In Colon L. Carter v. Aetna Life Insurance Company, the U.S. District Court for the District of Maine held that Aetna did not act arbitrarily and capriciously in denying Plaintiff’s claim for long term disability (LTD) benefits. Specifically, the Court held that “the insurer had a reasonable basis and sufficient evidence to deny the plaintiff’s claim for benefits. The Court therefore grants the insurer’s and denies the plaintiff’s motion for summary judgment.”

Factual and Procedural History

Plaintiff was an estimating analyst, a job considered sedentary, at Bath Iron Works (BIW), a subsidiary of General Dynamics. He had a history of spinal surgeries dating back to 2003. In March 2015, he was in a car accident that involved his cervical spine and he required physical therapy.

He returned to work for a while, but finally quit work completely on December 15, 2015. His initial claim for short term disability (STD) benefits was granted and apparently paid for directly by his employer, BIW.

Through the years, he was treated by a number of health care professionals, including his primary care physician, surgeons, a neurosurgeon, a physical therapist, a psychiatrist, and others. In January 2016, Plaintiff began treatment with Dr. Trotta, a psychiatrist and pain specialist.

On May 4, 2016, Plaintiff applied for LTD benefits, but that claim was denied. His claim was based on his “chronic neuropathic pain, chronic spinal disorder, and chronic pain syndrome.”

Several appeals ensued. Ultimately, Plaintiff submitted medical records going back to 2011. The Court found that some of the records “support his claim, others support Aetna’s denial of his claim.”

Finally, Aetna had Dr. Howard Grattan, a board-certified physician in physical medicine and pain management, review Plaintiff’s medical records. He concluded that Plaintiff did not have any on-going neurological or cognitive disabilities that would interfere with him doing his sedentary job. Plaintiff’s treating physician, Dr. Trotta, reviewed Dr.Grattan’s report and opined that he understood how Dr. Grattan came to his conclusion. Aetna finally concluded its review and denied Plaintiff’s claim for LTD benefits. Plaintiff then filed this ERISA lawsuit.

Aetna’s Decision was Reasonable and Based on Substantial Evidence

Aetna stated its denial hinged on there being no objective evidence that Plaintiff could not perform his job duties. This was not a case like fibromyalgia where there is no objective test that can support a plaintiff’s claim of pain interfering with the ability to do their job. In this situation, the Court noted that there should be objective evidence of Plaintiff’s claim to having physical limitations such that he could not do his job.

Contrary to Plaintiff’s claim that Aetna relied only on Dr. Grattan’s opinion, the Court found that “the record illustrates that some of Mr. Carter’s own doctors ‘were not certain as to his ability to work.’” Even if there was conflicting evidence in the file, “’the existence of contrary evidence does not, in itself, make the administrator’s decision arbitrary.’”

The Court ultimately upheld Aetna’s denial, stating that based on the evidence before it, “the Court concludes Aetna had a reasonable basis and sufficient evidence to deny Mr. Carter’s claim.”

This case was not handled by our office, but we believe it can be instructive to those who are fighting with their insurance company over the denial of their claim for LTD benefits. If you have questions about this case, or any question about your disability claim, contact one.