United States District Court, S.D. California
MARIFE S. JARILLO, Plaintiff,
RELIANCE STANDARD LIFE INSURANCE CO., Defendant.
ORDER GRANTING PLAINTIFF'S MOTION FOR JUDGMENT;
[DOC. NO. 26] AND DENYING DEFENDANT'S CROSS-MOTION FOR
JUDGMENT [DOC. NO. 27]
MICHAEL M. ANELLO United States District Judge.
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, 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.
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).
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
Fed. R. Civ. P. 52(a)(1).
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.
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
“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.
Plan also contains the following limitation for mental or
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.
Plaintiff's Medical Treatment
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.
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 ¶
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.
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
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.
Reliance's Finding of Disability
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.
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.
Reliance Continues to Administer Plaintiff's
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.
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.
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.
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.
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 ...