In this case, Christopher Draper (“Draper”) worked as a truck driver/courier for Federal Express Corporation (“Fed Ex”). His job duties included doing things such as “maneuvering packages of any weight above 75 lbs. with appropriate equipment and/or assistance from another person.” This claim arose from a denial of Draper’s short-term disability (STD) benefits which originated as the result of back pain that he was experiencing.
Fed Ex’s STD plan was administered and serviced by Aetna Life Insurance Company (“Aetna”). The plan defined disability as:
Occupational Disability:
Provided, however, that a Covered Employee shall not be deemed to be Disabled or under a Disability unless he is, during the entire period of Disability, under the direct care and treatment of a Practitioner and such Disability is substantiated by significant objective findings which are defined as signs which are noted on a test or medical exam and which are considered significant anatomical, physiological or psychological abnormalities which can be observed apart from the individual’s symptoms. In the absence of significant objective findings, conflicts with managers, shifts and/or work place setting will not be factors supporting disability under the plan.
Further, “Occupational Disability” is the “inability of a Covered Employee because of a medically-determinable physical impairment or Mental Impairment, to perform the duties of his regular occupation.” The plan did not define what a significant finding was.
Draper began seeking treatment for his chronic back pain in June of 2016. He received an MRI in April 2016, showing “mild decreased disc height and desiccation with vacuum phenomenon. Central-right paracentral protrusion/extrusion indents the cal sac and buts the descending S1 nerve roots bilaterally right greater than left with posterior displacement of the descending right S1 nerve root. No central canal or foraminal stenosis.” An x-ray indicated findings that were similar in the same month. As a result of his pain, Draper had a lumbar epidural steroid injection at L5-S1 on July 5, 2016. Draper also had a cervical MRI showing “minimal disc bulging at C5-6.”
By April 2017, Draper aggravated his injury, which caused his pain to increase. Then, Draper filed for STD benefits. He met with Dr. Michael Stormont, where he was diagnosed with “lumbago” and “radiculopathy of lumbar region” and was prescribed Percocet. Dr. Stormont recommended Draper not work for two months, limiting his work to “light-duty and no lifting over 20 lbs.” Six days after this, Dr. Stormont filed an Attending Physician Statement showing Draper had “no limitations of functional capacity” and that he could complete “heavy work activity.”
Next, Draper was seen by Dr. Kelly Kiehm, a neurologist. She indicated that he was “healthy and in no apparent distress,” even though his MRI showed “mild degenerative changes and a small herniated disc that would not explain all of his pain.” Dr. Kiehm also saw a “broad-based disc at C5-6 causing some effacement of the cord,” but was “not sure” if that was the cause of his pain.
Draper was also treated by neurologist Dr. Sarah Blake. She believed Draper had a “full range of motion with all extremities against gravity and resistance.” However, she diagnosed Draper with “other cervical disc displacement” and “other intervertebral disc displacement.” She opined that he was “unable to perform his job duties, and quite frankly, if he is taking medications which sedate him and impair his driving to control his pain, then I think it is best if he stays off work until we are able to taper him off of [his pain] medication.”
Aetna then gathered Draper’s medical records and submitted them to neurologist Dr. Ryan Trombly for a peer review. Dr. Trombly believed that the records did not support an impairment that functionally prevented Draper from performing his job duties. Draper’s MRI was submitted for review, and his records were updated for Dr. Kene Ugokwe’s perusal. He determined that the records did not provide enough to show a functional impairment preventing Draper from completing his job duties.
Because of all of these peer medical reviews, Aetna denied Draper’s claim for STD benefits. Draper appealed and was again denied benefits after review by an appeal review committee. Overall, the committee stated that Draper demonstrated full strength in his extremities. Further, the committee stated that diagnostic testing only showed “minimal degenerative changes.”
Draper claims that Aetna’s evaluation did not explain why his MRI was not a “significant finding.” However, Aetna explained that the MRI only showed minimal degenerative changes. The court held that even though Aetna did not perform a robust analysis of the MRI, it still substantiated denying Draper’s claim.
Draper also argued that he had an issue with Dr. Ugokwe’s report and review of his MRI. Again, the court agreed with Aetna and stated that while Dr. Ugokwe’s report did not go into detail regarding the MRI, he still considered other testing and properly drew conclusions regarding the impact of Draper’s degenerative changes.
Draper also argued that Aetna “cherry-picked” evidence by looking only at early treatment and initial physician statements. However, the court held that Aetna’s denial letters of Draper’s claim sufficiently explained its reasoning for denying it. As such, it held that Aetna did not “cherry-pick” evidence related to Draper’s claim. In fact, the court held that the evidence within Dr. Ugokwe and Dr. Trombly’s reports regarding Draper’s records supported the decision.
Draper finally attempted to argue that Aetna had acted improperly in denying his benefits because it did not conduct a physical examination at any time. However, the court believes that it was appropriate for Aetna to rely on the evidence in the file to make its decision related to Draper’s STD benefits.
For the above-noted reasons, the court held that Aetna’s denial decision was not arbitrary and capricious. In fact, it was supported by a sufficient review process of Draper’s medical records and evidence. Therefore, the court ruled in favor of Aetna and against Draper.
Note: the Ortiz Law Firm did not handle this claim. It is merely summarized here to demonstrate how Federal Courts handle short- and long-term disability insurance claims.
Here is a copy of the decision in PDF: Draper v. Aetna