christopher Wilcox brought this action for judicial review of the denial of his claim for long-term disability (LTD) benefits by Defendant Aetna Life Insurance Company under section 502(a)(1)(B) of the Employee Retirement Income Security Act (ERISA). Wilcox asserts that Aetna's decision was arbitrary and capricious while Aetna contends that it made its decision after a full and fair review. The court has jurisdiction over this case under 29 U.S.C. § 1132. Currently before the court are cross motions for summary judgment and Wilcox's unopposed motion for leave to file documents with restricted electronic access. For the reasons that follow, Aetna's motion for summary judgment will be granted, Wilcox's motion for summary judgment will be denied, and the case will be dismissed.

         BACKGROUND

         Starting in 2004, Wilcox was employed full time as a life and property insurance sales person for McCormick, Klessig & Assoc., Ltd. primarily selling life and commercial property insurance. Aetna issued an ERISA-governed employee welfare plan (the Plan) to Wisconsin Manufacturers & Commerce, Inc. Wilcox's employer was a participating employer under the policy as well as the Plan Administrator, though Aetna administered claims under the Plan.

         The Plan provides, in relevant part, the following:

Test of Disability
From the date that you first become disabled until the end of the Own Occupation Period, you will be deemed to be 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 Own Occupation Period, 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.
If your own occupation requires a professional or occupational license or certification of any kind, you will not be deemed to be disabled solely because of the loss of that license or certification.

         Administrative Record (AR) 2242, Dkt. No. 17-7 at 148. The “own occupation period” is defined in the Plan as “[t]he first 24 months that a Monthly Benefit is payable during a period of disability.” AR 2233, Dkt. No. 17-7 at 139. The Plan defines a “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.” AR 2259, Dkt. No. 17-7 at 165.

         On September 9, 2014, Wilcox initiated a claim for LTD benefits under the Plan. Aetna solicited further information from Wilcox in September. Aetna also faxed an Attending Physician's Statement (APS) form to Dr. Mazin Ellias, Wilcox's pain specialist, and was informed that Dr. Ellias was out of the office and unable to complete the APS. In October, Aetna received an APS from Dr. Mark Szmanda-Wilcox's neurologist-dated October 31, 2014, wherein he identified spinal degeneration and post-concussion syndrome as Wilcox's medical conditions. Regarding Wilcox's abilities and limitations, Dr. Szmanda wrote “defer” and did not fill out any of the fields in that section. Over the course of the next three months, Aetna spoke with Wilcox over the phone and requested information from Wilcox's employer.

         On March 24, 2015, after its medical consultants reviewed the records submitted by Wilcox, Aetna advised Wilcox in writing that it denied his claim, finding that Wilcox was not disabled from performing both his own occupation as well as a reasonable occupation. Aetna stated:

In view of the above, we have determined that the medical information on file fails to support a functional impairment from your own occupation. Despite numerous diagnoses which have changed over time, we do not have a provider willing to speak to impairment. While Dr. Szmanda completed a portion of the Attending Physician Statement it is unclear if he is disabling you from work activity. A note from Dr. John Myers an internal medicine provider indicates that he is not willing to complete disability paperwork. At this time, we are unable to accept liability on your Long Term Disability application and it has been denied.

AR 1875, Dkt. No. 17-6 at 169.

         Wilcox appealed Aetna's decision on September 22, 2015, arguing that he was disabled from performing his own occupation and any reasonable occupation as defined by the Plan. Wilcox requested multiple extensions to submit information related to his appeal and to obtain legal counsel, which Aetna granted. Among the additional information submitted was a second APS from Dr. Szmanda dated April 23, 2015, an APS from Dr. Kneeland dated August 17, 2015, and a letter and APS from Dr. Ellias dated December 30, 2016.

         Dr. Szmanda identified low back pain, fibromyalgia, and lumbar stenosis as conditions that impaired Wilcox, and indicated that Wilcox was capable of performing light work with the following limitations: no driving due to pain medication, no sitting in a chair for more than two hours due to leg and back pain as well as weakness, and no standing for more than one hour. AR 467-68, Dkt. No. 17-2 at 207-08. Dr. Szmanda limited Wilcox to working two hours a day, five days a week and listed pain and medication as objective findings that substantiate impairment. Id.

         Dr. Kneeland identified the same limiting conditions as Dr. Szmanda and also indicated Wilcox would be capable of performing light work, but did not check any boxes indicating the number of hours and days Wilcox could work. AR 471-72, Dkt. No. 17-2 at 211-12. Dr. Kneeland listed generalized fatigue, muscle pain, and medication side effects as objective findings that substantiate impairment. Id. Dr. Kneeland did not check any boxes related to the number of hours and days Wilcox could work, and instead deferred to Dr. Szmanda's recommended limitations. Id.

         Dr. Ellias identified cervical/lumbar spine degenerative joint disease and musculoskeletal knee/shoulder and side effects from medication-slow reaction time as well as mental and psychological effects-as conditions that impaired Wilcox. AR 484, Dkt. No. 17-2 at 224. Dr. Ellias indicated Wilcox had no ability to work. AR 485, Dkt. No. 17-2 at 225. In his letter, Dr. Ellias stated Wilcox's restrictions are both physical, restricting him “to sedentary type of work, ” and cognitive side effects of his medications that “further impair his judgment/reaction time.” AR 479, Dkt. No. 17-2 at 219. Dr. Ellias opined that these limitations, combined with the personality dysfunction identified by Dr. Azizi, “make it impossible” for Wilcox to return to gainful employment. Id. In addition to these APS forms, Wilcox submitted medical records from multiple providers dating back to 2009.

         Aetna obtained an independent medical review from Dr. Chalonda Hill, who was hired by a third-party vendor. Dr. Hill is board certified in occupational medicine and holds a diploma from the American Board of Internal Medicine and the American Board of Preventative Medicine. Dr. Hill submitted a report, dated February 1, 2017, based on her review of Wilcox's medical records that spanned from June 14, 2014, to December 30, 2016. As part of the report, Dr. Hill also spoke with Dr. Ellias, who informed her that Wilcox (1) suffers from cervical and lumbar pain due to degenerative disc disease; (2) has been treated with radiofrequency ablation and opioid medications; (3) has limited range of motion of the cervical and lumbar spine due to his conditions; and (4) suffers from seizure disorder. AR 447, Dkt. No. 17-2 at 187. Dr. Hill noted Dr. Ellias' opinion in her report:

It is Dr. Ellias' opinion that due to cervical and lumbar degenerative disc disease, decreased range of motion combined with seizure disorder, he is unsure if he is able to function in any job. He also notes a psychological aspect involving stress may play a role in limiting his abilities.

Id.

         Based on her review of the records, Dr. Hill opined that Wilcox was functionally limited from June 10, 2014, to the present due to cervical degenerative disc disease, lumbar degenerative disc disease, seizure disorder, bilateral knee degenerative joint disease, left avulsion distal fracture of distal fibula, failed back syndrome, and long-term opioid use. Id. Dr. Hill stated that Wilcox was capable of full-time work with the following restrictions:

Able to sit up to 1 hour at a time for a total of 8 hours per day. Allow for 5 minute breaks after sitting one hour for position change.
Able to walk up to 20 minutes at a time for a total of 2 hours per day.
Able to stand up to 30 minutes at a time for a total of 2 ...

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