United States District Court, N.D. California
August 29, 2005.
RICHARD H. AGUILAR, Plaintiff,
NEW UNITED MOTOR MANUFACTURING, INC. DISABILITY INSURANCE INCOME PLAN, Defendant.
The opinion of the court was delivered by: WILLIAM SCHWARZER, Senior District Judge
FINDINGS OF FACT AND CONCLUSIONS OF LAW
Plaintiff Richard H. Aguilar brings this action, arising under
the Employee Retirement Income Security Act of 1974 ("ERISA"),
29 U.S.C. § 1132, against Defendant New United Motor Manufacturing,
Inc. Disability Insurance Income Plan ("the Plan"), challenging
the denial of his claim for short-term and long-term disability
benefits that he alleges are due to him under the terms of the
A pretrial conference was held on October 25, 2004, at which
the Court (White, J.) appropriately determined and the parties
conceded that Plaintiff's claim would be reviewed de novo
because the Plan contains no language delegating authority to the
Plan Administrator to interpret the terms of the Plan. See
Kearney v. Standard Ins. Co., 175 F.3d 1084, 1089 (9th Cir.
1999) (citing Firestone Tire & Rubber Co. v. Bruch,
489 U.S. 101, 109 (1989)). The Court additionally held that it would not exercise its discretion to
admit evidence outside of the administrative record in its
evaluation of the Plan Administrator's decision. See id. at
The parties submitted trial briefs and proposed findings of
fact and conclusions of law, and made arguments at a bench trial
hearing on February 4, 2005. The case was reassigned to the
undersigned on June 27, 2005.
The Court, having reviewed the administrative record, the
hearing transcripts, and the papers submitted by the parties, now
finds for Defendant and against Plaintiff.
The action arises under ERISA, 29 U.S.C. § 1132, and this Court
has jurisdiction over Plaintiff's claim pursuant to
29 U.S.C. § 1132(e) .
III. FINDINGS OF FACT
The following facts are taken from the administrative record
("PLAN") submitted by the parties, which contains the only
relevant and admissible evidence in the trial of this matter.
See Kearney, 175 F.3d at 1090-91.
Plaintiff was employed by New United Motor Manufacturing, Inc.
("NUMMI") from February 1985 to December 2000, as a production
line inspector. PLAN 0284-85. As an employee of NUMMI, Plaintiff
was a participant in NUMMI's employee welfare benefit Plan, which
was funded through the purchase of a group insurance policy
issued by the Life Insurance Company of North America ("LINA").
A. The NUMMI Disability Income Insurance Plan
The Plan provides for disability benefits if, because of injury
or sickness, an employee is unable to perform all the material
duties of any occupation available at the Plant for which he is
or may reasonably become qualified based on his education,
training or experience. PLAN 0005, 0309.
Under the Plan, short-term disability benefits are payable for
a maximum of 52 weeks after a seven-day benefit waiting period
during which the participant must be continuously and totally
disabled. PLAN 0027. Long-term disability benefits are payable
after 52 weeks of continuous disability. PLAN 0009. If a
participant is 50 or older when the disability began, long-term benefits are payable until the earlier of (a) the
participant's sixty-fifth birthday or (b) the date the
participant ceased to be disabled. PLAN 0015.
The Plan agrees to pay benefits for "Eligible Employees," which
include: 1) all active full-time hourly employees of NUMMI
working a minimum of 40 hours per week and 2) all active
full-time salaried employees of NUMMI working a minimum of 40
hours per week. PLAN 0290.
The Plan provides for the termination of insurance on the date
that an employee's "Active Service" ends. PLAN 0295. An employee
is considered to be in Active Service under the terms of the Plan
on a scheduled work day if: 1) the employee is "performing in the
usual way all of the regular duties" of work for the employer on
a full time basis that day, or 2) the day is a scheduled holiday,
vacation day or period of employer-approved paid leave of
absence. PLAN 0305. The Plan provides that if an employee is not
in Active Service on the date the coverage would otherwise become
effective, it will become effective on the date the employee
returns to Active Service. PLAN 0295. The Plan states that if
Active Service ends due to disability for which benefits are or
may become payable, an employee's insurance will continue as long
as the benefits are payable for the disability. PLAN 0295.
B. Plaintiff's Claim for Disability Benefits
Plaintiff's last day of work at NUMMI was December 1, 2000,
PLAN 0285-86, and it is undisputed that Plaintiff was an eligible
Plan participant on that date. The record provides no reason
given by Plaintiff or noted by NUMMI on or around December 1,
2000, why Plaintiff did not return to work.*fn1 See
Hearing Transcript at 17, lines 13-25.
On January 22, 2002, Plaintiff initiated a claim for disability
benefits by telephone to LINA. PLAN 0281-91. This telephone call
was followed by an integrated application for shortterm and
long-term benefits on or about February 12, 2002. PLAN 0199-0200.
On January 23, 2002, in response to Plaintiff's claim, LINA
sent a request for Plaintiff's medical records to Vasdeep Kahlon,
M.D., a psychiatrist identified by Plaintiff as his treating physician. PLAN 0274-76. By letter dated March 15, 2002, LINA
advised Plaintiff that it had not received any medical records
from Dr. Kahlon and requested Plaintiff's assistance in obtaining
such records. PLAN 0273. LINA also notified Plaintiff that if no
medical information was received by April 28, 2002, a decision on
his claim for benefits would be made based on the information in
his administrative record. PLAN 0273.
By letter dated March 28, 2002, LINA advised Plaintiff that it
was still awaiting medical records and information from Dr.
Kahlon and again told Plaintiff that it would make a decision
based on the available information on April 28, 2002. PLAN 0271.
By letter dated April 29, 2002, LINA denied Plaintiff's
short-term disability benefit claim because it had not received
any records from Plaintiff or Plaintiff's medical providers upon
which to base an evaluation of Plaintiff's claim. PLAN 0265-67.
In this letter, LINA noted that it had requested, unsuccessfully,
records from Dr. Kahlon on February 6 and 21, and March 7, 2002.
On April 29, 2002, LINA received an Attending Physician's
Statement from James Rennert, M.D., dated April 29, 2002, wherein
Dr. Rennert stated that Plaintiff suffered from major depressive
disorder and panic disorder and that he was disabled from
working. PLAN 0268-70. Dr. Rennert stated that Plaintiff had been
disabled since December 1, 2000. PLAN 0268-70. LINA subsequently
received an Attending Physician's Statement from Dr. Kahlon,
dated May 20, 2002, wherein Dr. Kahlon diagnosed Plaintiff with
major depression and panic disorder. PLAN 0260. Dr. Kahlon noted
that he treated Plaintiff from December 1, 2000 to January 15,
2002, after which time Plaintiff transferred exclusively to
Kaiser and Dr. Rennert for further treatment.*fn2 PLAN 0260.
Dr. Kahlon stated that Plaintiff was currently under the care of
Dr. Rennert and that Plaintiff was still on disability, but he
did not specify when Plaintiff became disabled. PLAN 0260.
Plaintiff appealed LINA's denial of benefits by letter dated
July 16, 2002. PLAN 0259. By letter dated July 26, 2002, LINA
advised Plaintiff that a decision to overturn its prior denial could not be made based upon the statements in the Attending
Physician's Reports alone. PLAN 0255.
By letter dated August 19, 2002, LINA affirmed its denial of
Plaintiff's claim, noting that Plaintiff had failed to submit any
additional medical evidence in support of his claim and that
Plaintiff had failed to submit a signed authorization to LINA so
that LINA could obtain further medical information on its own.
PLAN 0253. LINA subsequently obtained Plaintiff's signed
authorization and agreed to re-review Plaintiff's claim. PLAN
By letter dated November 1, 2002, LINA notified Plaintiff that
he had failed to demonstrate that he was totally disabled as of
December 1, 2000, but stated that it would request records from
Dr. Kahlon. PLAN 0195. LINA received Dr. Kahlon's records on
December 18, 2002. PLAN 0176-87. Dr. Kahlon's records showed that
Dr. Kahlon evaluated Plaintiff on December 1, 2000, and filled
out a mental evaluation form on that date. PLAN 0178-81. Dr.
Kahlon noted that Plaintiff was irritable, restless, and
hypoactive, but in the section entitled "Liabilities and Special
Needs," Dr. Kahlon marked only that Plaintiff had "poor coping
skills." PLAN 0181. At the end of the form, Dr. Kahlon prescribed
the antidepressant Paxil for Plaintiff, but nowhere indicated
that Plaintiff was disabled and/or unable to perform any work at
the NUMMI Plant. PLAN 0178-81.
By letter dated January 6, 2003, LINA reconfirmed its denial of
Plaintiff's claim for benefits because the medical records failed
to establish that Plaintiff was totally disabled as of December
1, 2000. PLAN 0150-53.
LINA received a letter, dated March 12, 2003, from Dr. Rennert,
challenging the denial of Plaintiff's claim for benefits and
stating that Plaintiff's treatment at Kaiser indicates that he
had a "difficult treatment-resistant case of Panic Disorder and
Depression." PLAN 0143. LINA also received a letter, dated March
12, 2003, from Dr. Diane Enos, a psychologist, who first treated
Plaintiff on February 11, 2002, and who stated that Plaintiff's
condition made him unable to return to work. PLAN 0145-46.
On April 14, 2003, LINA received a third appeal from Plaintiff.
PLAN 0142. By letter dated April 21, 2003, LINA reconfirmed its
denial of Plaintiff's claim, noting that the reports from Dr. Rennert and Dr. Enos, relating to treatment provided
after February 11, 2002, did not show that Plaintiff was disabled
as of December 1, 2000. PLAN 0140-41. LINA also notified
Plaintiff that he had exhausted all administrative levels of
appeal. PLAN 0140-41.
By letter dated April 29, 2003, Plaintiff objected to LINA's
April 21, 2003, denial and requested a copy of his claim file.
PLAN 0113-14. With this letter, Plaintiff sent LINA additional
records, including copies of "disability slips" from Drs. Kahlon
and Rennert that advise medical leave for Plaintiff. PLAN
0116-0139. The records indicate that although Dr. Kahlon was
treating Plaintiff as of December 1, 2000, the first disability
slip available shows that Dr. Kahlon did not put Plaintiff on
medical leave until December 20, 2000. PLAN 0116-35. The records
also indicate that Dr. Rennert certified that Plaintiff was
disabled as of December 1, 2000, even though Dr. Rennert's first
evaluation of Plaintiff did not occur until January 29, 2001.
LINA did not treat Plaintiff's April 29, 2003 letter as an
appeal because Plaintiff had been previously notified that he had
exhausted all appeals. PLAN 0140-41. By letter dated May 27,
2003, LINA sent Plaintiff a copy of his file. PLAN 0112.
This litigation ensued.
III. CONCLUSIONS OF LAW
Plaintiff bore the burden of providing evidence to LINA showing
that he is entitled to disability benefits under the Plan. See
Kearney, 175 F.3d at 1091 (stating that if claimant believed
particular medical data should have been reviewed by the Plan
administrator, the claimant "should have sent it to [the
administrator]"); Chamberlain v. Allstate Ins. Co.,
931 F.2d 1361, 1364 (9th Cir. 1991) (holding that under California law,
"[a]n insured bears the burden of proving that a claim falls
within the scope of the policy"); Jordan v. Northrop,
63 F. Supp. 2d 1145, 1150 n. 2 (C.D. Cal. 1999) (stating that in
determining a claim for disability benefits under ERISA, "it is
not the duty of the administrator to seek out evidence which is
not before them") aff'd, 370 F.3d 869 (9th Cir. 2004); PLAN
0313 (requiring plaintiff to submit proof of loss in order to
receive benefits). The medical records provided by Drs. Kahlon, Rennert, and Enos
support Plaintiff's argument that he is or was disabled and
unable to work at some point in time. However, under the terms of
the Plan, Plaintiff must establish that he was totally disabled
as of December 4, 2000,*fn3 because Plaintiff's coverage
under the Plan terminated on December 4, 2000, when he ceased to
be in "Active Service." PLAN 0295. The Plan provides for the
continuation of insurance if Active Service ceases due to a
"Disability for which Monthly Benefits are or may become
payable." PLAN 0295. This means, again, that Plaintiff must
establish that he was disabled and unable to perform the duties
of any occupation available at the Plant as of December 4, 2000.
PLAN 0309. Plaintiff has failed to present evidence to prove
disability as of that date.
The only record evidence reflecting Plaintiff's claim that he
was disabled as of December 4, 2000, is: 1) a "Visit
Verification/Family Leave" form filled out by Dr. Rennert on
February 13, 2002, stating that Plaintiff is disabled and unable
to work, and has been so disabled since December 1, 2000, PLAN
0136; and 2) an Attending Physician Statement filled out by Dr.
Rennert on April 29, 2003, again commenting that Plaintiff has
been disabled since December 1, 2000. PLAN 0270. Dr. Rennert does
not provide any support for his finding that Plaintiff was
disabled as of December 1, 2000, however, and the record
indicates that Dr. Rennert first evaluated Plaintiff on January
29, 2001, at the earliest. PLAN 0083, 0136.
The most relevant medical records with regard to the date of
Plaintiff's disability are those of Dr. Kahlon, who evaluated
Plaintiff on December 1, 2000. PLAN 0178-81. During this
evaluation, Dr. Kahlon noted that Plaintiff had poor eye contact
and was irritable, hypoactive, restless, depressed, and anxious.
PLAN 0180-81. Dr. Kahlon's assessment was that Plaintiff has "poor coping skills" and that Plaintiff should
be treated with the antidepressant Paxil. PLAN 0180-81. However,
Dr. Kahlon nowhere noted on any of the relevant forms that
Plaintiff was disabled or that he was unable to perform his
duties at NUMMI. PLAN 0178-81. Moreover, the disability slips
that Plaintiff submitted to LINA after LINA had already denied
his third appeal show that the first date for which Dr. Kahlon
advised medical leave for Plaintiff was December 20, 2000. PLAN
Therefore, although the record presents what may be viewed as
conflicting evidence on the issue of Plaintiff's date of
disability, the Court is charged with evaluating the
persuasiveness of conflicting evidence and deciding which is more
likely true. See Kearney, 175 F.3d at 1095. Although Dr.
Rennert stated that Plaintiff was disabled as of December 1,
2000, the Court must evaluate the credibility of Dr. Rennert's
statement by looking at the basis upon which Dr. Rennert rendered
his conclusion. See id. It is undisputed that Dr. Rennert did
not evaluate Plaintiff on December 1, 2000. The first evaluation
by Dr. Rennert appears to have been on January 29, 2001. PLAN
0083. Therefore, Dr. Rennert had no personal knowledge of
Plaintiff's condition on December 1, 2000, and provides no other
basis for reaching his conclusion regarding Plaintiff's date of
disability. PLAN 0083. Plaintiff argues that a doctor may make a
diagnosis without having observed a disability on a particular
day, and that Dr. Rennert looked at Dr. Kahlon's notes from the
December 1, 2000, evaluation and was able to reach a conclusion
even though Dr. Kahlon made no comment regarding disability.
Hearing Transcript at 6, lines 16-21. However, the fact that Dr.
Rennert first evaluated Plaintiff two months after the alleged
onset of the disability coupled with the fact that Dr.
Rennert's report was sent to LINA only after Plaintiff's claim
for benefits had already been denied weakens the credibility of
Dr. Rennert's conclusion regarding the onset date of disability.
The treating physician who saw Plaintiff on December 1, 2000,
Dr. Kahlon, gave no indication that Plaintiff was disabled and
unable to work as of that date, PLAN 0178-81, and first advised
Plaintiff to take medical leave from work on December 20, 2000.
PLAN 0116. Therefore, the earliest date that Plaintiff can show
evidence of disability under the Plan is December 20, 2000. Plaintiff ended Active Service, as defined under the Plan, on
December 4, 2000, at the latest, because on that scheduled day of
work, Plaintiff was not "performing in the usual way all of the
regular duties" of his work.*fn4 PLAN 0295, 0305. Insurance
therefore terminated as of December 4, 2000, unless Plaintiff
returned to work which he never did or unless Plaintiff
proved that his Active Service ended due to an eligible
disability, which he has not. PLAN 0295.
Because short-term and long-term disability benefits require
Plaintiff to have shown disability at the time he ceased Active
Service and during the relevant waiting periods, PLAN 0292, 0295,
Plaintiff has not shown that he is entitled to such benefits.
A review of the administrative record indicates that Plaintiff
has failed to establish that he was disabled as of the date
required in order to receive short-term and long-term disability
benefits. The denial of his claim for disability benefits was
therefore appropriate. For the reasons set forth above, the Court
finds for Defendant and against Plaintiff.
IT IS SO ORDERED.
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