North Carolina Judge Agrees with AETNA Life Insurance Company’s Denial of Disability Benefits

Tina Worsley, Executrix of the Estate of Mark Worsley had her case against AETNA Life Insurance Company and Duke Energy Long-Term Disability Insurance Plan decided by the United States District Court, Western District of North Carolina, Charlotte Division on January 25, 2011. Claiming that the termination of Mark Worsley’s disability benefits was an abuse of discretion, Worsley and her North Carolina disability lawyer challenged the reasonableness of the termination of Mark Worsley’s benefits.

Since Worsley’s policy was obtained through his employer Duke Energy, Worsley’s claim was governed by ERISA. Worsley had the difficult burden of proving that AETNA’s decision to deny benefits were unreasonable. Eight factors are considered by a Court when determining the reasonableness of an insurer’s decision to terminate an employee’s disability benefit; and these eight factors include:

  • “the language of the plan;
  • the purposes and goals of the plan;
  • the adequacy of the materials considered to make the decision and the degree to which they support it;
  • whether the fiduciary’s interpretation was consistent with other provisions in the plan and with earlier interpretations of the plan;
  • whether the decision-making process was reasoned and principled;
  • whether the decision was consistent with the procedural and substantive requirements of ERISA;
  • any external standard relevant to the exercise of discretion; and
  • The fiduciary’s motives and any conflict of interest it may have.”

 

 

Background of Mark Worsley’s Disability Claim

Having worked at Duke Energy as a line technician, Mark Worsley was injured in a car accident when he hit a deer in November of 1996. After recovery from the accident, Worsley returned to Duke Energy in 1997 and was given a desk job until he was able to return to his line technician job. At first approved to continue as a line technician even though medicated for pain, Worsley was disqualified for that position when a new Duke Energy physician came on board and reviewed Worsley’s case. Worsley’s taking of the type prescription that he was prescribed at the time was a deal-breaker for working in the capacity of a line technician according to the new physician.

Consequently, Worsley was assigned to a “sit down” job at Duke Energy as a dispatcher. Due to the sedentary nature of the new assignment, Worsley complained to his doctor that he was drowsy from his medication while on the job, and consequently had started falling asleep at his desk. Experiencing difficulties at work and AETNA’s refusal to accommodate Worsley, Worsley left his Duke Energy job in 2001. Upon his departure, Worsley applied for long-term disability benefits from AETNA and became eligible for disability benefits in 2009. A few days after becoming eligible for those benefits, Worsley received a letter from AETNA informing him that after 24 months of disability, he would have to “meet the more stringent ‘any occupation’ definition of disability to remain eligible for LTD benefits.”

Previous to the car accident, Worsley had suffered “from a shrapnel injury to his shoulder” while serving in Vietnam in 1969. The car accident Worsley was in “left him in a coma,” and resulted in Worsley having three surgeries in 1983 to attempt to correct the problem. In pain after returning to work at Duke Energy, Worsley sought assistance to deal with his pain and attended rehabilitation sessions. Investigating Worsley’s pain via a CT scan, Worsley’s doctor recommended more surgery and after recovery, stated that he believed Worsley would need to have an office job and could not be expected to perform his previous job as a line technician.

Worsley’s Disability Worsens

After exiting his job, Worsley continued to have pain, and in fact, reported that his pain increased substantially at that time. After an MRI, Worsley was informed by his physicians that little could be done to relieve his pain and the deterioration of his shoulder. Armed with Vicodin and Methadone, Worsley attempted to regain his life. From 2003 until 2006, Worsley received disability benefits from AETNA.

On April 26, 2006 AETNA asked Worsley to undergo a Functional Capacity Evaluation (FCE) and a Transferable Skills Analysis (TSA), as a result of discrepancies between his treating physician’s reports and a surveillance video that suggested Worsley was not as hurt as he claimed or showed. Worsley was determined to be “reasonably qualified to perform in a supervisory position.” With conflicting opinions from three doctors, one from Worsley’s attending physician who said that Worsley was disabled, one from a reviewer who claimed Worsley was capable of working, and one from an outside psychiatrist whose report was neutral, Worsley’s disability benefits were terminated.

The Western District of North Carolina’s Considerations

By law, the North Carolina District Court was limited by whether the insurer abused its discretion in terminating Worsley’s benefits. In determining if an insurer’s administrator has abused its discretion, the Court must take into consideration eight factors:

  • The Plan’s language
  • The Plan’s purposes and goals
  • The adequacy of the material used to make the decision to terminate Worsley’s benefits
  • The interpretation of the Plan by the fiduciary
  • The reasonableness of the decision
  • The adherence to ERISA standards
  • The external standards relevant to the decision
  • The motives and degree of conflict of interest of the insurer

The North Carolina Court’s Decision

Worsley maintained that Aetna did not have the right to use an abuse of discretion standard in the review of his claim, and claimed that the insurer was obligated to consider the entirety of Worsley’s claim when making its decision. Unfortunately for Worsley, the Court didn’t see Worsley’s claim the same light. After reviewing the eight factors and examining the case law that AETNA’s lawyers presented, the Western District Court of North Carolina determined that it was “not free to disturb an administrator’s determination where it is reasonable, even if the Court ‘would have come to a different conclusion independently.’ ”

With an obligation to attempt to uphold adecision of the non-moving party (i.e. AETNA), the Court was somewhat bootstrapped to side with AETNA in that the evidence they were presented with and the restrictions on the factors they could consider hampered coming to any other decision than the one they came to.

Both parties, Worsley and AETNA, having filed motions for summary judgment were at the mercy of the Court. And, in the end, the Western District Court of North Carolina denied Worsley’s motion and dismissed his complaint, thus, giving the victory to AETNA.