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Very Plaintiff Friendly Decision – W.D. NC

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  • Very Plaintiff Friendly Decision – W.D. NC

    Here’s a new decision out of the Western District of North Carolina, Larry Cline v. Aetna Life Insurance Company. This is a pretty lengthy and thorough opinion. The court first finds that subjective evidence is not only relevant, but may be sufficient to support a long term disability claim. The court also finds that there was objective medical evidence to support the plaintiff’s claim.

    Moreover, the medical evidence existing alongside the raw testing evidence received scant attention in Defendant’s analysis. Defendant relies heavily on the facts that an EMG nerve conduction study and an ultrasound test were essentially negative. Yet the reports of the very doctors conducting those tests-Drs. Welshofer and Lesher-found explanatory factors underlying Plaintiff’s symptoms as noted in the statement of facts. Dr. Welshofer: the S1 nerve root “can get irritated” and act as in the case of “a circuit breaker” tripping. Dr. Lesher: “I think Larry’s symptoms are related to chronic radiculitis given his sensory involvement affecting the lateral aspect of his foot and diminished right Achilles reflex.” (AR 7000223). In addition, Defendant’s preoccupation with cause is off point. While the precise cause is relevant to a discussion of an impairment, the practical effects on ability to perform certain specified duties controls under the Plan. Examples of effects are Plaintiff’s doctors keeping Plaintiff out of work and the safety concerns of his treating doctors as related to specific functions of Plaintiff’s occupation.

    Subsequent to his decompression surgery for lumbar stenosis, Plaintiff’s reports to his doctors, and to Defendant as part of the claim process, unwaveringly recounted the ongoing effects of his right leg condition, namely its propensity intermittently to give way, or buckle, such as to undermine a reasonable level of confidence in his ability to perform the several identified essential requirements of his job, as set forth in NetJet’s specifications. Moreover, his credibility in relating his experience has not been expressly attacked, most notably not by his examining and treating physicians, nor Defendant’s counsel, nor Defendant in its denial of the claim. In support of Plaintiff’s claim for LTD benefits, he submitted numerous reports and letters from his treating physicians, who point out that while objective testing hasn’t pinpointed a measurable cause of Plaintiff’s right leg collapsing, it is not a feigned symptom. Dr. Edwards declared that “the giving way of Mr. Cline’s leg is likely due to neurologic dysfunction related to his previous herniated disk or the aftermath of his surgery.” AR 7000218 at 54.
    The court finds that the defendant did not properly take into consideration the plaintiff’s job as a pilot.

    This tunnel vision defect may be seen also in the lack of consideration given to the issue of safety as it relates to the duties of a pilot such as Plaintiff. The question of safety in itself naturally arises in the context of the medical condition of a pilot. Moreover, the Plan of insurance directs one to take account of the duties and responsibilities of an insured pilot, which self-evidently spring from and implicate consideration of the safety of a plane in flight. Yet Defendant’s decision documents denying the claim for disability insurance benefits barely discuss that component of the evidence beyond mere mention of it, and fail to explain its role in Defendant’s denial of the claim.
    The court concludes that defendant’s reviews were deficient because they did not review all of the medical evidence including the opinions of the treating physicians.

    The most authoritative, specific and substantial evidence before Defendant on the appeal and the reconsideration request, as to Defendant’s medical condition and its relationship to the material duties of his own occupation, comes from that letter of April 21, 2015, from Dr. Edwards himself. Dr. McKenas did not have the benefit of this letter in preparing his physician review because it was written and came into evidence subsequent to that review. Likewise, he did not have Dr. Senft’s letter of March 21, 2015, confirming his opinion as treating and referring physician and due to his background as a flight surgeon in the United States Army, that Plaintiff is “unsafe to fly commercial or private aircraft.” (AR 7000186). But Defendant did have such benefit and nonetheless concluded that there was “no evidence” of Defendant’s inability reliably to perform in his own occupation.

    The only evidence to the contrary of Dr. Edwards’s report and those of the other doctors is that of Dr. McKenas, whose report, while independent, is ostensibly derivative of the findings of Plaintiff’s doctors. The latter, however, uniformly reveal no doubts of Plaintiff’s credibility concerning his symptoms, found a medical basis for them and concluded he could not be expected to perform the necessary material functions of his own occupation in the light of those symptoms.

    This certainly constitutes evidence of an objective functional deficit in Plaintiff’s leg and is far from “no evidence”. Defendant’s reliance on Dr. McKenas’s report is not supported by the record.
    The court finds that a remand is not appropriate and awards the reinstatement of benefits.

    The Court finds that Defendant has demonstrated a manifest unwillingness to give fair consideration to Plaintiff’s evidence in the record, which shows that claimant is entitled to benefits. The record includes reports and letters from Plaintiff and his treating physicians, who document Plaintiff’s condition and urge that it is unsafe for Plaintiff to pilot an airplane, a condition of his employment. Despite this evidence, Defendant relies predominantly on Dr. McKenas’s flawed report. The Court finds it an unreasonable abuse of discretion to disregard Plaintiff’s treating physicians’ recommendations. Defendant’s reluctance to reassess Dr. McKenas’s report after Plaintiff pointed out that certain underlying facts were incorrect, is an indicator of Defendant’s unwillingness to give fair consideration to Plaintiff’s evidence. Accordingly, the Court finds it appropriate to order that Defendant retroactively award Plaintiff’s LTD benefits.
    The opinion is attached below.
    Attached Files