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McDonough v. Aetna Life Ins. Co.

United States Court of Appeals, First Circuit

April 15, 2015

JOSEPH McDONOUGH, Plaintiff, Appellant,
v.
AETNA LIFE INSURANCE COMPANY, Defendant, Appellee. BIOGEN INC. and BIOGEN INC. GROUP LONG TERM DISABILITY PLAN, Defendants

Page 375

APPEAL FROM THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF MASSACHUSETTS. Hon. Douglas P. Woodlock, U.S. District Judge.

Mala M. Rafik, with whom Socorra A. Glennon and Sean K. Collins were on brief, for appellant.

Stephen D. Rosenberg, with whom Caroline M. Fiore and The Wagner Law Group were on brief, for appellee.

Before Barron, Selya and Stahl, Circuit Judges.

OPINION

Page 376

SELYA, Circuit Judge.

This case, brought under the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. § § 1001-1461, presents two issues. The first concerns the operation of an " own occupation" test within the definition of disability contained in a long-term disability (LTD) plan. The second concerns the operation of ERISA's penalty provision for late disclosure or non-disclosure of relevant plan documents. See 29 U.S.C. § 1132(c)(1)(B). After careful consideration, we vacate the district court's entry of summary judgment with respect to the termination of disability benefits and remand that issue for further consideration by the claims administrator. At the same time, we affirm the district court's imposition of a $5,000 penalty for the belated production of a plan document.

I. BACKGROUND

Plaintiff-appellant Joseph McDonough worked in the information technology division of Biogen Idec, Inc., now known as Biogen Inc. (Biogen). In March of 2007, he assumed the position of Senior Analyst III, Systems Administration. This was a high-pressure job, with responsibility for providing support for the server infrastructure at Biogen locations around the world (24 hours a day, 365 days a year).

In November of the following year, the appellant suffered the sudden onset of right-side numbness, dizziness, and blurred vision. He was hospitalized and provisionally diagnosed with a stroke. Although this diagnosis could not be confirmed, some of his symptoms persisted and he did not return to work.

The appellant was eligible for disability benefits through a Biogen employee welfare benefit plan underwritten by defendant-appellee Aetna Life Insurance Company (Aetna). Biogen serves as the plan administrator and Aetna serves as the claims administrator. Withal, Aetna has plenary discretion to determine " whether and to what extent employees and beneficiaries are entitled to benefits."

A plan participant is disabled within the meaning of the plan on any day that the participant is " not able to perform the material duties of [his] own occupation solely because of: disease or injury; and [his] work earnings are 80% or less of [his] adjusted predisability earnings." A participant's material duties are those " normally required for the performance of [the participant's]

Page 377

own occupation," so long as they " cannot be reasonably[] omitted or modified." The plan defines a participant's " own occupation" as the occupation " routinely perform[ed]" by the participant at the time the disability began as that occupation is " normally performed in the national economy," rather than how it is performed for the employer.

The appellant successfully applied for LTD benefits under the plan, commencing May 23, 2009. From that point forward, he and his health-care providers kept Aetna informed of his treatment and prognosis. Despite extensive therapy, the appellant continued to experience physical symptoms including sudden right-side weakness and loss of balance. He also suffered from anxiety, panic attacks, and the like. With this in mind, the appellant's primary care physician (PCP) referred him for mental health care in June 2009. Some of his health-care providers suggested that his physical symptoms might be a reaction to stress associated with the demanding nature of his job.

In September of 2009, the appellant's PCP reported that the appellant was continuing to experience right-side weakness but had a " sedentary level of functionality" and " could work 5 days a week and 8 hours per day." Based on this report, Aetna began to evaluate the appellant's continued eligibility for benefits. Soon thereafter, two of the appellant's mental health providers jointly reported that he suffered debilitating panic attacks four to five times per week and projected that -- due to a combination of these attacks, sleeplessness, and anxiety -- the appellant would be unable to work for a year.

On October 29, 2009, Aetna informed the appellant by letter that his LTD benefits would be terminated as of October 31, 2009. In Aetna's judgment, the appellant no longer met the plan's definition of disability. This judgment was premised in large part on his PCP's conclusion that he could perform sedentary work 40 hours per week. Aetna wrote off the contradictory report of the appellant's mental health providers, concluding that it " lacked examination findings [sufficient] to support a functional impairment from a clinical standpoint."

The appellant challenged the benefits-termination decision through Aetna's internal appeals procedure. In support, he submitted medical records from physicians, mental health providers, and physical therapists, highlighting the symptomatology that (in his view) precluded him from satisfying the physical and cognitive requirements of his job. These symptoms included right-side numbness and weakness, which he said significantly impeded his fine-motor skills for typing and writing. They also included anxiety, sleeplessness, and frequent panic attacks, which he said would impair his ability to cope with the stressful and ...


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