LaShondra Davis v. Aetna Life Insurance Company
699 F. App'x 287
| 5th Cir. | 2017Background
- Davis, an Experian customer support associate, stopped full-time work in April 2010 and applied for STD then LTD benefits under Experian’s Plan administered and underwritten by Aetna.
- Treating rheumatologist Dr. Cheatum repeatedly diagnosed lupus, severe fatigue, pain, cognitive problems, and completed worksheets stating Davis was chronically and permanently disabled.
- Aetna initially paid STD and LTD under the 24-month "own occupation" period; after that period benefits continued only if Davis could not perform "any reasonable occupation."
- Aetna obtained an IME (Dr. Crane), periodic peer reviews (Drs. Braun and Ayyar), medical records, an unfavorable SSDI ALJ decision, video surveillance, and social-media/public-records searches; peer reviewers concluded Davis could perform sedentary work with occasional limitations.
- In March 2014 Aetna terminated LTD benefits, concluding the total record did not support continuous limitations precluding any reasonable occupation; Davis appealed administratively then sued under 29 U.S.C. § 1132(a)(1)(B).
- The district court granted summary judgment for Aetna; on appeal the Fifth Circuit reviewed for abuse of discretion and affirmed, finding substantial evidence supported Aetna’s decision and no procedural unreasonableness from its conflict of interest.
Issues
| Issue | Plaintiff's Argument | Defendant's Argument | Held |
|---|---|---|---|
| Procedural unreasonableness / conflict of interest | Aetna’s dual role biased the decision; Aetna favored consultants over treating physician and withheld evidence from reviewers | Aetna considered treating physician’s records, provided reviewers relevant evidence, and reached same conclusion as SSDI ALJ; no indicia that conflict affected decision | No abuse of discretion; conflict not shown to have influenced outcome or process |
| Qualifications of peer reviewers | Drs. Braun and Ayyar are not rheumatologists; therefore not suitably qualified to evaluate lupus-related limitations | Occupational medicine specialists had appropriate training/experience to assess functional capacity for "any reasonable occupation" | Aetna’s choice of reviewers was reasonable; no abuse in relying on their opinions |
| Treatment of treating physician and claimant’s subjective reports | Aetna improperly discounted Dr. Cheatum’s repeated opinions and Davis’s reports of pain/fatigue/cognitive limits | Aetna considered and addressed those reports; it permissibly credited independent reviewers over treating physician where supported by record | Court found Aetna did not arbitrarily ignore treating evidence; decision within reasonable range |
| Use of surveillance and social-media evidence | Video/social media showed only "good days" and do not disprove disabling flares; Aetna over-weighted such evidence | Surveillance and social-media were part of the record used to assess credibility and functional capacity alongside medical opinions and IME | Reliance on surveillance/social media was reasonable in context of full record; not an abuse of discretion |
Key Cases Cited
- Metro. Life Ins. Co. v. Glenn, 554 U.S. 105 (2008) (conflict of interest is a factor in reviewing administrator decisions)
- Black & Decker Disability Plan v. Nord, 538 U.S. 822 (2003) (administrators need not give special deference to treating physicians)
- Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101 (1989) (ERISA causes of action and review principles)
- Corry v. Liberty Life Assurance Co. of Boston, 499 F.3d 389 (5th Cir. 2007) (abuse-of-discretion standard and substantial-evidence framing)
- Schexnayder v. Hartford Life & Accident Ins. Co., 600 F.3d 465 (5th Cir. 2010) (procedural unreasonableness and weight given to conflicts)
- Ellis v. Liberty Life Assurance Co. of Boston, 394 F.3d 262 (5th Cir. 2005) (definition of substantial evidence standard)
- Cedyco Corp. v. PetroQuest Energy, LLC, 497 F.3d 485 (5th Cir. 2007) (standard of review for cross-motions for summary judgment)