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Robinson v. Aetna – Claim Sent Back To Insurer To Assess Disability Under Plan’s “Any Occupation” Definition

Plaintiff Laverne Robinson brought a lawsuit against Aetna Life Insurance Company (“Aetna”) and Mondelez Global LLC Employee-Paid Group Benefits Plan (“the Plan”) for unpaid long-term disability (“LTD”) benefits under the Employee Retirement Income Security Act of 1974 (“ERISA”).

Robinson was a former utility machine operator for Mondelez. As an employee, she could receive disability benefits under the Plan. Aetna served as the disability claims administrator (“DCA”).

Must “Be Receiving Social Security Disability Insurance Benefits to Continue to Receive LTD Benefits Beyond 24 Months

To qualify for the Plan’s LTD benefits for more than 24 months, Robinson needed to “be receiving” Social Security Disability Insurance (“SSDI”) from the Social Security Administration (“SSA”) by the end of the initial 24 months of LTD payments.

Timeline

Robinson ceased working on April 29, 2016, due to several serious cardiac health issues, including a heart valve replacement, a stroke, atrial fibrillation (A-Fib), and a Pacemaker.

She filed for LTD benefits, and Aetna approved the application on October 28, 2016. 

Robinson later applied for Social Security Disability benefits, but that SSDI claim was not approved by the end of the initial 24 months of LTD payments or by October 29, 2018.

However, in March 2020, the SSA retroactively awarded Robinson SSDI, effective October 1, 2016.

Aetna Argues “Too Little Too Late”

Per Aetna’s interpretation of the Plan, SSA’s retroactive award of SSDI made no difference. They argued that because Robinson was not receiving SSDI on October 29, 2018, Robinson was ineligible for further LTD payments from Aetna. Robinson countered that Aetna’s interpretation violates ERISA.

The Court Ruled in Favor of Robinson

Because the Plan granted discretionary authority to Aetna, the court assessed Aetna’s determination under an arbitrary and capricious standard of review:

However, Aetna’s strict reading disregards the fact that Robinson effectively was receiving SSDI benefits by the end of October 2018 because of Robinson’s retroactive award. The court, therefore, stands by its prior conclusion: “Because the SSA concluded that she was entitled to SSDI benefits beginning October 1, 2016, she effectively became eligible for continued receipt of LTD benefits within the Plan’s 24-month window.” Robinson, 2021 WL 4206785, at *7. By common sense, when something happens retroactively, it changes the conditions of the past; the verb tense of the Plan’s provision does not alter the effect of retroactivity.

For these reasons, the Court granted Robinson’s motion for summary judgment and remanded the case to Aetna to determine whether, apart from the timing of her SSDI award, Robinson was otherwise eligible for benefits under the Plan.

Click here for a PDF copy of the Robinson v. Aetna decision.