United States District Court, N.D. Georgia, Atlanta Division
For Yolonda Smith, Plaintiff: William Phillips Tinkler, Jr., LEAD ATTORNEY, William Tinkler Jr., Attorney at Law, P.C., Decatur, GA.
For Cox Enterprises, Inc., as Administrator of the Cox Enterprises, Inc. Long Term Disability Plan, Defendant: Elizabeth Johnson Bondurant, LEAD ATTORNEY, Nikole Marie Crow, Womble Carlyle & Rice, LLP-Atl, Atlanta, GA, USA; Kenton Jones Coppage, LEAD ATTORNEY, Smith, Moore, Leatherwood, LLP, Atlanta, GA, USA.
Timothy C. Batten, Sr., United States District Judge.
This case is before the Court on the parties' cross-motions for summary judgment [7, 9]. For the reasons set forth below, Defendant Cox Enterprises, Inc.'s motion will be granted
A. The Long-Term Disability Benefit Plan
Plaintiff Yolonda Smith seeks to recover long-term disability benefits under Cox's employee welfare benefit plan. The plan is administered by Aetna Life Insurance Company, and decisions pursuant to the policy are governed by the Employee Retirement
Income Security Act of 1974, 29 U.S.C. § 1001 et seq. The plan provides, in pertinent part:
You are considered totally disabled while either of the following applies to you:
o In the first 24 months of a period of total disability: You are not able, solely because of injury or disease, to work at your own occupation.
o After the first 24 months of a period of disability: You are not able, solely because of injury or disease, to work at any reasonable occupation. (A reasonable occupation is defined as any gainful activity which you are or reasonably could become qualified to perform through education, training or experience earning equal to your LTD [(Long Term Disability)] benefit but no less than 60 percent of pre-disability earnings. It does not include work under an approved rehabilitation program).
Cox Summary Plan Description, p. 86. [7-2].
Aetna, as the administrator of the plan, has the discretionary authority to interpret its terms and to make eligibility determinations. The plan expressly provides:
In accordance with Section 503 of Title I of [ERISA], AEtna Life Insurance (" AEtna" ) is hereby designated as the Named Fiduciary under the Cox Enterprises Group Insurance Plans (" Plan" ) with complete authority to review all denied claims for benefits under the Plan's Contract No. 050398 . . . . In exercising its fiduciary responsibility, AEtna shall have the discretionary authority to determine, subject to the terms of the Plan, whether and to what extent participants and beneficiaries are entitled to benefits, and to construe disputes or doubtful Plan terms. AEtna shall be deemed to have properly exercised such authority unless it has abused its discretion hereunder by acting arbitrarily and capriciously.
Administrative Services Contract. [7-3] at 19. Smith does not dispute that Aetna held discretionary authority to review and determine claims for long-term disability.
B. Smith's Position: Human Resources Analyst
Smith was employed by Cox at the Atlanta Journal Constitution as an HRIS Analyst, also known as a Human Resources Specialist. A detailed job analysis form, completed by Cox in connection with Smith's claim, describes her job duties as follows:
Maintains and verifies the data integrity of the AJC Human Resources systems with a high degree of confidentiality. Enters data accurately, runs system interfaces, and creates/generates reports using report writing software. Identifies and recommends solutions for process improvement using existing technology thereby increasing efficiencies. Assists with system testing for new releases, enhancements and hardware changes, as well as analyzing results. Works closely with other staff, departments, and Vendors in order to obtain user ids, troubleshoot various issues, and provide HR Systems end-user training. Provides operational support to the benefits and payroll areas as assigned.
Administrative Record at 122. According to the work history form submitted by Smith herself, she was " responsible for reports for the company [and] also maintain[ing]
org[anizational] structure." Id. at 182. The job analysis form indicates that Smith's position required her to work eight hours per day, of which seven required sitting, half an hour involved walking, and the remaining half hour involved standing. No kneeling, squatting, climbing, pushing, pulling or overhead work was required.
I. Aetna's Review of Smith's Claims
In 2005, Smith was diagnosed with Meniere's disease vestibular, hypoactive labyrinth, and dizziness, which caused episodes of vertigo, headaches, and often nausea and vomiting. On April 22, 2011, Smith stopped working for Cox and applied for short-term disability benefits. In May 2011, Aetna denied her claim. On appeal in October 2011, Aetna affirmed that denial. In January 2012, she applied for long-term disability, and on April 16, Aetna denied that claim as well. Smith administratively appealed, and in October 2012 Aetna again affirmed its decision. Smith then filed this action, challenging the long-term disability denial. Because Smith filed her claims for short-term and long-term disability in short sequence, and because the medical documentation reviewed in both proceedings overlaps substantially, the Court will address below the substance of all medical documentation received and reviewed by Aetna from 2010 through 2012.
A. Smith's Short-Term Disability Claim
After leaving work in April 2011, Smith submitted a claim for short-term disability. During the claims process, Aetna received records and reports from Smith's two treating physicians, otolaryngologist Dr. Fermin Stewart, and neurologist Dr. Michele Harvey.
1. Summary of Dr. Stewart's Attending Physician Records (Otolaryngology)
Dr. Stewart appears to have treated Smith from January 2006 through 2012. See id. at 199 (office visit dates for the patient are listed as January 9, 2006 through January 2012). His first submission to Aetna was a Form WH-380-E, in connection with an initial request by Smith in March 2010 for leave under the Family and Medical Leave Act. Dr. Stewart identified her diagnoses at that time as Meniere's disease with " dizzy spells" and " syncope episodes." Id. at 125. He noted that during episodes of dizziness, it would be " impossible for [Smith] to drive or sometimes keep her balance." Id. at 126. He also indicated that he had referred Smith to Dr. Michele Harvey, a neurologist.
On April 18 and May 9, 2011, Dr. Stewart submitted nearly identical attending physician statements, in which he confirmed Smith's diagnosis of Meniere's disease and listed her symptoms as " dizzy, vertigo." Id. at 132, 135. Dr. Stewart
went on to state in a handwritten note on the attending physician statement forms that " patient should be on total disability." Id.
Aetna also received and reviewed clinical records from Dr. Stewart dated March 30, May 18, May 20, June 29, and October 3, 2011. In his March 30 medical notes, Dr. Stewart states that " [Smith] reports episodes of imbalance . . . . She continues to be fearful of laying back or turning quickly as this would sometimes induce a brief sensation of dizziness. Her symptoms are occasionally associated with nausea. She does not report a significant deterioration in her hearing." Id. at 204. His physical examination on that date led to the following observations:
The membrane of right is intact. There's no significant retraction. No fluid is noted in the middle ear space. A pressure equalizing tube is in place and patent in the left tympanic membrane. No fluid is noted in the middle ear space. The nose has boggy inferior turbinates. The posterior pharyngeal wall has clear, thick phlegm. No significant cervical adenopathy is found to inspection on palpation. No observable cranial nerve weakness is appreciated.
On May 18, he noted that Smith still complained of " periodic muffling of the hearing with pressure and periods of increased tinnitus" but " no drainage from the ears [was] reported." Id. at 206. He did state that at that time, Smith's episodes of vertigo were associated with " extreme nausea and sometimes vomiting and/or diarrhea," but observed that she was able to successfully perform a Romberg test (a physical exam of neurological function, positioning, and balance) and that Hall-Pike testing did not reveal nystagmus.
On May 20, Dr. Stewart sent a letter to Aetna (addressed " To Whom It May Concern" ) in which he stated that Smith " suffers from intermittent episodes of incapacitating vertigo consistent with Meniere's disease." Though he did not indicate how frequently she experienced symptoms, he did note that when symptoms occur, they " still appear to significantly interfere with her ability to function." Id. at 202. Dr. Stewart's May 20, 2011 letter to Aetna, addressed " To Whom It May Concern," states in its entirety:
This patient suffers from intermittent episodes of incapacitating vertigo consistent with Meniere's disease. She had had testing in the past which shows a hypofunctioning left labyrinthine system and has been evaluated with imaging studies. She has been managed with the traditional low-salt diet and diuretic with limited success. Management of eustachian tube function has also been addressed and have improved her symptom frequency. When symptoms do occur they still appear to significantly interfere with her ability to function. Her hearing continues to restrict her options with respect to surgical intervention.
Finally, in June 2011, Dr. Stewart again noted that Smith was suffering from " randomly recurring episodes of vertigo" and " occasional tinnitus." Id. at 203. She reported " occasional episodes of pressure in the ears," but he observed no drainage from the ears, and she had no significant sinus complaints. Similar to his earlier examinations, he observed clear thick phlegm at the posterior pharyngeal wall
and mild retraction of the tympanic membrane, but no ulceration, no fluid in the inner ear, no significant adenopathy, no nystagmus, and Romberg ...