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Murphy v. Aetna Insurance Co.

United States District Court, D. Rhode Island

January 24, 2017

MARJORIE MURPHY, Plaintiff,
v.
AETNA INSURANCE COMPANY, Defendant.

          MEMORANDUM AND ORDER

          Mary M. Lisi, Senior United States District Judge

         The plaintiff in this case, Marjorie Murphy (“Murphy”), challenges the termination of long term disability (“LTD”) benefits under an employee benefit welfare plan. Both Murphy and the defendant, Aetna Insurance Company (“Aetna”), have filed cross-motions for summary judgment. The matter before the Court is Murphy's objection to the November 22, 2016 Report and Recommendation (“R&R”), in which Magistrate Judge Sullivan recommends that Murphy's motion be denied and Aetna's motion be granted (ECF No. 24). Murphy filed a timely objection to the R&R (ECF No. 25), to which Aetna filed a response (ECF No. 26). The Court has reviewed the R&R, the objection thereto, the parties' memoranda in support of their respective motions for summary judgment and those portions of the administrative record (“AR”) on which the parties rely. Having done so, the Court adopts the R&R in its entirety.

         I. Summary of Facts[1]

         Murphy was employed by FM Global as a Claim Technical Assistant from June 2000 until April 27, 2006, when she began a medical leave of absence due to acute liver failure related to alcoholic hepatitis. (PSUF ¶1, DSUF ¶¶1-3, Compl. ¶9).

         As part of her employment, Murphy was eligible for long-term disability (“LTD”) benefits under a group policy (the “Policy”) administered by Aetna. (DSUF ¶¶ 9). The Policy contains the following provision:

For the purposes of Section 503 of Title 1 of the Employee Retirement Income Security Act of 1974, as amended (ERISA), Aetna is a fiduciary with complete authority to review all denied claims for benefits under this policy. This includes, but is not limited to, the denial of certification of the medical necessity of hospital or medical treatment. In exercising such fiduciary responsibility Aetna shall have discretionary authority to:
determine whether and to what extent employees and beneficiaries are entitled to benefits; and construe any disputed or doubtful terms of this policy.
Aetna shall be deemed to have properly exercised such authority unless Aetna abuses its discretion by acting arbitrarily and capriciously. (DSUF ¶11, (Administrative Record, AR 00043).

         Under the Policy, Murphy received LTD benefits for the first two years after a “waiting period”, because she was unable to work at her own job at FM Global. (DSUF ¶ 5, 6). Specifically, the Policy provision required that Murphy not be “able, solely because of injury or disease, to perform the material duties of [her] own occupation.” (DSUF ¶12). After that two-year period, Murphy's eligibility for receiving LTD benefits depended on a determination that she was unable to work at “any reasonable occupation.” (DSUF ¶¶7, 12). “Reasonable Occupation” was defined in the Policy as “any gainful activity for which you are, or may reasonably become, fitted by education, training, or experience. It does not include work under an Approved Rehabilitation Program.” (DSF ¶10, AR 0003).

         Although Murphy's liver disease stabilized after hospitalization and abstinence from alcohol, she still suffers from cirrhosis, renal insufficiency, pancreatitis, and liver disease. (DSUF ¶14). Nevertheless, Murphy did work part-time (15 hours per week) from October 1, 2008 to May 8, 2009, while she was collecting LTD benefits. (DSUF ¶15). During that time, Murphy's primary physician was internist Keith Callahan, M.D. (“Dr. Callahan”); while Raymond Mis, D.O. was her gastroenterologist (“Dr. Mis”). (DSUF ¶¶16, 17).

         In October 2009, Murphy's application for Social Security Benefits was denied; she took no appeal in court. According to the Complaint, although Aetna notified Murphy at that time that her benefits would be terminated, she successfully appealed that decision and her benefits were reinstated. Compl. ¶20.

         The Administrative Record reflects that Murphy was regularly seen by Dr. Mis and that he reported his findings and conclusions to Dr. Callahan. DSUF ¶22. In a March 10, 2011 letter, Dr. Mis noted, inter alia, that Murphy's cirrhosis and renal insufficiency were “stable;” that she suffered from fatigue; and that she “remained quite active going swimming on a daily basis.” DSUF ¶ 23, AR 000807-808. Subsequent letters by Dr. Mis reflect that Murphy, who had undergone surgery for a complete hip replacement in 2011, continued to complain of fatigue, but that she continued to swim daily and tried to get motivated to do aerobic exercise at the gym. DSUF ¶24, AR 815, 817.

         According to a letter dated May 15, 2012, Murphy, whose chief complaint was fatigue at that time, remained “quiet active and has actually asked if she can return to work.” Murphy also reported that she exercised almost six days a week; that she stayed quite active with her son and her pet; and that she was bored. DSUF ¶25, AR 00819. Further letters from Dr. Mis for the period from November 20, 2012 through December 3, 2013 state that Murphy continued to exercise; that she underwent shoulder replacement surgery; that she continued to complain of fatigue (although she apparently did not follow up with Dr. Callahan to address that issue); and that she became a foster mother. DSUF ¶¶28-33, AR 000821-831.

         Murphy's case was reviewed by Aetna staff clinical consultant Kimberly Harris, R.N. (“Nurse Harris”) on January 25, 2013, after which she recommended that Aetna Senior LTD Claims Analyst Richard Collins (“Collins”) obtain additional records from Dr. Mis to evaluate Murphy's functional capacity. DSUF ¶35, AR 00239-45). After receiving additional information from Dr. Mis, Nurse Harris noted that Dr. Mis opined that Murphy was unable to work but that “[m]edical information does not support that [Murphy] would be precluded from frequent sitting, occasionally standing/walking and lifting up to 10 lbs. And her activities appear to be beyond these activities.” DSUF 38, AR 000264-67). The record ...


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