Phillips v. Aetna Life Insurance Company

Background

David Phillips worked for more than twenty years as a systems engineer at the Boeing Company in Missouri. After he was assaulted in March 2019, he suffered serious injuries, including a subdural hematoma, an intraventricular hemorrhage, facial fractures, and rib fractures. He received short-term-disability benefits through a Boeing-sponsored plan that Aetna did not administer.

In August 2019, Phillips applied for long-term-disability benefits under Boeing’s Aetna-administered plan. The plan provided benefits when an illness or injury prevented a participant from working. During the first 24 months, the participant had to be unable to perform the material duties of his own occupation. The participant also had to establish disability throughout a 26-week elimination period and would no longer be considered disabled if, among other circumstances, he was no longer under a physician’s regular care or refused an Aetna-requested medical examination.

Medical and benefits record

In June 2019, Phillips’s treating neurosurgeon, Dr. Richard Bucholz, cleared him to return to work as of June 24, 2019. After a June 20 computed-tomography scan showed complete resolution of the hematoma and hemorrhage, Phillips was discharged from the neurology clinic. Dr. Bucholz later recorded that Phillips had no symptoms or functional impairments preventing him from returning to work. Phillips also told an Aetna representative that he had not seen a physician since his last neurology appointment at the end of June.

After Aetna denied his application, Phillips obtained an October 2019 examination from a family-medicine physician. That physician believed Phillips could not return to his previous employment because of cognitive impairment, memory loss, and other issues, and recommended neuropsychological testing. Aetna scheduled the testing, but Phillips did not attend and did not respond to Aetna’s letter and at least three phone calls. Phillips later submitted the family-medicine physician’s letter and records from a July 2020 neurology visit. The neurologist noted that Phillips denied difficulty with routine daily activities, ordered a brain magnetic-resonance-imaging scan, and recommended neuropsychological testing if his cognition worsened. The opinion states that Phillips did not undergo the recommended testing or an MRI.

Aetna’s independent medical reviewer examined the records and consulted Dr. Bucholz’s office. The reviewer concluded that the records did not support severe cognitive impairment. Aetna denied Phillips’s appeal, leading to the lawsuit.

Court’s analysis

Phillips brought one claim under the Employee Retirement Income Security Act, a federal law governing many employee-benefit plans. The parties agreed that the court should use de novo review, meaning the court would independently decide whether Phillips qualified for benefits without deferring to Aetna’s decision. Phillips had the burden of proving by a preponderance of the evidence—that his evidence was more convincing than not—that he was disabled under the plan.

The court found the evidence supporting Phillips’s claimed disability to be very limited. It emphasized that the physicians who identified cognitive concerns also recommended testing that was never completed. The court concluded that Aetna could properly deny benefits based solely on Phillips’s refusal to undergo the neuropsychological examination Aetna scheduled. The court rejected Phillips’s explanation that he did not know about the examination, noting Aetna’s phone calls, and rejected his later explanation that he feared participating during the COVID-19 pandemic because the examination was scheduled several weeks before the stay-at-home orders he cited.

The court also rejected Phillips’s argument that Dr. Bucholz’s return-to-work clearance was a mistake. It noted that Phillips had not provided an affidavit or other document from Dr. Bucholz correcting the clearance. The court concluded that the objective evidence did not support disability during the elimination period.

Disposition

The court granted Defendant Aetna Life Insurance Company’s Motion for Summary Judgment, denied Plaintiff David Phillips’s Motion for Summary Judgment, and ordered that judgment be entered accordingly.