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Ajmeri v. Bank of America Health & Welfare Plan & Aetna

United States District Court, Third Circuit

August 28, 2013

YASMEEN AJMERI, Plaintiff,
v.
BANK OF AMERICA HEALTH & WELFARE PLAN & AETNA, Defendants.

OPINION

JOEL A. PISANO, District Judge.

This case involves a claim for short-term disability benefits[1] under the Employee Retirement Income Security Act of 1974, as amended, 29 U.S.C. ยง 1132(a)(1)(B) ("ERISA), brought by Plaintiff Yasmeen Ajmeri ("Plaintiff" or "Ajmeri") against Defendants Bank of America Corporation ("BOA") and Aetna Life Insurance Company ("Aetna" and collectively with BOA, "Defendants").[2] Before this Court are two motions for summary judgment: one filed by Plaintiff and one filed by Defendants. The Court decides these matters without oral argument pursuant to Fed.R.Civ.P. 78. For the reasons set forth below, the Court will deny Plaintiff's motion for summary judgment and grant Defendants' motion for summary judgment.

I. Background

The Court finds that the following facts are supported by the evidence of record and are undisputed.[3]

A. Plaintiff's Employment with Bank of America

Plaintiff has been employed by BOA since December 2005. At the time she filed for disability benefits, Plaintiff held the position of Senior Teller and her job functions included: receiving and paying out money; cashing and depositing checks; keeping records of customers' transactions; recording transactions into a computer and issuing receipts; counting incoming and outgoing cash and balancing a cash drawer; and performing other related services, such as issuing travelers checks and money orders.

B. The Plan

BOA sponsored the Bank of America Group Benefits Plan (the "BOA Plan"), which included a short-term disability plan (the "STD Plan"). BOA funded the STD Plan and made benefit payments through its regular payroll process. The STD Plan contained a one-week unpaid elimination period. Thereafter, the STD Plan paid 100% of a Claimant's base pay for up to eight (8) weeks and 70% of a claimant's base pay for up to an additional seventeen (17) weeks when combined with any other available disability benefits.

The STD Plan defined "disabled" as "your inability to perform your essential occupation functions, including working your regularly scheduled hours, for more than seven consecutive calendar days because of... illness." The STD Plan also contained additional eligibility requirements, including a requirement that employees receive appropriate treatment from a health care provider on a continuing basis while on STD leave and that employees be at work or on paid parental leave as of the date of disability to be eligible for benefits. The STD Plan also stated that STD benefits will not be paid if a claimant fails to provide satisfactory objective medical evidence of disability or continuing disability. It further provided that benefits will end when a participant is no longer considered disabled; is capable of performing the essential functions of her job; or fails to provide satisfactory medical evidence of disability.

BOA contracted with Aetna to serve as the Claims Administrator for the BOA Plan and provide certain claim services for several component plans, including the STD Plan. BOA, through its plan administrator, delegated to Aetna the discretionary authority to: determine a claimant's eligibility for benefits; construe the terms of the STD Plan; resolve questions relating to claims under the STD Plan; and review denied claims. As an employee of BOA, Plaintiff was a participant in the STD Plan and eligible to receive benefits, provided she met the plan's eligibility requirements.

C. Plaintiff's Initial Claim for Benefits Under the STD Plan

On October 4, 2010, Plaintiff's physician, Dr. Lauren Maza, diagnosed her with depression and anemia. Plaintiff submitted a claim for short-term disability benefits ("STD benefits") to Aetna on that same date. Her submission included a statement from Dr. Maza regarding her diagnosis and a recommendation from Dr. Maza that Plaintiff should be out of work for two weeks. Several weeks later, on October 18, 2010, Aetna[4] determined that the information provided to date did not support a finding of functional impairment because Plaintiff could still perform her role as a Senior Teller. In particular, Aetna found that Plaintiff was still capable of communicating effectively with others, making decisions and solving problems, and using appropriate judgment. Aetna decided to suspend Plaintiff's claim in order to provide Plaintiff the opportunity to submit additional records to support her claim for benefits.

Plaintiff failed to provide any additional information or respond to Aetna's attempts to contact Plaintiff. Therefore, on October 29, 2010, Aetna sent Plaintiff a letter stating that the information she had submitted did not support functional impairment from a mental or physical condition. Specifically, Aetna stated that there was a lack of clinical findings, such as observed behavioral and cognitive impairments, that would preclude Plaintiff from functioning in her role as a bank teller. Aetna provided Plaintiff with information about the type of clinical data necessary to substantiate her claim, such as "observed cognitive, emotional, behavioral, and risk factors" and informed Plaintiff of her right to submit additional information in support of her claim. Plaintiff promptly filed an appeal of Aetna's denial of benefits.

After Aetna issued its decision, Dr. Maza submitted a letter to Aetna, which contained additional details regarding Plaintiff's diagnosis. Among other things, Dr. Maza explained that Plaintiff "has severe depression and anxiety; concentration and focus are impaired" and that Plaintiff suffers from "sweats, tachycardia... under stressful circumstances." She also indicated that Plaintiff's depression and anxiety were related to work and that Plaintiff suffered from stress and nightmares. She stated that Plaintiff could return to work in approximately two months (or possibly earlier, if she was assigned to another supervisor) and indicated that she was not seeing a therapist.[5] Aetna determined that this additional information did ...


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