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Hopper v. Aetna Life Insurance Co.

United States District Court, D. New Hampshire

October 5, 2015

Gary Hopper
Aetna Life Insurance Company Opinion No. 2015 DNH 191



Gary Hopper claims that Aetna Life Insurance Company (“Aetna”) violated the Employee Retirement Income Security Act (“ERISA”), 29 U.S.C. §§ 1001-1461, by terminating his long-term disability benefits under a plan it administered for his employer. Before the court are motions for judgment on the administrative record filed by both parties. Each motion is duly opposed. For the reasons that follow, Aetna’s motion is granted, and Hopper’s motion is denied.

I. Background

Until May of 2011, Hopper worked as a machinist for Ametek, Inc. While he was employed by Ametek, he was covered by a plan, administered and insured by Aetna, that provides both short-term disability (“STD”) and long-term disability (“LTD”) benefits. Under that plan, Aetna has “discretionary authority to determine whether and to what extent eligible employees and beneficiaries are entitled to benefits and to construe any disputed or doubtful terms under this Policy, the Certificate or any other document incorporated herein.” Administrative Record (hereinafter “AR”), at D 000149. The plan further provides that Aetna “shall be deemed to have properly exercised such authority unless [it] abuse[s] [its] discretion by acting arbitrarily and capriciously.” Id.

Shortly before he left Ametek’s employment, Hopper applied for and was awarded STD benefits. In his application, Hopper identified various medical conditions that precluded him from working in dusty or dirty environments. Those conditions include allergies, eczema, asthma, Bowen’s Disease, amblyopia, dry eye, decreased visual acuity, s/p penetrating keratoplasty, herpes simplex keratitis, open angle glaucoma, and keratoconus. After Hopper’s STD benefits were exhausted, he was awarded LTD benefits for a 24-month period running from August 23, 2011, through August 23, 2013. Under the applicable test of disability, he was entitled to LTD benefits based upon Aetna’s determinations that he could not perform the duties of his own occupation as a machinist, and that his earnings fell below a specified threshold.

Under the Aetna plan, when Hopper had collected LTD benefits for 24 months, he became subject to a stricter test of disability that entitled him to LTD benefits only if he was “unable to work at any reasonable occupation solely because of an illness, injury or disabling pregnancy-related condition.” AR, at D 000164. The plan defines “reasonable occupation” as “any gainful activity” for which a plan participant is “or may reasonably become, fitted by education, training, or experience; and [w]hich results in, or can be expected to result in, an income of more than 80% of [the participant’s] adjusted predisability earnings.” Id. at D 000182. Under the plan, eligibility for LTD benefits ends when, among other things, a plan participant “no longer meet[s] the LTD test of disability.” Id. at D 000165.

In January of 2013, Aetna notified Hopper that as of August 23, 2013, he would become subject to the stricter “any reasonable occupation” test and that his claim would be reviewed under that test. In a letter dated August 15, 2013, Aetna informed Hopper that he was not entitled to LTD benefits under the “any reasonable occupation” test because he could perform the occupations of machinist, bench assembler, and tool programmer. In rendering that decision, Aetna did determine that Hopper was “precluded from . . . performing tasks that required the ability to see small print or fine detail without the use of a magnifying device / ability to adjust print font sizes.” AR, at D 000285.

Hopper appealed Aetna’s decision. He pointed out that Ametek had discharged him from his position as a machinist “because his employers determined that his continued employment would pose a danger to himself and others.” AR, at D 000287. He also noted medical issues, including vision problems, that precluded him from working in the three occupations Aetna identified, and also asserted that Aetna’s findings were “inconsistent with those of the social security administration.” AR, at D 000288.

Initially, Aetna agreed with Hopper. In a letter dated January 10, 2014, Aetna explained:

Based upon our review of all the information submitted and gathered during the claim and appeal, we have overturned our original decision to terminate Mr. Hopper’s benefits; our review has established that the employment options identified do not fit within all of his physical restrictions and limitations. As a result, [Hopper’s] claim has been returned to the claims operation team and will be re-opened by [the] Disability Benefits Manager (DBM) for review and benefit payment, effective August 23, 2013.

Pl.’s Mem. of Law (doc. no. 13) 13.

Approximately three weeks later, Hopper received another letter from Aetna. In it, Aetna informed Hopper that it agreed with him that “the original occupations [it had] identified would not be appropriate as [he was] precluded from working in an environment that would [involve] expos[ure] to dust and dirt as this [would] trigger a flare up of [his medical] condition.” AR, at D 000758. Aetna went on to explain that it had Hopper’s medical documentation reviewed by a dermatologist and an ophthalmologist, and then determined that he “would have sustained full duty work capacity in an office environment.” Id. Then, based upon a review by a vocational rehabilitation consultant, Aetna determined that Hopper could work as an assignment clerk. Aetna also explained that it gave little weight to the fact that Hopper was receiving Social Security disability benefits, based upon its own Transferrable Skills Analysis (“TSA”).

Hopper appealed. Again he argued that Aetna’s denial of benefits was “inconsistent with the federal government’s determination that [he] is disabled and eligible for Social Security Disability benefits.” AR, at D 000193. He also described his visual impairments and explained that they were the cause of Ametek’s decision to terminate his employment as a machinist. Finally, he noted his long career as a machinist and argued that he ...

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