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Williams v. Sun Life Assurance Co. of Canada

May 26, 2010

LAURA WILLIAMS, PLAINTIFF,
v.
SUN LIFE ASSURANCE COMPANY OF CANADA, SUN LIFE FINANCIAL, COMMUNITY HOSPITALS OF CENTRAL CALIFORNIA DBA COMMUNITY MEDICAL CENTERS EMPLOYEE BENEFIT PLAN AND DOES 1-10 DEFENDANTS.



The opinion of the court was delivered by: Anthony W. Ishii Chief United States District Judge

FINDINGS OF FACT AND CONCLUSIONS OF LAW

This is an action pursuant to the federal Employee Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. § 1001 et seq. In this action, plaintiff Laura Williams ("Plaintiff") seeks to recover benefits she contends were wrongfully denied by defendant Sun Life Assurance Company of Canada ("Sun Life"), acting as claims administrator for defendant Community Hospitals of Central California dba Community Medical Centers Employee Benefit Plan (collectively, "Defendants"). The parties in this case have completed discovery and have agreed that the case be submitted to the court for findings of fact and conclusions of law based on the administrative record as augmented by order of this court and with augmentation as stipulated by the parties. Federal question jurisdiction exists pursuant to 28 U.S.C. § 1331. Venue is proper in this court.

PROCEDURAL HISTORY AND GENERAL FACTUAL BACKGROUND

Plaintiff was, at all times relevant to this action, an employee of Community Hospitals of Central California ("Community Hospitals") covered under a disability insurance plan administered by Community Hospitals of Central California dba Community Medical Centers Employee Benefit Plain (hereinafter, the "Plan"). Defendant Sun Life functioned as the third-party insurer of the Plan and also functioned as the claims administrator. Pursuant to the Plan, a participant is "Totally Disabled" for purposes of entitlement to long term disability benefits under the Plan if the participant is "unable to perform the Material and Substantial Duties of his own Occupation" "during the Elimination Period [of six-months] and the next 24 months."

Plaintiff was involved in a motor vehicle accident in September 2004 wherein she sustained spinal injuries. Plaintiff underwent a disketomy in February 2005 and was able to return to work as a rehabilitation scheduler in May 2005. On March 13, 2006, Plaintiff sustained a re-injury of her spine when the hydraulics in a chair in which she sat suddenly failed and "bottomed out," jarring her spine. The following day, Plaintiff was seen by Dr. Rea Wong, M.D., ("Dr. Wong") the Medical Director for Occupational Health for Community Hospitals who examined Plaintiff and completed a Doctor's First Report of Occupational Health or Injury that reflected her conclusion that Plaintiff was unable to return to work and was disabled. As part of the initial examination, Plaintiff received an MRI examination which was interpreted to "indicate a large left paracentral herniated disk with enhanced scarring that extends to and surrounds the left L1 nerve root. Additionally, [Plaintiff] has some posterior disk bulge at L5-S1 that contacts the undersurface of the L5 nerve roots bilaterally." (AR 234). On the basis of these findings, Plaintiff was referred to a neurologist, Dr. Alan Birnbaum, M.D. ("Dr. Birnbaum") for additional diagnostic work-up and management. Both Dr. Wong and Dr. Birnbaum examined Plaintiff on a number of occasions following the initial assessment and neither ever cleared Plaintiff to return to work. A more thorough discussion of Plaintiff's medical history will be undertaken below.

On November 14, 2006, Plaintiff applied for group disability benefits under the Plan. Sun Life, in its role as benefits administrator, denied the application on February 27, 2007, based on their determination that Plaintiff was not medically disabled from returning to her job during the entire Elimination Period from March 13, 2006 through September 11, 2006. Plaintiff appealed the denial under the Plan. On September 17, 2007, Sun Life affirmed the denial and informed Plaintiff that all administrative remedies had been exhausted. The complaint in the instant action was filed on March 19, 2008.

Plaintiff's first amended complaint was filed on April 17, 2008. On December 1, 2008, Plaintiff moved to amend the administrative record with a statement by Dr. Wong to clarify her intent with regard to an ambiguous form that had been submitted to Sun Life. During the pendency of that motion, Plaintiff filed the now-operative Second Amended Complaint ("SAC") on January 5, 2009. The court granted Plaintiff's motion to augment the Administrative record on March 9, 2009, and denied Defendants' motion to file a response to the amended Administrative record on July 8, 2009. Defendants' trial brief was filed on November 2, 2009. Pursuant to the stipulation of the parties, the court issued an order on January 27, 2010, submitting the matter on written briefs and on the administrative record without need for oral argument. Plaintiff submitted her trial brief on January 28, 2010.

LEGAL STANDARD

"[T]he default standard of review in ERISA cases is de novo and [. . .] discretion exists only if it is 'unambiguously retained.' [Citation.]". Opeta v. Northwest Airlines Pension Plan, 484 F.3d 1211, 1216 (9th Cir. 2007) (citing Kearney v. Standard Ins. Co., 175 F.3d 1084, 1090 (9th Cir. 1999)). The parties to this case agree that the court's review in this case should be de novo. The parties have also stipulated that the case be tried to the court on the basis of submitted trial briefs without oral argument. Bench trial on the record before the plan administrator subject to the court's discretionary power to consider evidence extraneous to the administrative record where necessary is appropriate. See Kearney 175 F.3d at 1094 -1095 ("guided by [Mongeluzo v. Baxter Travenol Disability Benefit Program, 46 F.3d 938 (9th Cir. 1995)], the district court may try the case on the record that the administrator had before it.") The question before the court in a bench trial is not whether there is an issue of material fact as is the case in a motion for summary judgment; rather, the court evaluates "the persuasiveness of conflicting testimony and decide[s] which is more likely true." Id. at 1095.

Pursuant to Rule 52(a) of the Federal Rules of Civil Procedure, the court must "find the facts specially and state its conclusions of law separately." "One purpose behind Rule 52(a) is to aid the appellate court's understanding of the basis of the trial court's decision. [Citation.] This purpose is achieved if the district court's findings are sufficient to indicate the factual basis for its ultimate conclusions. Vance v. American Hawaii Cruises, Inc., 789 F.2d 790, 792 (9th Cir. 1986). The district court is not required to base its findings on each and every fact presented at trial, id., neither is the court required to state findings as to undisputed allegations. Nuelsen v. Sorensen, 293 F.2d 454 (9th Cir. 1961).

FINDINGS OF FACT

1. Plaintiff was an employee of Community Hospitals of California ("Community"), an entity that sponsored an ERISA-governed employee disability plan (the "Plan") for eligible employees, the benefits of which were funded through a group long term disability policy issued by Sun Life Assurance Company of Canada ("Sun Life"). Sun Life functioned as the Plan claims administrator that reviewed and decided the claim submitted by Plaintiff.

2. Plaintiff was employed by Community as a Rehabilitation Scheduler. Plaintiff was, at all times relevant to this action, an enrolled member of the Plan through Community's compensation package. Plaintiff paid an additional premium to the Plan for enhanced coverage that would entitle her to benefits payments equal to 66% of her pre-disability pay (less offsets) if Plaintiff were to become disabled.

3. Pursuant to plan provisions, a plan participant is "totally disabled" and therefore entitled to plan benefits if "during the Elimination Period and the next 24 months, the employee, because of Injury or Sickness, is unable to perform the Material and Substantial Duties of his Own Occupation. After Total or Partial disability benefits combined have been paid for 24 months, the Employee will continue to be Totally Disabled if he is unable to perform with reasonable continuity any Gainful Occupation for which he is or becomes reasonably qualified for by education, training or experience . . . . To qualify for benefits, the Employee must satisfy the Elimination Period with the required number of days of Total disability, Partial Disability or a combination of days of Total and Partial Disability." The Elimination Period was 180 days which includes the time interval between March 15, 2006, and September 11, 2006. (AR 65).

4. Plaintiff's Long Term Disability claim identified Plaintiff's job as requiring 7 hour of sitting per day, approximately one-half hour each of standing and walking. The form identifying the physical aspects of Plaintiff's work specified that each of the activities, standing, walking and sitting, were performed "at will." Plaintiffs' job was also identified as requiring occasional bending, and occasional push/pull motions. Plaintiff's job also required the ability to lift 10 pounds and carry 5 to 10 pounds. (AR 100).

5. Plaintiff's relevant medical history is summarized by a patient history taken by Dr. Berjt T. Kalamkarian, M.D., of the Comprehensive Pain Management Center. The history reveals that Plaintiff reported "a history of motor vehicle accident following which she underwent surgery by Dr. V. Roy Smith at the L5-S1 level. She went back to work in May of 2005. On March 13, 2006, while sitting on her chair, the hydraulic [lift mechanism] failed and [Plaintiff] fell on her back severely aggravating her pain going down to the lower extremities with numbness of the left foot." (AR 207).

6. Plaintiff was seen by the Community's Employee Health Service the following day, March 14, 2006, where she reported having felt a "jolting sensation" at the time of the accident, followed later that night by the development of pain radiating to her left knee with leg numbness and weakness. Plaintiff was referred to Dr. Wong M.D., Medical Director of the Occupational Health and Wellness Department for Community. (AR 262). Plaintiff was determined to be Temporarily Disabled as of March 14, 2006. (AR 262).

7. The Doctor's First Report of Occupational Injury or Illness ("First Report") is dated March 14, 2006. The First Report declares Plaintiff disabled through March 16, 2006.

8. Plaintiff was subsequently seen a number of times by Dr. Wong, including the dates of March 16, 2006 (AR 330), March 20, 2006 (AR 329), March 21, 2006 (AR 331), March 28, 2006 (AR 322), July 7, 2006 (AR 313), September 6, 2006 (AR 308), October 10, 2006 (AR 302) and November 7, 2006 (AR 299). Significantly for purposes of this discussion, Plaintiff's period of Temporary Disability was extended through March 20, 2006, on the visit of March 16, 2010; was extended through March 21, 2006, on the visit of March 20, 2006; and was extended through April 11, 2006, on the visit of March 28, 2010. On the visit of March 21, 2006, Plaintiff was referred to Dr. Alan Birnbaum, a neurologist.

9. Plaintiff was examined by Dr. Birnbaum on April 4, 2006. Dr. Birnbaum noted: Mrs. Williams unfortunately by simple observation alone has tolerance of seating far too inadequate to allow anything for not save continuation of temporary total disability. The chances of her reaching maximum medical improvement prior to September of this year seem poor.

10. On a follow-up evaluation performed on May 9, 2006, Dr. Birnbaum recommended that Plaintiff remain off-work until approximately June 15, 2006. (AR 287). An examination by Dr. Birnbaum on June 22, 2006, extend the period of disability to August 1, 2006. (AR 285). On September 6, 2006, Dr. Birnbaum noted problems with pain control, recommended the use of longer-acting pain medications, and deferred determination of continuing temporary disability to Dr. Wong. (AR 282). On December 12, 2006, Dr. Birnbaum noted continuation of problems with pain management and noted the need for further imaging tests and possibly a repeat EMG. (AR 280).

11. On May 26, 2006, Plaintiff received a neurosurgical consultation by a Dr. Ali Najafi, M.D. Dr. Najafi's consultation report discusses then-current MRI findings including "Postoperative changes with mild-to-moderate dusk bulge at the L5-S1 with enhancing scar tissue in the left epidural space. There is a circumferential disk bulge at the L4-L5 with mild-to-moderate narrowing of the foramen." (AR 352).

12. Between August 7, 2006, and November 28, 2006, Plaintiff was further evaluated by a Dr. Berj Kalamakrian M.D. for control of pain. Dr. Kalamakarian's report echoed the report by Dr. Najafi and, in addition, observed that Dr. Birnbaum had performed electrodiagnositc studies on or about August 3, 2006, that revealed abnormalities compatible with a diagnosis of left S1 Radiculopathy. (AR 201). Dr. Kalamakarian also noted that Plaintiff was taking the maximum allowable dose of Tylenol and Vicodin without achieving adequate pain relief. Id.

13. On November 28, 2006, Dr. Kalmkarian performed an epidural steroid injection into the L4 - L5 space.

14. On February 1, 2007, Dr. Wong completed an Attending Physician Statement ("APS"), which is a pre-printed form supplied by Sun Life. The ...


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