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Geiger v. Aetna Life Insurance Co.

United States Court of Appeals, Seventh Circuit

January 6, 2017

Donna Geiger, Plaintiff-Appellant,
v.
Aetna Life Insurance Company, Defendant-Appellee.

          Argued December 5, 2016

         Appeal from the United States District Court for the Northern District of Illinois, Eastern Division. No. 15-cv-3791 - Amy J. St. Eve, Judge.

          Before Wood, Chief Judge, Easterbrook, Circuit Judge, and Shadid, District Judge [*]

          Shadid, District Judge.

         Plaintiff-appellant Donna Geiger's long term disability insurance benefits were terminated after Aetna Life Insurance Company ("Aetna"), the insurer and administrator of her employee welfare benefit plan ("the Plan"), found that she no longer met the Plan's definition of total disability from any gainful occupation. After unsuccessfully appealing the termination decision, Geiger brought an action seeking reinstatement of her benefits in the United States District Court for the Northern District of Illinois. The district court denied Geiger's request to conduct limited discovery and ultimately granted summary judgment in favor of Aetna and against Geiger, holding that Aetna's decision was not arbitrary and capricious or a product of a conflict of interest warranting discovery. We affirm.

         I. Background

         Geiger was an account executive for Sprint Nextel ("Sprint") from 2001 to 2009. As a Sprint employee, she received group long term disability insurance coverage under the Plan issued and underwritten by Aetna. On October 6, 2009, Geiger stopped working at Sprint and claimed short term disability precipitated by lumbar back pain and an L5-Sl discectomy from 2007, as well as bilateral ankle pain caused by avascular necrosis of the talar bones.[1] Sprint approved Geiger's disability claim later that same month.

         Geiger had surgery on both ankles in January 2010 and underwent a left ankle arthroscopy and full ankle replacement in December 2010. During that time, Aetna determined that Geiger was disabled from her occupation as an account executive under the Plan and approved her claim for long term disability benefits. Aetna reasoned that Geiger was dis- abled from her own occupation "due to bilateral avascular necrosis in ankles, which caused [Geiger] severe pain/' and "she is unable to perform occupational duties as an account executive because [she] is unable to do the required walking and driving for this occupation." Geiger received benefits in the amount of $4, 012 per month, equal to 50% of her predisability earnings. Upon her approval for Social Security disability benefits, this amount was reduced to $784.

         The Plan provided Geiger with benefits for up to 24 months if she continued to be disabled from her own occupation. After 24 months, the Plan requires a claimant to be unable to work at any reasonable occupation, which the Plan defines as "any gainful occupation for which you are, or may reasonably become, fitted by: education; training; or experience; and which results in; or can be expected to result in; an income of more than 60% of your adjusted predisability earnings."

         Aetna reviewed Geiger's claim as the end of the initial 24-month period approached and investigated whether she met the more stringent "any reasonable occupation" definition of disability. As part of the investigation, Aetna invoked its right under the Plan to have Geiger examined by a physician of its choice, and on May 31, 2012, Dr. White examined Geiger and found her capable of performing sedentary work with minimal walking or standing. Aetna also placed Geiger under surveillance on two occasions in May 2012, where she was observed driving and visiting multiple stores. On August 20, 2012, Aetna informed Geiger that she no longer met the Plan's definition of disability and terminated her benefits.

         Geiger appealed Aetna's determination in February 2013. As part of the review, Aetna obtained peer reviews from two independent physicians, Drs. McPhee and Cirincione. Dr. McPhee concluded that Geiger's ankle condition would not preclude her from sedentary work. Dr. McPhee also consulted Geiger's anesthesiologist, Dr. Bukhalo, who agreed that Gei-ger was capable of sedentary work. Dr. Cirincione reached the opposite conclusion, finding that Geiger could not perform sedentary work.

         On May 1, 2013, Aetna reinstated Geiger's benefits, finding "sufficient medical evidence to support a functional impairment which precluded the employee from performing the material duties of her own occupation, " and concluding that Geiger met the more stringent standard of "being totally disabled from any gainful occupation" necessary to continue benefits beyond the 24 month period.

         Because the Plan required proof of continued disability, Aetna began a subsequent review of Geiger's disability claim in December of 2013 and January of 2014 by conducting physical activity surveillance on four occasions. The surveillance videos showed Geiger climbing into and driving an SUV, shopping at multiple stores, and carrying a bag. Aetna also requested an "Attending Physician Statement" ("APS") from four of Geiger's physicians, but only Dr. Roy responded. On January 17, 2014, Dr. Roy completed the APS, confirmed Geiger's diagnoses, and opined that she was unable to work.

         Aetna considered Dr. Roy's evaluation in conjunction with the previous peer review reports it received from Drs. White, McPhee, and Cirincione, and informed Geiger that it had submitted her medical file claim report for a comprehensive clinical review on April 7, 2014. Aetna first obtained a clinical review from an in-house nurse, Ms. Judy Tierney Ms. Tierney ...


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