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Alvarado v. Aetna Life Insurance Co.

United States District Court, N.D. Illinois, Eastern Division

September 6, 2016

KIM ALVARADO, Plaintiff,
v.
AETNA LIFE INSURANCE COMPANY, Defendant.

          MEMORANDUM OPINION AND ORDER

          REBECCA R. PALLMEYER United States District Judge.

         Plaintiff Kim Alvarado contends that Defendant Aetna Life Insurance Company wrongfully terminated the long-term disability benefits owed to her under her employer-sponsored benefit plan. She filed this action challenging that decision pursuant to the Employee Retirement Income Security Act of 1974 ("ERISA"). See 29 U.S.C. § 1132(a)(1)(B). The parties have filed cross-motions for summary judgment. For the reasons stated below, the court grants Plaintiff's motion [52] and denies Defendant's motion [48].

         FACTUAL BACKGROUND

         Plaintiff worked as a senior client services associate at UBS Financial Services from November 19, 2004 until October 8, 2012. (DSF ¶ 8; PSF ¶ 10.) During that time, she participated in the company's employer-sponsored long-term disability plan, which was issued, underwritten, and administered by Defendant for the benefit of eligible UBS employees. (Def.'s Stat. of Undisputed Mat. Facts [50] (hereinafter "DSF") ¶ 3; Pl.'s Stat. of Mat. Facts [54] (hereinafter "PSF") ¶ 1.) The Plan's "Test of Disability" defines disability as follows:

You are disabled if, because of injury or illness, you are unable to perform all the material duties of your own occupation, or solely due to injury or illness, are unable to earn more than 80% of your pre-disability earnings. After disability benefits have been payable for 24 months, you are considered disabled if, solely due to injury or illness, you are: (1.) unable to perform the material duties of any reasonable occupation for which you are, or may reasonably become, qualified based on education, training or experience solely due to injury or illness; and (2.) unable to earn 80% or more of your pre-disability earnings.

(DSF ¶ 6; PSF ¶ 7 (emphasis in original).) The Plan grants Defendant the discretionary authority "to determine whether and to what extent eligible employees and beneficiaries are entitled to benefits and to construe any disputed or doubtful terms under this Policy." (DSF ¶ 7; PSF ¶ 9.)

         Plaintiff's primary job responsibilities at UBS included answering phones, completing forms, and typing. (PSF ¶ 11.) In addition, her job required her to engage in the following physical activities: "frequent" reaching, "occasional" lifting of up to ten pounds, repetitive hand use for simple grasping, sitting for seven hours per day, and walking for one hour per day. (DSF ¶ 19; PSF ¶ 11.) In 2012, Plaintiff developed pain and numbness in both of her hands, and by September of that year, her symptoms had progressed to the point that she found it difficult to use her arms for daily activities. (PSF ¶ 12.)

         I. Plaintiff's Carpal Tunnel Diagnosis and Surgeries

         Although electrodiagnostic tests did not suggest that Plaintiff had any muscle or nerve problems, three physicians who examined her suspected that she had carpal tunnel syndrome. On October 5, 2012, her orthopedic physician, Dr. Robert Markus, diagnosed her with "suspected carpal tunnel syndrome" that had been resistant to conservative treatment attempts. (DSF ¶ 9; PSF ¶ 13.) But a nerve conduction study (NCV) and an electromyogram (EMG)- electrodiagnostic tests used to assess muscle and nerve damage-administered that day returned normal results. (DSF ¶ 10; PSF ¶ 14.) At a follow-up appointment five days later, Dr. Markus noted that he was "unable to account for patient's symptoms which are suggestive of carpal tunnel syndrome, but electrodiagnostic studies are normal, " and he recommended that she see an orthopedic hand specialist. (PSF ¶ 15.) On November 1, 2012, Dr. Neal Labana, a hand surgeon, evaluated Plaintiff and determined that she was suffering from De Quervain's tenosynovitis[1] and carpal tunnel syndrome, and he administered a corticosteroid injection to Plaintiff's right wrist. (DSF ¶ 11; PSF ¶ 16.) After a return visit on November 8, Dr. Labana recommended that Plaintiff remain off work for the next three weeks. (DSF ¶ 11; PSF ¶ 17.) The same day, Defendant notified Plaintiff that her claim for short-term disability benefits had been approved effective October 8, 2012. (PSF ¶ 18.)

         Though Dr. Labana eventually released Plaintiff in January to return to work with some restrictions on her physical activities, Plaintiff continued to struggle with performance of job-related tasks such as typing, filing, and lifting objects weighing over five pounds. (Id. ¶¶ 23-24.) On January 24, 2013, Plaintiff was evaluated by Dr. Anton Fakhouri, a hand and upper extremity orthopedic specialist, who remarked that "she has clear evidence of . . . carpal tunnel syndrome despite unremarkable EMG. This is consistent with a false negative result." (Id. ¶ 25.) Plaintiff elected to undergo surgery on both wrists, and Dr. Fakhouri recommended that she remain off work until a future date "to be determined." (Id.) On February 11, 2013, Dr. Fakhouri performed carpal and cubital tunnel release surgery along with a medial epicondylectomy[2] on Plaintiff's left arm. (DSF ¶ 12; PSF ¶ 26.) Plaintiff underwent the same surgery on her right arm on May 20, 2013. (DSF ¶ 22; PSF ¶ 31.)

         II. Plaintiff's Suspected Cervical Spine Problems

         Plaintiff reported for follow-up visits with Dr. Fakhouri for the next few months. Although Dr. Fakhouri noticed some continued tenderness, as well as contusions on her hands and a rash on her forearm and elbow resulting from falls she had suffered, he noted that Plaintiff was "doing well" and that he would consider releasing her to return to work in August 2015. (PSF ¶¶ 32-33, 35.) By the time she saw Dr. Fakhouri on August 22, Plaintiff exhibited full range of motion in her right elbow, and the doctor recommended that she discontinue physical therapy and avoid heavy lifting and other difficult activities for two to three weeks. (DSF ¶ 25; PSF ¶ 36.) By that point, he expected, she would be ready to return to light-duty work. (Id.) At her next visit on September 5, however, Plaintiff complained about a new pain extending from her neck to her right arm, as well as swelling of her right elbow. (PSF ¶ 37.) Dr. Fakhouri's examination revealed cervical spine tenderness and a positive Spurling test.[3] (Id.) An X-ray that day revealed degenerative joint disease in Plaintiff's cervical spine. (Id.) Dr. Fakhouri also posited that the swelling in her right elbow may be caused by tendonitis. (Id.) He administered a cortisone injection and also prescribed a corticosteroid for inflammation, an anti-convulsant, and an opioid analgesic for pain. (Id.)

         One week later, Plaintiff underwent a neck MRI exam that revealed cervical spinal stenosis, [4] most marked at the C6-7 level of her spine. She also exhibited moderate neural foraminal stenosis[5] at several levels. (DSF ¶ 26; PSF ¶ 38.) Dr. Fakhouri met with Plaintiff again on September 19. (PSF ¶ 39.) She reported minimal improvement in her symptoms and added that she had experienced significant pain from trying to type at home. (Id.) Dr. Fakhouri referred her for epidural steroid injections and advised her to follow up with a spine surgeon if her symptoms persisted for another four weeks. (Id.) In the meantime, he recommended that she remain off work. (Id.)

         III. Defendant's Denial of Plaintiff's Long-Term Disability Benefits

         Defendant approved Plaintiff's initial claim for short-term disability benefits through April 15, 2013, which would be approximately two months after Plaintiff's first surgery. (DFS ¶ 13.) On March 22, while recovering from her first surgery but before her second surgery, Plaintiff completed an application for long-term disability benefits. That claim was approved on April 8, effective April 14, 2013. (DFS ¶¶ 14, 16.) In administering benefit plans, Defendant employs nurses to act as "medical consultants" and conduct reviews of beneficiaries' claims. One of those nurses, Nurse Laura Doble, conducted a review of Plaintiff's claim on July 15, 2013 and noted that Plaintiff had had surgery on her left arm that February and on her right arm that May. (DSF ¶ 23.) Doble observed that the usual recovery time for Plaintiff's surgery was six weeks according to the Medical Disability Advisor, and that that guideline would support restrictions and limitations on Plaintiff's work through July ...


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