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April 28, 2003


The opinion of the court was delivered by: Maxine M. Chesney, United States District Judge


In this action, plaintiff Mary Bruce challenges defendant Aetna Life Insurance Company's*fn1 decision to deny her claim for disability benefits under a group insurance policy subject to the Employee Retirement Income Security Act ("ERISA"). Pursuant to the Court's previous orders, the Court reviews the decision de novo, based on the administrative record. (See Order Re: Standard of Review, filed April 9, 2002, at 2:21-22; Order Denying Pl.'s Mot. for Summ. J., filed May 10, 2003, at 5:2-4, 15-17; Order Denying Pl.'s Mot. to Submit Additional Evidence, filed September 3, 2002.)

On February 21, 2003, the Court conducted a trial on the administrative record. Gregory C. Cattermole of the Law Offices of Joseph W. Carcione, Jr., appeared on behalf of plaintiff. Allison M. Dibley of Sedgwick, Detert, Moran & Arnold appeared on behalf of defendant. Having considered the administrative record, the trial briefs, and the arguments of counsel, the Court finds and rules as follows.


In an ERISA case, disputes of fact are "resolved by trial." Kearney v. Standard Ins. Co., 175 F.3d 1084, 1094 (9th Cir.), cert. denied, 528 U.S. 964 (1999). "In a trial on the record, . . . the judge can evaluate the persuasiveness of conflicting testimony and decide which is more likely true." Id. at 1095.*fn2 The trial court "consider[s] anew both the legal and factual aspects of [the plaintiff's] claim." Thomas v. Oregon Fruit Products Co., 228 F.3d 991, 995 (9th Cir. 2000).


On April 26, 1994, plaintiff was injured in an automobile accident. (Administrative Record ("AR") at 483.) At that time, plaintiff was employed by Kaiser Permanente ("Kaiser") as an administrative nurse, (AR at 482), and was a participant in Kaiser's long-term disability insurance plan under a policy issued by New York Life Insurance Company ("New York Life"). (AR at 552-67.)

On October 18, 1994, plaintiff applied for disability benefits, stating that as a result of injuries incurred in the automobile accident, she was totally disabled as of April 27, 1994. (AR at 483.) On December 6, 1994, New York Life approved plaintiff's claim for long term disability benefits "on the basis disability commenced 4/27/94." (AR at 476.)

On January 5, 1998, New York Life notified plaintiff of its decision denying plaintiff's claim, effective November 30, 1997. (AR at 89-91.) New York Life explained that although medical records indicated plaintiff has cervical sprain, headaches, and lumbar pain, a vocational consultant had determined that plaintiff had the qualifications and residual physical capacity for several vocations and that New York Life had not received "medical documentation supporting total disability from performing any occupation." (AR at 89-90.) New York Life also informed plaintiff of her right to request that New York Life review the denial. (AR at 90.) Thereafter, plaintiff requested such review. (See AR at 51.) On November 12, 1998, after considering additional information provided by plaintiff and her treating physician, New York Life reaffirmed its denial of benefits, stating "[W]e are reaffirming our determination that you did not meet the policy definition of disability at the time your benefits were terminated, November 30, 1997." (AR at 19.)

On November 1, 1999, plaintiff filed a complaint in state court. On April 28, 2000, defendant removed the action to district court.


A. Analysis of Plaintiff's Claim

Under the terms of the subject policy, New York Life was required to pay disability benefits "upon receipt of due proof that the employee, while insured under [the] policy, became totally disabled as defined [in the policy] as a result of bodily injury or sickness . . . ." (AR at 539.) The policy defines "totally disabled" as follows:

An employee shall be considered totally disabled if during a period of 24 consecutive months from the beginning of his qualifying period he is unable to perform with reasonable continuity the substantial and materials acts necessary to pursue his usual occupation in the usual or customary way, and if at the end of said 24 month period and during the continuance thereafter of his disability, he is unable to engage with reasonable continuity in another occupation in which he could reasonably be expected to perform ...

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