A Federal Court on Long Island, New York, has determined that Aetna’s decision to terminate benefits to an ERISA claimant was arbitrary and capricious, where Aetna failed to address substantial evidence that was in the record. Despite the Court providing deference to Aetna, and applying the challenging arbitrary and capricious standard of review to its consideration of the issues, Judge Bianco determined that Aetna failed to properly credit the subjective complaints of the claimant, who was suffering from trigeminal nerve disorder, which was apparently caused by a root canal dental procedure.
The claimant’s treating doctor advised that the claimant was suffering from constant moderate to severe head and facial pain, causing neurocognitive issues and additional areas of pain in other regions. Aetna based its claim termination upon the opinion of a doctor it hired to conduct a purely paper review of the medical records. This doctor determined that the records did not support any functional impairments due to the claim largely being based upon subjective complaints of pain. On appeal of the terminated claim, the claimant submitted additional medical support from her doctor, who addressed the subjective complaints being credible and consistent with the clinical evaluation. Following its consideration of the appeal, including another paper only medical review, Aetna partially reversed and accepted a closed period of claim liability, while continuing to deny further benefits.
Because the Court was applying the deferential arbitrary and capricious standard of review to Aetna’s claim determination, the Court in its discretion, chose to confine its review to the contents of the administrative record created by Aetna and the claimant, and did not permit the expansion of the record for the Court’s consideration. The Court opined that Second Circuit authority proscribes that “the subjective element of pain is an important factor to be considered in determining disability.” Because Aetna credited the subjective complaints of pain during one portion of the claim and not the latter portion of the claim, the Court was perplexed by such conduct. The Court also determined that Aetna failed to provide the claimant with a full and fair review of her claim.
However, the Court did not reach the conclusion that benefits should be awarded, but, rather, determined that a remand to Aetna to properly consider all of the evidence, was appropriate.
VALENTINE V. AETNA LIFE INS. CO.