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Hopper v. Aetna Life Insurance Co.

United States District Court, D. New Hampshire

May 16, 2016

Gary Hopper
v.
Aetna Life Insurance Company Opinion No. 2016 DNH 194

          ORDER

          LANDYA MCCAFFERTY, UNITED STATES DISTRICT JUDGE

         In a previous order, document no. 20, the court granted judgment in favor of Aetna Life Insurance Company (“Aetna”) on Gary Hopper’s claim that Aetna, as the administrator of a long-term disability (“LTD”) plan, violated the Employee Retirement Income Security Act (“ERISA”), 29 U.S.C. § 1001-1461, by terminating his LTD benefits. That claim was one of four that plaintiff asserted in his complaint. Because the parties did not address plaintiff’s other three claims in the motions that resulted its previous order, that order did not address those claims. In a subsequent pleading, plaintiff gave up the claim for breach of contract he had asserted in Count III. Currently before the court are the parties’ motions for judgment on the administrative record on Count II, which asserts a claim that Aetna violated 29 U.S.C. § 1133(2), and Count IV, which requests a declaratory judgment that Hopper is entitled to LTD benefits.[1]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. As an Ametek employee, he was covered by an LTD plan that was both administered and insured by Aetna. Under that plan, an employee with an impairment that prevents him from performing his own job is entitled to two years of LTD benefits. After two years, however, an employee is entitled to LTD benefits only if he meets a stricter test, which requires an impairment that precludes him from performing “any reasonable occupation.”

         In 2011, Hopper was awarded LTD benefits for a 24-month period running through August 23, 2013. That award was based upon a determination that Hopper could no longer perform his work as a machinist because he was suffering from, among other things, eye problems and skin conditions. In January of 2013, Aetna notified Hopper that on August 23, he would become subject to the stricter “any reasonable occupation” test and that his claim would be reviewed under it. On August 15, Aetna informed Hopper that, as of August 23, he would no longer be eligible for LTD benefits because he could perform the occupations of machinist, bench assembler, and tool programmer. On that basis, Aetna terminated Hopper’s benefits.

         Hopper appealed that decision to Aetna. During the appeal process, Aetna procured physician reviews of Hopper’s medical records from Dr. Samuel Winn, an ophthalmologist, and Dr. Vesna Petronic-Rosic, a dermatologist. Dr. Winn opined that Hopper’s visual impairments disqualified him from working as a machinist, as a bench assembler, or as a tool programmer. Dr. Petronic-Rosic, in turn, when asked whether Hopper was capable of performing any of those three occupations, gave the following response:

No, he is not; the claimant cannot work in a dusty factory environment. All the options listed in the Labor Market Analysis [i.e., the occupations of machinist, bench assembler, and tool programmer] involve work in a centralized facility, i.e., factory environment. He is capable of sustained full-time employment in an office environment, but no such options are listed.

Administrative Record (hereinafter “AR”), at D 000276. In a letter to Hopper’s counsel dated January 10, 2014, Aetna overturned its decision to terminate Hopper’s LTD benefits and explained:

[O]ur review has established that the employment options identified do not fit within all of [Mr. Hopper’s] physical restrictions and limitations. As a result, your client’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.

Doc. no. 13 at 13.

         On January 29, Hopper heard from Aetna again. In what it calls a “redenial letter, ” AR, at D 001021, Aetna told Hopper that while he was precluded from working as a machinist, bench assembler, or tool programmer, he could work as an assignment clerk. Accordingly, Aetna determined that Hopper was ineligible for LTD benefits.

         After announcing that decision, the letter also told Hopper that Aetna would “review any additional information [he] care[d] to submit, ” and described the kinds of information he might submit. AR, at D 000760. Aetna also told Hopper that: (1) he was entitled to a review of its decision; (2) he could request copies of documents related to his claim; and (3) if he did “not agree with the final determination upon review, [he had] the right to bring a civil action under section 502(a) of ERISA.” Id. Finally, Aetna described the steps Hopper would need to take to obtain a review of its decision.

         On February 14, Hopper’s counsel asked Aetna for “a copy of the complete contract (policy) used in [Aetna’s] letter of January 29, 2014.” AR, at D 000263. By letter dated February 25, Hopper’s counsel acknowledged receipt of a “copy of the ‘Benefit Plan’ booklet.” AR, at D 000261. In addition, he requested

a complete copy of whatever materials which in amy [sic] way are claimed to govern Aetna’s decision making process, procedural requirement[s] which bind the fiduciary and the employee, and the required reasonable procedures which must be exhausted before resorting to a judicial forum.

AR, at D 000261. Aetna’s Senior LTD Benefit Manager, Sammy Maurice, responded:

We are in receipt of your letter dated 02/25/2014. It appears you are indicating that you have not received all of the documentation initially requested. We have sent you a copy of the claim file and we have sent you a copy of the LTD booklet. At this point I am still unclear as to what else you are requesting.

AR, at D 000766.

         In letters dated April 15 and April 23, 2014, Hopper’s counsel attempted to clarify his request. In the former, he indicated he was “trying to ascertain the claim procedures which were in effect at the time [Hopper’s] claim was originally made or which may be [in] effect at this time.” AR, at D 000257. He then explained his need for that information: “Before we can resort to our judicial remedies, we must demonstrate that either we have exhausted the administrative remedies in place as required under the United States Department of Labor regulations, or, such an appeal would be a useless gesture.” Id. In his subsequent letter, Hopper’s counsel elaborated:

         This document [i.e., a copy of Aetna’s “claims procedures”] is essential for the claimant to ascertain the next step in obtaining the appropriate remedy. Without this information, we are unable to ascertain:

1- Whether the administrator has enacted and adopted claims procedures as required by the law.
2- Whether the claims procedures as adopted by the Administrator are consistent with the mandates of the law and are reasonable as required by the law.
3- The appropriate remedy for a self-reversal by the Administrator as was done in this case.
4- Whether the remedy for the self-reversal is voluntary or mandatory.
5- Whether the administrator has acted consistent[ly] with the mandates of the procedures as it may have adopted or they may exist.

AR, at D 000254. Counsel then reiterated his concern that without the “claims procedures, ” it was impossible to determine the proper forum in which to contest Aetna’s decision to terminate Hopper’s benefits. In the motion currently before the court, Hopper says he never got the information he requested from Aetna until March of 2015, five months after he filed this suit. He does not, however, indicate what that ...


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