An insurance company’s denial of a long-term disability claim has been remanded by Jane Magnus-Stinson, chief judge for the U.S. District Court for Southern District of Indiana.
Kimberly Garner worked at an Amazon’s fulfillment center since July 2012, but has been unable to return to her job because of a medical issue involving urinary incontinence that dates to at least 2009.
Since a July 25, 2016, surgery, Garner attempted to return to work Nov. 14, 15, and 16, 2016, but was unable to continue. Dr. Michael LaRosa, Garner’s primary care physician, placed Garner off work Nov. 17, 2016.
She subsequently applied for and was denied twice for long-term disability benefits through Amazon’s insurance company, Aetna.
Aetna first referred Garner to Holly Shepler, a registered nurse, who concluded Jan. 17, 2017 she was not impaired. Aetna rejected Garner’s claim Jan. 24, 2017. Three days later, Garner’s claim was referred by Aetna back to Shepler for further review, who only reaffirmed her prior conclusion.
Garner appealed the denial of her claim Jan. 31, 2017. Her records were reviewed by Dr. Stuart Fine, a urologist and associate clinical professor at the Medical College of Wisconsin, who also concluded she was not disabled. Her appeal was denied March 13, 2017.
Garner then sued Aetna on April 25, 2017, under the Employee Retirement Income Security Act. She called Aetna’s decision “arbitrary and capricious,” and sought attorney’s fees along with both past and future benefits.
Magnus-Stinson granted Garner’s motion in part, saying Aetna’s decision was not supported by the evidence. However, a remand to Aetna, not an award of benefits, was deemed as the appropriate course of action.
The court found that Fine’s conclusions based on a consultation with Garner’s urogynecologist, Dr. Douglass Hale, “fails the substantive reasonableness test because it completely lacks evidentiary support.”
“Dr. Fine’s conclusions drawn from Dr. Hale’s treatment primarily rest on two grounds: 1) that Dr. Hale did not think more surgery was needed, and 2) that Dr. Hale told Dr. Fine that Ms. Garner was not disabled,” the court found. “Without any explanation or acknowledgment of the issues raised by Ms. Garner, Aetna fully credited Dr. Fine’s statements regarding Dr. Hale. This decision was procedurally unreasonable.”
The court also rebuked Fine for disregarding LaRosa’s concerns.
“Dr. Fine did not provide any reasoning at all for his wholesale rejection of Dr. LaRosa’s opinions,” they wrote. “Aetna failed to give Ms. Garner a full and fair review by relying upon Dr. Fine’s unreasoned rejection of Dr. LaRosa’s treatment records.”
The case is Garner v. Aetna Life Insurance Co., 1:17-cv-1307.