United States District Court, E.D. Kentucky, Central Division, Lexington
MEMORANDUM OPINION AND ORDER
DANNY C. REEVES, District Judge.
Plaintiff Linda Hulst was employed as a marketing executive with Marriott International, Inc. ("Marriot") in Hawaii until March 30, 2011. At all relevant times, Hulst was covered under Marriot's group LTD plan governed by the Employee Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. § 1001, et seq. Defendant Aetna Life Insurance Company ("Aetna") provides LTD coverage to Marriott in addition to administering the Plan. Hulst seeks review of Aetna's denial of her claim for long-term disability ("LTD") benefits under an employee disability benefit program (the "Plan") sponsored by Marriot under 29 U.S.C. § 1132(a)(1)(B). Both parties have filed motions for judgment. [Record Nos. 29, 30] Hulst alleges that Aetna's decision is arbitrary and capricious. Conversely, Aetna argues that its decision is supported by substantial evidence and should be affirmed. [Record No. 29] For the reasons that follow, judgment will be entered in favor of Aetna.
The Plan delegates to Aetna the discretion to make benefit determinations and to interpret the terms of the Plan. [ See Policy, p. 63; see also Record No. 29-1, pp. 1-2; Record No. 30-1, p. 8-9.]
The Plan defines "disability" as:
From the date that you first became disabled and until monthly benefits are payable for 24 months you meet the test of disability on any day that:
You cannot perform the material duties of your own occupation solely because of an illness, injury or disabling pregnancy-related condition; and
Your earnings are 80% or less of your adjusted predisability earnings.
After the first 24 months of your disability that monthly benefits are payable, you meet the plan's test of disability on any day you are unable to work at any reasonable occupation solely because of an illness, injury or disabling pregnancy-related condition.
[Policy, p. 8 (emphasis in original)]
Additionally, "Own Occupation" is defined in the Plan as:
The occupation that you are routinely performing when your period of disability begins. Your occupation will be viewed as it is normally performed in the national economy instead of how it is performed:
For your specific employer; or
At your location or work site; and
Without regard to your specific reporting relationship.
[Policy, p. 26]
Hulst claims that while she was an employee of Marriott she became disabled due to fibromyalgia, fatigue, and depression. She subsequently filed a claim for LTD benefits with Aetna. Aetna conducted a clinical review and physician peer review. During its investigation of the plaintiff's claim, Aetna determined that the evidence of record did not support any restrictions, limitations, or impairments that would prevent Hulst from performing her own occupation. By letter dated September 22, 2011, Aetna informed Hulst that her claim had been denied because the evidence did not support her assertion that she was unable to work at her own occupation. [AR, p. 130-32] She then appealed Aetna's determination. [AR, 58-59]
Hulst was afforded the opportunity to supplement the administrative record prior to Aetna's appellate review of its initial denial of LTD benefits. After Hulst supplemented the record, Aetna again reviewed the full the record and sought the opinions of two additional consultative physicians. As part of this review, both peer-to-peer conversations and written responses were elicited from Hulst's treating physicians. On May 16, 2012, Aetna again determined that the evidence did not support Hulst's claim that she was unable to perform her own occupation and upheld its denial of benefits.
Hulst filed this action on November 14, 2012, alleging that Aetna's decision to deny LTD benefits was arbitrary, capricious, and unsupported by substantial evidence. Hulst contends that she is disabled under the terms of the Plan and seeks reversal of Aetna's decision with reinstatement of benefits, including past due benefits. [Record No. 30]
A. Standard of Review
ERISA itself does not specify a standard of review. Generally, a challenge to an ERISA denial of benefits is reviewed de novo. Moon v. Unum Provident Corp., 405 F.3d 373, 378 (6th Cir. 2005) (citing Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989)). However, if the plan in question grants the plan administrator discretionary authority to determine benefit eligibility, such determination will be upheld unless it is arbitrary or capricious. Id. Here, the parties do not dispute that the Plan grants such discretion to Aetna. Likewise, the parties have stipulated that the Court should apply an arbitrary or capricious standard to Aetna's denial of LTD benefits. [Record No. 21]
The arbitrary and capricious standard is the "least demanding form of judicial review." Farhner v. United Transp. Union Discipline Income Prot. Program, 645 F.3d 338, 342 (6th Cir. 2011) (internal quotation marks omitted). When it is possible to offer a reasoned explanation, based on the evidence, for a particular outcome, that outcome is not arbitrary or capricious. Elliott v. Metro. Life Ins. Co., 473 F.3d 613, 617 (6th Cir. 2006). Essentially, "the Plan Administrator's ...