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Jarillo v. Reliance Standard Life Insurance Co.

United States District Court, S.D. California

April 19, 2017



          HON. MICHAEL M. ANELLO United States District Judge.

         Plaintiff Marife S. Jarillo (“Plaintiff”) filed the instant action against Defendant Reliance Standard Life Insurance Company (“Reliance” or “Defendant”) pursuant to the Employee Retirement Income Security Act, 29 U.S.C. § 1001, et seq. (“ERISA”). See Complaint. Plaintiff alleges one cause of action pursuant to 29 U.S.C. § 1132(a)(1)(B), seeking to recover benefits under a group long-term disability (“LTD”) policy issued by Reliance to Plaintiff's employer. Complaint ¶¶ 17-20. On January 10, 2017, the parties filed opening trial briefs. Doc. Nos. 26, 27. On February 7, 2017, the parties filed responsive trial briefs. Doc. Nos. 29, 30. The Court conducted a bench trial on February 28, 2017, wherein the Court heard oral argument from both parties. Doc. No. 38. Having considered the parties' submissions, the administrative record[1], the arguments made by counsel at the bench trial, and for the reasons set forth below, the Court GRANTS Plaintiff's motion for judgment, and DENIES Defendant's cross-motion for judgment.


         Section 502(a)(1)(B) of ERISA states that a plan participant or beneficiary may bring a civil action “to recover benefits due to him under the terms of his plan, to enforce his rights under the terms of the plan, or to clarify his rights to future benefits under the terms of the plan.” 29 U.S.C. § 1132(a)(1)B); see also CIGNA Corp. v. Amara, 563 U.S. 421, 445-46 (2011).

         Pursuant to ERISA, a plaintiff is entitled to a bench trial on the administrative record. Kearney v. Standard Ins. Co., 175 F.3d 1084, 1095 (9th Cir. 1999) (en banc), cert. denied, 528 U.S. 964 (1999). Where the court is “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.'” Arko v. Hartford Life and Accident Ins. Co., 2014 WL 5140358, at *5 (N.D. Cal. 2014) (citing Kearney, 175 F.3d at 1094-95). Federal Rule of Civil Procedure 52(a)(1) provides in pertinent part:

In an action tried on the facts without a jury or with an advisory jury, the court must find the facts specially and state its conclusions of law separately. The findings and conclusions may be stated on the record after the close of the evidence or may appear in an opinion or a memorandum of decision filed by the court. Judgment must be entered under Rule 58.

Fed. R. Civ. P. 52(a)(1).

         Findings of Fact[2]

         Plaintiff began working for the Sycuan Band of The Kumeyaay Nation in 2002 as a “Club Sycuan Representative” in its marketing department. In May 2010, Plaintiff injured her back at work while attempting to lift a heavy box. Plaintiff submitted a claim for long-term disability (“LTD”) benefits to Reliance. Reliance approved Plaintiff's claim, and paid benefits at the rate of $1764.90 per month (equal to 60% of Plaintiff's pay as provided for in Reliance's LTD plan). On April 10, 2015, Reliance terminated Plaintiff's disability benefits. Plaintiff appealed the claim decision, but Reliance upheld its decision on August 18, 2015.

         A. Plan Terms

         Reliance's group LTD Plan (“Plan”) provides disability benefits to employees at the rate of 60% of their qualified earnings until age 67, as long as the employees are “totally disabled” as defined in the Plan. AR 07-08. The Plan provides the following definitions for total disability:

“Totally Disabled” and “Total Disability” mean, that as a result of an Injury or Sickness: (1) during the Elimination Period and for the first 24 months for which a Monthly Benefit is payable, an Insured cannot perform the material duties of his/her Regular Occupation . . . (2) after a Monthly Benefit has been paid for 24 months, an Insured cannot perform the material duties of any occupation. Any occupation is one that the Insured's education, training or experience will reasonably allow. We consider the Insured Totally Disabled if due to an Injury or Sickness he or she is capable of only performing the material duties on a part-time basis or part of the material duties on a Full-time basis.

AR 10.

         The Plan also contains the following limitation for mental or nervous disorders:

Monthly Benefits for Total Disability caused by or contributed to by mental or nervous disorders will not be payable beyond an aggregate lifetime maximum duration of twenty-four (24) months unless the Insured is in a Hospital or Institution at the end of the twenty-four (24) month period. The Monthly Benefit will be payable while so confined, but not beyond the Maximum Duration of Benefits. . . Mental or Nervous Disorders are defined to include disorders which are diagnosed to include a condition such as: (1) bipolar disorder (manic depressive syndrome); (2) schizophrenia; (3) delusional (paranoid) disorders; (4) psychotic disorders; (5) depressive disorders; (6) anxiety disorders; (7) somatoform disorders (psychosomatic illness); (8) eating disorders; or (9) mental illness.

AR 23.

         B. Plaintiff's Medical Treatment

         On May 16, 2010, Plaintiff injured her back at work while attempting to lift a heavy box. On May 17, 2010, Dr. Arjun Reddy examined Plaintiff and diagnosed her with lumbar radiculopathy. AR 3101. Plaintiff ceased working as a marketing representative for Sycuan that day. AR 60.

         On May 24, 2010, Plaintiff returned to Dr. Reddy's office for a follow-up examination. AR 3097. Dr. Reddy found that Plaintiff's condition had only slightly improved, so Dr. Reddy ordered an MRI of Plaintiff's lumbar spine. Id. Dr. Reddy also prescribed Norco (opioid pain medication). Id. On June 1, 2010, Plaintiff underwent an MRI of her lumbar spine. AR 1538. The MRI revealed a 4.2 millimeter central disc protrusion at ¶ 5-S1. Id.

         On June 10, 2010, Dr. Jean-Jacques Abitbol, M.D. (a spinal surgeon), examined Plaintiff and diagnosed her with lumbar radiculitis. AR 1662. Dr. Abitbol prescribed Medrol Dosepak, a steroid to reduce inflammation, and advised Plaintiff to refrain from any strenuous activity and/or heavy lifting. Id. Later that month, Plaintiff began physical therapy. The initial physical therapy evaluation revealed tenderness over the lumbar spine, low back pain, decreased range of motion, decreased strength, tenderness to palpation, decreased function, and a disc protrusion at ¶ 5-S1. AR 1558-59. Plaintiff's condition declined after three weeks of physical therapy, so Plaintiff began a course of acupuncture. Plaintiff received a course of twelve acupuncture treatments from July 29, 2010 through September 13, 2010. AR 2287, 2282. Plaintiff returned to physical therapy in October 2010.

         In February 2011, Plaintiff was referred to Dr. William Wilson for a pain management consultation. AR 1620. Dr. Wilson recommended Plaintiff receive steroid injections in connection with her back pain. AR 1618. Plaintiff was scheduled to undergo an injection with Dr. Wilson on February 25, 2011. However, due to Plaintiff's anxiety, Dr. Wilson was unable to proceed with the procedure. AR 1621. Dr. Wilson stated, “[u]nless her anxiety can be treated to a certain extent, she will be a poor candidate for procedures or for surgery (based upon her MRI, I do not believe she is a surgical candidate).” Id. Moreover, Dr. Wilson opined that “there is a chance that if her anxiety were reduced, her symptoms would be significantly less severe.” Id.

         On May 10, 2011, County Medical Service (“CMS”) authorized Dr. Brenton Wynn to treat Plaintiff. AR 3878. Following Dr. Wynn's examination, he concluded Plaintiff suffered from chronic low back pain, L5-S1 disc herniation, facet arthropathy in the lumbar spine, and bilateral lumbosacral radiculopathy. AR 1337. Dr. Wynn recommended Plaintiff undergo an epidural steroid injection, start Neurontin for her nerve pain, undergo an electrodiagnostic/nerve conduction study, and return to physical therapy. Id.

         C. Reliance's Finding of Disability

         In March 2011, Plaintiff submitted a claim to Reliance for LTD benefits. AR 60. Plaintiff indicated her injury rendered her unable to walk or stand for long periods. AR 59. Ms. Blanca Navarro completed an Attending Physician Statement (“APS”) in support of Plaintiff's claim, identifying Plaintiff's diagnosis as an “L5-S1 protrusion, ” and noting that Plaintiff was limited in her movements and her ability to perform activities of daily living. AR 63.

         Upon receipt of Plaintiff's claim, Reliance obtained medical records from Plaintiff's doctors. On June 20, 2011, Registered Nurse Patricia Toth reviewed Plaintiff's medical information, and opined that restrictions and limitations preventing sedentary-level work were supported from the date Plaintiff stopped working. AR 2739- 40. Following Nurse Toth's review, Reliance approved Plaintiff's claim effective August 15, 2010 (following expiration of the Plan's 90-day elimination period). AR 2922-24. Reliance advised Plaintiff that it would need to obtain updated medical information from her treating physicians to determine if she remained disabled beyond September 1, 2011, and noted that the applicable definition of disability would change after 24 months of disability payments per the terms of the Plan. AR 2923.

         D. Reliance Continues to Administer Plaintiff's Claim

         On April 23, 2012, Reliance informed Plaintiff that the definition of disability effective for the first 24 months would expire on August 15, 2012. AR 2957-58. At that time, Plaintiff would need to be unable to perform the material and necessary duties of “any occupation” in order to be considered totally disabled. AR 2957.

         In August 2011, Dr. Wynn completed a supplemental APS diagnosing Plaintiff with chronic low back pain, disc herniation, facet arthropathy, and L/5 radiculopathy. AR 4156. Dr. Wynn indicated that Plaintiff received injections to her lower back in June and August 2011. Id.

         In May 2012, Plaintiff underwent a second MRI of her lumbar spine in response to her ongoing complaints of chronic low back pain and radiculopathy. AR 4016. The MRI revealed a small left paracentral protrusion at ¶ 5-S1, but noted there was no significant central stenosis. Id. The results indicated the disc bulge “[m]ay slightly contact the arising left S1 root, ” but noted that the findings were otherwise “unchanged” from the previous MRI in June 2010. Id.

         As of May 22, 2012, CMS had not yet approved Plaintiff for physical therapy, and Plaintiff was unable to afford the acupuncture treatments recommended by Dr. Wynn. AR 2073. Without any treatment, Plaintiff's pain increased. In October 2012, Plaintiff was involved in a car accident and sustained injuries to her lower back. AR 1818.

         In September 2012, Reliance requested Plaintiff participate in a Functional Capacity Evaluation (“FCE”). AR 3819. Physical therapist L. Michelle Smith, MPT, CEAS, performed the FCE on September 24, 2012 (AR 3821), and the FCE lasted for three (3) hours (AR 3826). Ms. Smith noted Plaintiff was unable to remain seated for 28 minutes before changing positions due to pain, indicating that she could sit on a frequent basis (34% to 66% of the day), but would need to change positions every 30 minutes. AR 3825. Ms. Smith noted that Plaintiff “was negative for inappropriate pain symptoms and ...

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