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Jones v. Aetna Life Insurance Co.

United States Court of Appeals, Eighth Circuit

May 8, 2017

Lisa Jones, Plaintiff- Appellant
Aetna Life Insurance Company; The Boeing Company Employee Health and Welfare Benefit Plan; Employee Benefit Plans Committee of The Boeing Company; The Boeing Company, Defendants-Appellees

          Submitted: December 13, 2016

         Appeal from United States District Court for the Eastern District of Missouri - St. Louis

          Before WOLLMAN, SMITH, [1] and BENTON, Circuit Judges.

          BENTON, Circuit Judge.

         Lisa E. Jones submitted a claim for disability benefits. Her plan administrator denied it. She sued under the Employee Retirement Income Security Act (ERISA) for denial of benefits and breach of fiduciary duty. The district court dismissed the fiduciary claim as "duplicative" of the denial-of-benefits claim. It then granted summary judgment against Jones on the denial-of-benefits claim. Having jurisdiction under 28 U.S.C. § 1291, this court affirms in part, reverses in part, and remands.


         Jones worked for The Boeing Company as a business and planning analyst. She was covered by Boeing's employee welfare benefit plan. The plan provided short-term (up-to-26-weeks) disability benefits funded by Boeing and administered by Aetna Life Insurance Company. It also provided long-term disability benefits funded and administered by Aetna.

         On October 16, 2013, Jones stopped working and submitted a claim for short-term benefits. On October 21, rheumatologist Dr. Francisco J. Garriga submitted an "Attending Physician Statement" with a primary diagnosis of "ankylosing spondylitis" (inflammatory arthritis primarily affecting the spine), and a secondary diagnosis of "migraines." Dr. Garriga first stated that Jones could not work through November 4. On October 23, Aetna approved her claim for short-term benefits effective October 24. Dr. Garriga then extended Jones's unable-to-work dates many times. Aetna extended her benefits and required updates from Dr. Garriga. On January 30, 2014, Aetna made what would be its final extension-through February 17.

         On February 26, Dr. Garriga extended Jones's unable-to-work date to April 28. At Aetna's request, he submitted a "Capabilities and Limitations" worksheet on March 17. It was mostly blank because "no formal testing has been done - would need PT appointment to accurately assess." On April 11, chiropractor Dr. Brian Dent submitted a "Capabilities and Limitations" worksheet stating that Jones was limited to working two to four hours per day pending flare-ups.

         On April 16, Aetna told Jones that her submitted information did not sufficiently document a level of impairment preventing her from working. Aetna requested more information. Aetna then sent Jones's file to Dr. Kia Swan-Moore for review. Dr. Swan-Moore reviewed the medical records and spoke to Dr. Garriga, who said "there is no physical clinical reason [Jones] cannot work however [Jones] continues to tell him that the pain is so intense she could not concentrate." Dr. Swan-Moore also tried, unsuccessfully, to contact Dr. Mahendra Gunapooti, a pain management specialist who Jones said had treated her. On April 24, Dr. Swan-Moore concluded, based on the medical records, Jones could work an eight-hour day for the period of February 17 through May 30 (with unlimited sitting, standing, and walking, and with some limits on pushing, pulling, and carrying). On April 28, Aetna essentially restated Dr. Swan-Moore's conclusions and told Jones her benefits were terminated effective February 17. The same day, Dr. Gunapooti sent records to Aetna. Those records showed that Jones reported chronic pain, was on numerous medications (including painkillers), and received epidurals. In light of Dr. Gunapooti's records, Dr. Swan-Moore reviewed her determination and tried to contact him (but was again unsuccessful). Dr. Swan-Moore reaffirmed her determination. Aetna reaffirmed its denial.

         On July 8, Jones submitted to a functional capacity evaluation by physical therapist Kevin J. Wilhite. He said Jones "demonstrated lifting performance that would place her in the Sedentary Physical Demand Category, " but he was "ultimately Unable to Classify her ability of work over an 8 hour work day due to her inability to complete the aerobic capacity testing" (which he did not conduct "due to safety concerns of using a treadmill with her gait performance and use of the cane"). He said, based on her self-reported pain, he "would not expect her to tolerate any activity over 2 hours, " and noted that "Productive Sedentary work for an 8 hour work day would not be expected based on this date's performance." Wilhite did say that Jones "demonstrated inconsistent performance, " including "movement and muscle recruitment patterns that were inconsistent when aware and unaware of observation." Aetna concluded that Wilhite's report did not support a disability finding, especially due to Jones's reported inconsistent performance.

         On July 17, Jones appealed the denial of benefits. She submitted Wilhite's report and a newer "Attending Physician Statement" from Dr. Garriga saying that her inability to work was "ongoing" and she "cannot remain standing for over 2 hrs." Aetna sent Jones's medical documentation to Dr. Daniel Gerstenblitt to see if Jones qualified as disabled between February 18 and April 16. Dr. Gerstenblitt tried to call Dr. Garriga seven times, leaving messages that were not returned. Dr. Gerstenblitt stated that Jones "appears to have chronic neck and back pain, " determined that her "functional capacity evaluation was an invalid study and self-limited, " and concluded that "there is absolutely no reason that she is incapable for performing in at least a sedentary position." Aetna denied Jones's appeal on October 8. On January 19, 2015, Jones asked Aetna to place in her file a letter from the Social Security Administration granting her disability benefits.

         In February 2015, Jones sued Aetna, the "Boeing Employee Health and Welfare Plan, " and the "Employee Benefit Plans Committee, the Boeing Company." Her amended complaint had two counts. Count I alleged that Aetna denied her short-and long-term disability benefits in violation of 29 U.S.C. § 1132(a)(1)(B). Count II alleged Aetna breached its fiduciary duty to her as a participant by (among other things) failing to obtain medical records, failing to tell her where to send evidence of disability, and using claims examiners with conflicts of interest, all in violation of § 1132(a)(3). The district court dismissed Count II as "duplicative" of Count I, and denied Jones's motion for discovery on the fiduciary-duty claim. It then granted summary judgment to Aetna on Count I, ...

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