Shaikh v. Aetna Life Insurance Company

Background

Anis Shaikh was employed as a Senior Manufacturing Test Development Engineer with Zonare Medical Systems, Inc. Through his employer, he participated in a group disability-benefits plan issued by Aetna Life Insurance Company. The plan provided short-term and long-term disability benefits.

On January 11, 2016, Shaikh’s car left an exit ramp and rolled over, causing a left clavicle fracture. He underwent surgery on January 20, 2016. He reported severe pain in his neck, shoulder, and arm and said he could not return to work. Aetna paid short-term disability benefits from January 18 through April 10, 2016, and long-term disability benefits from April 10, 2016, through March 16, 2017. Aetna then terminated the long-term disability benefits, and denied Shaikh’s appeal on May 25, 2017.

The Social Security Administration later approved Shaikh’s disability application and found that he became disabled under its rules on January 8, 2016. The opinion states that the Social Security award letter was not available when Aetna made its decision.

Legal standard and plan terms

Shaikh sued under the Employee Retirement Income Security Act, or ERISA, seeking judicial review of Aetna’s denial and an award of benefits. The parties had stipulated that the court would review the claim de novo, meaning the court would independently consider the legal and factual issues rather than defer to Aetna’s decision.

Under the plan’s “Test of Disability,” a participant qualified during the first 24 months of benefits if an injury or disease prevented the participant from performing the substantial and material acts necessary for the participant’s own occupation. After that period, the participant had to be unable to work with reasonable continuity in any occupation that could reasonably be performed in light of the participant’s circumstances and abilities.

The court’s findings

Aetna argued that objective medical evidence showed improvement and that, by March 2017, Shaikh no longer had limitations severe enough to prevent sedentary work. Aetna relied mainly on an October 2016 electrodiagnostic study that did not confirm brachial plexopathy and a March 2017 shoulder magnetic resonance imaging scan showing minimal degenerative changes, a bone spur, and a small tear.

The court found that Aetna focused too heavily on objective evidence. The court noted that the neurologist who performed the electrodiagnostic study had stated that such studies can be normal in mild cases of brachial plexopathy. The court also found that imaging of Shaikh’s cervical spine showed structural changes, including posterior spondylosis and significant narrowing around the nerve openings.

The court gave substantial consideration to Shaikh’s continuing reports of pain and to the medical records documenting that pain. Several treating physicians recorded ongoing pain despite prescription medication. Shaikh also repeatedly reported difficulty lifting objects. Three treating physicians opined that he could lift no more than five pounds. Aetna’s retained physician, who did not examine Shaikh, opined that he could lift up to 20 pounds for part of the relevant period and had no supported functional impairment after March 7, 2017. The court found that physician’s conclusions insufficiently explained and found that Shaikh could lift no more than five pounds.

Shaikh’s former position involved designing, building, and programming automated test fixtures for medical ultrasound imaging systems. Zonare’s human-resources manager stated that the position required Shaikh to frequently lift pans weighing up to 51 pounds. A vocational analysis identified the position as correlating with both a “Light” strength occupation requiring occasional exertion of up to 20 pounds and a “Sedentary” strength occupation requiring occasional exertion of up to 10 pounds. Because Shaikh could lift no more than five pounds, the court found that he could not perform the substantial and material acts of his own occupation.

Disposition

The court found it appropriate to award benefits for the remainder of the plan’s 24-month “Own Occupation” period. It remanded the matter to Aetna to determine the amount of long-term disability benefits owed to Shaikh from March 16, 2017, through April 10, 2018.

The court separately remanded the question whether Shaikh qualified for benefits under the plan’s “Any Occupation” provision. The court noted that the record lacked a medical evaluation addressing that issue. The court granted Shaikh’s motion for judgment and denied Aetna’s cross-motion for judgment. It did not decide Shaikh’s request for prejudgment interest.