“Mossler V. Aetna Life Insurance Company”

Mossler v. Aetna Life Insurance Company”

2014 U. S. LEXIS 89046 (C. D. Cal., June 30, 2014)

Mr. Mossler was formerly employed by City National Bank as a senior vice-

president/leader of the entertainment group. Mr. Mossler became disabled by fibromyalgia, myofascial pain syndrome, degenerative disease and spinal stenosis and explained that he suffered pain throughout his body which limited his functioning including his ability to sit, stand and walk. Mr. Mossler explained that his condition had slowly worsened over five years. While his application for long term disability benefits was pending, Mr. Mossler applied for and was awarded Social Security Disability benefits. Nonetheless, Mr. Mossler’s claim for LTD benefits was denied.

Mr. Mossler hired us. We submitted a comprehensive appeal, which was denied. We then filed suit.

The district court found in favor of Mr. Mossler and ordered Aetna to pay his LTD benefits. The district court explained that while physicians hired by Aetna provided conflicting evidence regarding Mr. Mossler’s diagnoses, the Court found Mr. Mossler’s treating physicians to be more credible because they have the opportunity to see and examine Mr. Mossler. The district court recognized that Mr. Mossler’s primary and most controversial diagnosis is fibromyalgia. The Court explained that Mr. Mossler’s diagnosis was well documented and was based on criteria created by the American College of Rheumatology. The Court rejected Aetna’s arguments that Mr. Mossler’s claim should be denied because, in part, he provided no objective evidence that fibromyalgia was totally disabling. The Court explained that in making that finding Aetna discounted Mr. Mossler’s subjective reports of pain and held that an insurance company cannot demand objective evidence of fibromyalgia in the absence of any evidence to even raise a question as to plaintiff’s credibility.

The Court also explained that in analyzing whether Mr. Mossler could perform his own occupation, Aetna and its reviewing physicians reasoned that Mr. Mossler’s own occupation was sedentary and that since, in their position, Mr. Mossler could sit and do other physical activities consistent with a sedentary job, he therefore could perform the material and substantial acts of his own occupation. The Court rejected Aetna’s view on this, explaining nowhere does the policy mention the word sedentary, reasoning to simply categorize Mr. Mossler’s own occupation as sedentary and engage in the narrow analysis of whether he could perform sedentary work was incorrect. The proper question was whether Mr. Mossler could perform the material and substantial acts of his own occupation. Mr. Mossler explained that he experienced fatigue and pain regularly, sometimes so much that he was unable to get out of bed and was also unable to work eight hours a day, five days a week, much less the extended hours necessary to successfully perform his own occupation in which he often had to work as much as 14 hours in a day. Mr. Mossler also explained that he had difficulty concentrating and remembering details and that his symptoms were aggravated by stress and that his job was extremely high stress. The Court concluded that even assuming Mr. Mossler could perform sedentary work he had many other intellectual responsibilities that require both financial expertise as well as a high level of interpersonal skills and thus could not perform his own occupation.

Aetna argued that despite Mr. Mossler’s subjective complaints of pain, his ability to exercise was well documented in the record. Aetna thus appeared to argue that Mr. Mossler was malingering because he was capable at different times of jogging or going to the gym. Mr. Mossler responded that he tried to move around as much as possible but it was painful and that he was encouraged to exercise as much as possible by his doctors. The Court explained that Mr. Mossler “appears motivated to return to work, which is consistent with his effort to exercise and lose weight. [Mr. Mossler’s] motivation to return to work is laudable and weighs against any finding of malingering based on [Mr. Mossler’s] efforts to exercise.

Finally, the Court reasoned that its analysis was supported by the Social Security Administration’s disability finding for Mr. Mossler.