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The "Arbitrary and Capricious" Standard and clarifying information: D. Colo

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  • The "Arbitrary and Capricious" Standard and clarifying information: D. Colo

    In this case, the court tackles the arbitrary and capricious standard as it relates to a Plaintiff who was denied STD benefits after being injured on the job. The court most notably seems to rely on the Plaintiff's assertion that the Defendant failed to perform an in-person medical examination when recommending the decision be reversed and remanded.

    However, the Court must bear in mind that Mark sought disability benefits and pursued her appeal without representation. The AR clearly indicates that she was trying her best to cooperate with Aetna and provide the requested documentation. In truth, Dr. Chang dropped the ball on his end, a fact that Aetna knew or should have known. “An ERISA fiduciary presented with a claim that a little more evidence may prove valid should seek to get to the truth of the matter.” Gaither v. Aetna Life Ins. Co., 394 F.3d 792, 808 (10th Cir. 2004). Aetna had a mechanism to obtain that additional evidence: an independent medical exam. While Defendants are technically correct that the Plan does not mandate an in-person medical examination (AR 24), Aetna could not “shut [its] eyes to readily available information when the evidence in the record suggests that the information might confirm the beneficiary’s theory of entitlement and when they have little or no evidence in the record to refute that theory.” 807. Given the obvious deficiencies of Dr. Andrew’s record review concerning Mark’s objective conditions, coupled with Dr. Chang’s inexplicable inability to gather clinical data, an independent medical exam was warranted. See Mason v. Reliance Standard Life Ins. Co., No. 14-CV-01415-MSK-NYW, 2015 WL 5719648 (D. Colo. Sept. 30, 2015) (unpublished). Aetna’s failure to conduct one, under these circumstances, was arbitrary and capricious.
    The court also touches upon the objective tests that the Defendant used in evaluating the Plaintiff's appeal, finding that they again failed to fully evaluate the claim:

    Moreover, while the Appeals Determination references the functional movement screens, it fails to address how these objective test results affected Mark’s ability to perform her job duties. For instance, the August 8, 2018 functional movement screen indicates that Mark had an “extreme” lack of balance, lacked core strength, and had stability issues. (AR 273-74.) The Court can easily see these conditions impairing Mark’s ability to “move and lift 55 pounds,” consistently bend/twist at the waist and knees, and operate, clean, and repair “binding and other auxiliary equipment,” all of which are indisputably part of her job responsibilities. However, Aetna failed to analyze this information. Instead, Defendants now argue that the functional movement screens offer no context for the resulting scores or explain how the test results implicate Mark’s ability to perform her job duties. If Aetna had trouble interpreting the screens of placing them in context, it could and should have asked for additional or clarifying information. See Gaither, 394 F.3d at 807 (“‘[I]f the plan administrators believe that more information is needed to make a reasoned decision, they must ask for it.’” (quoting Gilbertson v. Allied Signal, Inc., 328 F.3d 625, 635 (10th Cir. 2003) (further citations omitted) (emphasis in original)). Aetna failed to do so, and thus acted arbitrarily and capriciously.
    As such, the court recommended the decision be reversed and remanded. The opinion is attached below.
    Attached Files