Billinger v. Bell Atlantic, 240 F.Supp.2d 274

New York

January 9, 2003

District Court Judge McMahon

Participant in long term disability plan, who had fibromyalgia, cervical myofascial disorder and lumbar myofascial disorder, brought action against plan and claims administrator, seeking to recover benefits, pursuant to (ERISA), and alleging promissory estoppel and breach of contract. The Defendant agreed that plaintiff had fibromyalgia but argued that Plaintiff’s medical condition was not severe enough to be disabling. February 1999, Plaintiff stopped working, and received short-term disability as well as workers’ compensation benefits.  She later applied for long term disability.  Her application for long term disability was denied based on an independent medical examination, a surveillance video, and the results of the functional capacity evaluation (FCE).  Plaintiff appealed.  Her appeal was denied. 

Although AETNA reviewed several items in its consideration, the notes of Dr. Bento Mascarenhas, a rheumatologist, and Dr. James Morrissey, an orthopedist, were highlighted by the court. Dr. Mascarenhas examined plaintiff and concluded that she had elements of psychogenic rheumatism and total body pain, but found no evidence of any significant arthritic disorder. He also stated that his examination of plaintiff was limited because of plaintiff's presumed anticipation of any pain during the examination, however gentle.   He found that plaintiff was capable of returning to sedentary work part-time starting at 2- hours a day and progressing further.  Dr. Morrissey examined Plaintiff in her workers compensation claim.  He also reported that plaintiff's subjective complaints of pain and self-limiting behavior during the examination prevented him from completing a full examination. Dr. Morrissey concluded there were no objective findings of musculoskeletal abnormality and soft mass, left supraclavicular region.  AETNA also considered Plaintiff’s notice of fully favorable decision from the Social Security Administration for disability insurance benefits. AETNA affirmed its original denial on the grounds that plaintiff was not totally disabled as defined by the Plan and was not prevented from engaging in any occupation or employment, for which she was qualified, or may reasonably become qualified based upon training, education, or experience. Evidence was presented to demonstrate that the Plaintiff was able to engage in sedentary work on at least a part-time basis.  A key issue in the plan administrator’s analysis was the discrepancies concerning Plaintiff’s capabilities throughout the record, particularly the activity on the surveillance tape and during the non-testing parts of her physical examinations that was suggestive of dissembling.

The court applied the arbitrary and capricious standard of review.  The court held that Defendant was permitted to evaluate Plaintiff's complaints of pain in light of the totality of her behavior.  Accordingly, it held that Aetna's denial of benefits was not arbitrary and capricious, given the totality of the record.  The court also noted, as has been previously established, that Social Security Administration determinations are not binding on ERISA plans.  The definition of disability to be employed by a benefit plan when evaluating a claim for long-term disability benefits is the one set forth in the Plan.

Plaintiff’s claims of promissory estoppel, breach of contract, and compensatory damages are all preempted under ERISA.  29 U.S.C. § 1144(a).