United States District Court, C.D. California
For Siamak Hodjati, an individual, Plaintiff: Alena Klimianok, Stephen Bernard, LEAD ATTORNEYS, Bernard and Bernard, Los Angeles, CA.
For Aetna Life Insurance Company Inc, a Connecticut Corporation, ADP Totalsource Inc, a Florida corporation, Defendants: Ronald K Alberts, LEAD ATTORNEY, Jessica Wolff, Gordon and Rees LLP, Los Angeles, CA.
ORDER AFFIRMING DENIAL OF BENEFITS AND GRANTING JUDGMENT IN FAVOR OF DEFENDANTS
STEPHEN V. WILSON, United States District Judge.
Siamak Hodjati brought this action for benefits pursuant to the Employee Retirement Income Security Act of 1974 (" ERISA"), 29 U.S.C. § 1001 et seq., against Aetna Life Insurance Company Inc. The Court held a trial on the administrative record on March 4, 2014. For the reasons set forth below, judgment is granted in favor of Defendants.
II. FINDINGS OF FACT
When presented with motions for judgment under Federal Rule of Civil Procedure 52, " the court conducts what is essentially a bench trial on the record, evaluating the persuasiveness of conflicting testimony and deciding which is more likely true." Caplan v. CNA Fin. Corp., 544 F.Supp.2d 984, 990 (N.D. Cal. 2008) (citing Kearney v. Standard Ins. Co., 175 F.3d 1084, 1094-95 (9th Cir. 1999)). Rule 52 " requires a court to 'find the facts specially and state separately its conclusions of law thereon.'" Vance v. Am. Hawaii Cruises, Inc., 789 F.2d 790, 792 (9th Cir. 1986) (quoting Fed.R.Civ.P. 52(a)). The Court, however, " is not required to base its findings on each and every fact presented at trial." Id. at 792. The following constitutes the Court's findings of fact.
A. ADP TotalSource Program
Siamak Hodjati worked for Payless Cellular, Inc. Payless Cellular contracts with ADP for administration of its employees' health and disability benefits. Specifically, Payless Cellular subscribes to ADP's TotalSource program, which operates under a " co-employment" model, whereby the customer (here, Payless Cellular) retained day-to-day control over the company while ADP manages critical human resources and employee benefits administration responsibilities. (A.R. 001-03, 031, 0596-97, http://www.adp.com/solutions/ employer-services/totalsource.aspx). As part of ADP's services for Payless Cellular, ADP entered into a Group Accident and Health Insurance Policy with Aetna. (A.R. 031). Aetna's long-term disability coverage--the benefit plan at issue in this case--consists of a " 'shell' containing general provisions relating to policyholder/insurance company matters, " and a " certificate" that includes a number of separate health and disability plans. (A.R. 031-043).
B. Aetna's Long-Term Disability Plan
Aetna's long-term disability plan provides monthly benefits to enrolled employees who are disabled and unable to work because of an injury, illness, or pregnancy-related condition. (A.R. 006). The test for disability is set out in the plan as follows:
From the date that you first became disabled and until monthly benefits are payable for 24 months you meet the test of disability on any date that:
o You cannot perform the material duties of your own occupation solely because of an illness, injury or disabling pregnancy-related condition; and
o Your earnings are 80% or less of your adjusted predisability earnings.
After the first 24 months of your disability that monthly benefits are payable, you meet the plan's test of disability on any day you are unable to work at any reasonable occupation solely because of an illness, injury or disabling pregnancy-related condition.
(A.R. 007 (emphasis omitted)). The plan defines " material duties" as " Duties that: Are normally required for the performance of your own occupation; and Cannot be reasonably omitted or modified." (A.R. 023 (emphasis omitted)). " Illness" is defined as:
A pathological condition of the body that presents a group of clinical signs and symptoms and laboratory findings peculiar to it and that sets the condition apart as an abnormal entity differing from other normal or pathological body states.
C. Hodjati's Disability Claim
On September 2, 2011, Hodjati stopped working because of frequent headaches, memory loss, and hand tremors. (A.R. 306). He filed a long-term benefits claim with Aetna on November 3, 2011. (A.R. 127, 271). Over the course of the next four months, Hodjati provided Aetna with information on his claimed disability. Specifically, Hodjati submitted a job analysis worksheet, evaluation notes from multiple visits to Dr. Howard Baer, and a CAT scan of his head.
1. Job Analysis Worksheet
In November 2011, Hodjati returned a completed job analysis worksheet to Aetna. (A.R. 284). According to the worksheet, Hodjati worked as a general manager for Payless Cellular, Inc., and his job duties included " business development, negotiating] new contracts, lead[ing] meetings, [sales and marketing, and supervising] the day to day operations." (Id.). Hodjati noted that he sometimes had to operate a vehicle for work, and he occasionally had to physically grasp things in the office. (Id.).
2. September 8, 2011 Appointment with Doctor Baer
Hodjati first met with Dr. Baer on September 8, 2011. (A.R. 339). Hodjati reported that he suffered continuous headaches, memory loss, and tremors in both his hands. (Id.). Hodjati told Dr. Baer that his headache and memory loss made it impossible for him to continue to work as a manager of a wireless business, where he worked six days a week for twelve hours a day. (Id.).
Dr. Baer conducted a physical exam and concluded that Hodjati was " well-nourished" and " in no obvious distress." (Id.). Dr. Baer noted some mild pain in Hodjati's neck, but he did not detect any other physical difficulties. (Id.). In his concluding remarks, Dr. Baer wrote that Hodjati suffered from cephalgia, i.e. headaches, from a cause " to be determined; " a tremor; and neck pain. (Id.). Dr. Baer ordered a CT scan of Hodjati's head and started Hodjati on 75 milligrams per day of Effexor, SNRI inhibitor. (Id.).
3. September 21, 2011 CT Scan
Hodjati underwent a CT scan on September 21, 2011. (A.R. 347). Dr. Loc Tran, a board certified neuroradiologist, prepared a report on the scan. (A.R. 348). According to Dr. Tran, Hodjati's brain displayed normal architectural features and density characteristics, and it lacked any discernable masses, brain lesions, or indicia of restricted blood supply. (A.R. 347). In sum, the CT scan was unremarkable. (Id.).
4. October 26, 2011 Appointment with Doctor Baer
Hodjati visited Dr. Baer again in late October. He repeated his complaint of " persistent head pain." (A.R. 324). The headache was " intermittent, but present every day"; however, it was less severe and less frequent now that he was " away from work and the stress of employment." (Id.). Dr. Baer again conducted a physical examination of Hodjati, noting no abnormalities. (Id.). And he further stated that Hodjati's " neurologic exam [was] within normal limits." (Id.). Dr. Baer prescribed Tramadol as a pain reliever, advising Hodjati to come back in about a month.
5. November 21, 2011 Appointment with Doctor Baer
In a November 21, 2011 appointment with Dr. Baer, Hodjati continued " to complain of intractable headache, some memory loss, pain in his upper neck[, ] [and] a persistent tremor." (A.R. 325). Dr. Baer detected a fine resting tremor in both upper extremities. (Id.). Dr. Baer decided that Hodjati would continue his present medications, and the two scheduled another appointment. (Id.).
6. November 30, 2011 Appointment with Doctor Baer
Nine days later, Hodjati repeated his complaints of headaches, memory loss, hand tremors, and upper neck pain. (A.R. 332). Specifically, the headache was " now intermittent, " and his neck pain radiated into the " posterior [part of the] skull." (Id.). Hodjati then explained that his memory problem was " present primarily when he [was] in a group of people." (Id.). And Dr. Baer again observed a tremor in both of Hodjati's hands. (Id.). However, Dr. Baer reiterated his opinion that the " neurologic exam [was] normal." (Id.). Dr. Baer said that he would consider the use of Inderal, a non-selective beta blocker, if Hodjati's symptoms persisted. (Id.).
7. January 4, 2012 Appointment with Doctor Baer
Hodjati again met with Dr. Baer on January 4, 2012. (A.R. 333). Hodjati continued to complain of near constant headaches and hand tremors. (Id.). Dr. Baer's neurologic exam of Hodjati revealed " normal deep tendon reflexes." (Id.). Dr. Baer prescribed Indeneral. (Id.).
8. February 1, 2012 Appointment with Doctor Baer
When Hodjati met Dr. Baer in February 2012, he told the doctor that his condition had not improved and the medication was ineffective. (A.R. 345). And Dr. Baer concluded that " [e]ssentially all the symptoms have not changed over the past 4-6 months." (Id.). Dr. Baer's physical exam notes revealed the same fine tremor in Hodjati's hands, but Dr. Baer apparently found that Hodjati had " no speech impediment" and normal reflexes. (Id.). Dr. Baer discontinued Hodjati's use of Inderal and decided to refer Hodjati to a neurologist. (Id.).
D. Aetna's Communications with Hodjati and Requests for Medical Records
Hodjati submitted the aforementioned information to Aetna. Although Hodjati filed his claim on November 3, 2011, he initially failed to furnish Aetna with all of his medical records; consequently, Aetna sent two letters, dated December 7 and 14, 2011, requesting all of the relevant documents. (A.R. 326, 328). On January 23, 2012, Aetna provided Hodjati with a 30 day extension to provide the records. (Id.). Two weeks later, Aetna ...