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Williamson v. Aetna Life Insurance Co.

United States District Court, D. Nevada

March 31, 2019





         Before the Court is Plaintiff's FRCP Rule 52 Motion for Judgment on the Pleadings and Administrative Record. ECF No. 18. For the reasons stated below, the Court grants Plaintiff's Motion and enters judgment in favor of Plaintiff.


         Plaintiff filed the Complaint on October 12, 2017. ECF No. 1. Plaintiff seeks declaratory and injunctive relief and disability benefits pursuant to an alleged wrongful termination of benefits under the Employee Retirement Income Security Act of 1974, 29 U.S.C. § 1001 et seq. (“ERISA”). Defendant filed its answer on November 17, 2017. ECF No. 5.

         The Court entered a scheduling order on December 21, 2017, requiring Defendant to disclose a copy of the ERISA administrative record by January 15, 2018. ECF No. 8. Following stipulated extension of time, Defendant provided the administrative record on June 22, 2018. ECF No. 17.

         Plaintiff filed the instant Motion for Judgment on July 6, 2018. ECF No. 18. The Court heard oral argument on this motion on March 6, 2019 and took the motion under submission. ECF No. 32.


         In reviewing a claim administrator's decision pursuant to ERISA, a court's standard of review depends upon the terms under the benefit plan. A denial of benefits “is to be reviewed under a de novo standard unless the benefit plan gives the administrator or fiduciary discretionary authority to determine eligibility for benefits or to construe the terms of the plan.” Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989). Where the plan grants discretion, abuse of discretion is the appropriate standard of review. Id.

         The parties dispute whether the plan grants Defendant discretion and thus whether a de novo or abuse of discretion review applies. “There are no ‘magic' words that conjure up discretion on the part of the plan administrator. . . . The Supreme Court has suggested that a plan grants discretion if the administrator has the ‘power to construe disputed or doubtful terms' in the plan.” Abatie v. Alta Health & Life Ins. Co., 458 F.3d 955, 963 (9th Cir. 2006) (citations omitted).

         The Court finds that the appropriate standard is de novo. This determination arises from a review of the record. Defendant filed two documents regarding the coverage in this case-a policy (“Policy”) and a booklet (“Booklet”). Both of these documents outline the plan and policy coverage. By its own admission, Defendant allegedly filed the “wrong” Policy in the administrative record. It then sought to file the “Corrected Policy” with a supplemental filing. ECF No. 24. The Court finds, however, that the Booklet with policy number GP-811383 is the only confirmed operative policy document. The Court rejects Defendant's attempt to rely upon the Corrected Policy. First, the Booklet has the latest effective date (January 1, 2012) of the policy documents submitted. Second, Defendant has not filed with its correction any affidavit or other document authenticating and confirming that the Corrected Policy was the policy in effect for this case. Third, there are discrepancies as noted by Plaintiff as to the policy numbers on the Corrected Policy versus the Booklet. For all of the reasons, the Court rejects Defendant's attempt to rely upon the Corrected Policy.

         Most importantly, the Court does not find that the Booklet contains language that confers or delegates discretion to the plan administrator or fiduciary. Defendant does not dispute this. The Court finds therefore that de novo review applies. However, the Court finds that the applicable standard is immaterial in this case. The Court finds that benefits must be reinstated even under the higher abuse of discretion standard. The Court will analyze this case under the higher standard to avoid unnecessary delays as to benefits if appellate review would lead to a different determination of the standard.

         In applying the abuse of discretion test, the Court considers whether it is “left with a definite and firm conviction that a mistake has been committed.” Salomaa v. Honda Long Term Disability Plan, 642 F.3d 666, 676 (9th Cir. 2011) (quoting United States v. Hinkson, 585 F.3d 1247, 1262 (9th Cir. 2009) (en banc)). To do so, the Court considers whether the plan administrator's decision was “(1) illogical, (2) implausible, or (3) without support in inferences that may be drawn from the facts in the record.” Id. (quoting Hinkson, 585 F.3d at 1262). The Court is limited to review of the administrative record before the plan administrator. Abatie, 458 F.3d at 970.


         The Court may hold a bench trial on the basis of an administrative record and make findings of fact pursuant to Rule 52(a). Kearney v. Standard Ins. Co., 175 F.3d 1084, 1095 (9th Cir. 1999). “Although Rule 43(a) requires that ‘testimony' be taken in open court, the record should be regarded as being in the nature of exhibits, in the nature of documents, which are routinely a basis for findings of fact even though no one reads them out loud.” Id. at 1094. District courts are permitted to “try the case on the record that the administrator had before it.” Id. at 1095.

         Rule 52 requires the Court to “find the facts specially and state its conclusions of law separately.” Fed.R.Civ.P. 52(a)(1). The Court must state findings sufficient to indicate the factual basis for its ultimate conclusion. Kelley v. Everglades Drainage District, 319 U.S. 415, 422 (1943). The findings must be “explicit enough to give the appellate court a clear understanding of the basis of the trial court's decision, and to enable it to determine the ground on which the trial court reached its decision.” United States v. Alpine Land & Reservoir Co., 697 F.2d 851, 856 (9th Cir. 1983), cert. denied, 464 U.S. 863 (1983) (citations omitted).

         Accordingly, having reviewed the administrative record, the Court makes findings of fact in this case as follows.

         A. Plaintiff's Prior Occupation

         1. Prior to February 15, 2012 Plaintiff worked as a customer service representative for Bank of America.

         2. Defendant utilizes the Dictionary of Occupational Titles in its assessment of insured's claims. The Dictionary of Occupational Titles defines sedentary work as follows: “Exerting up to 10 pounds of force occasionally (Occasionally: activity or condition exists up to 1/3 of the time) and/or a negligible amount of force frequently (Frequently: activity or condition exists from 1/3 to 2/3 of the time) to lift, carry, push, pull, or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking or standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and all other sedentary criteria are met.”

         3. Plaintiff was employed in a sedentary position. Her job as a customer service representative required constant sitting (up to 10 hours per day), focus and concentration, and constant use of both hands for typing.

         B. Relevant Terms of Plaintiff's Policy

          4. Plaintiff was insured by an ERISA benefits plan provided by Defendant and maintained by Bank of America.

         5. The plan pays a monthly benefit if the insured is disabled and unable to work. For the first 18 months, an “own occupation” test of disability applies. Thereafter, an insured must be unable to work at any “reasonable occupation.” A reasonable occupation is any gainful activity for which the insured is, or may reasonably become, fitted by education, training, or experience and which results in, or could be expected to result in, an income of more than 60% of the claimant's adjusted pre-disability earnings.

         6. Benefits terminate when Defendant determines that the insured no longer satisfies the test for long-term disability or when ...

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