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Roberts v. Anthem Life Insurance Co.

United States District Court, C.D. California

June 7, 2017


          Present: The Honorable BEVERLY REID O'CONNELL, United States District Judge




         Pending before the Court is Plaintiff Richard Roberts's (“Plaintiff”) Motion to Remand. (Dkt. No. 35 (“Motion” or “Mot.”).) After considering the papers filed in support of the instant Motion, the Court deems this matter appropriate for resolution without oral argument of counsel. See Fed. R. Civ. P. 78; C.D. Cal. L.R. 7-15. For the following reasons, the Court GRANTS Plaintiff's Motion.


         A. Factual Background[1]

         This Action arises under the Employee Retirement Income Security Act of 1974, 29 U.S.C. §§ 1001 et seq. (“ERISA”). Plaintiff Richard Roberts (hereinafter, “Roberts”) is a resident of Sacramento County, California. (Dkt. No. 11 (“FAC”) ¶ 2.) Defendant Anthem Life Insurance Company (hereinafter, “Anthem” or “Defendant”) is a corporation organized under Ohio law, with its principal place of business in Ohio. (Dkt. No. 19 (“Answer”) ¶ 3.) Plaintiff began working as a software engineer at Vindicia, Inc. (hereinafter, “Vindicia”) on October 20, 2014. (See FAC; Mot. at 2.) Through his employment with Vindicia, Roberts participated in the Vindicia Long Term Disability & Life Insurance Plan (hereinafter, the “Plan”). (FAC ¶ 6.) The Plan is a long-term disability plan sponsored by Vindicia and governed by ERISA. (FAC ¶ 3.) The Plan provides for payment of monthly long-term disability benefits after a 90-day elimination period. (Dkt. No. 41, Administrative Record (hereinafter, “AR”) at 151-57.) Anthem is the insurer and claims administrator for the Plan. (FAC ¶¶ 3, 6.)

         On December 6, 2014, a car hit Mr. Roberts while he was riding his bicycle. (AR at 492.) As a result, Roberts sustained a concussion and began experiencing frequent headaches, dizziness, and confusion. (AR at 492.) Roberts returned to work a few days later. (Mot. at 5.) On March 27, 2015, Roberts was involved in a physical altercation at a concert and sustained additional, severe brain injuries, including a second concussion. (Mot. at 4.) Then, in early May 2015, he fell to the ground from a possible seizure. (Mot. at 5.) On May 12, 2015, Roberts ceased working at Vindicia. (Mot. at 6.)

         B. Administrative History

         On June 5, 2015, Roberts submitted his claim for benefits under the Plan (the “Claim”). (AR at 182-84.) Anthem received the Claim on July 13, 2015. (AR at 182- 84.) Roberts indicated experiencing the following symptoms: migraines, confusion, memory issues, balance, emesis, and dry heaving. (AR at 588.) Roberts's Claim also reflects that his disability prevented him from working beginning on April 15, 2015. (AR at 183.) On October 13, 2015, Dr. Gary Greenhood, a physician consultant for Anthem, reviewed Roberts's records. (Opp'n at 4.) Dr. Greenhood concluded that Roberts's disability prevented Roberts from working for the period May 12 - July 23, 2015. (Opp'n at 4; AR at 822.). Dr. Greenhood stated the “submitted information support[s] impairment sufficiently severe to have precluded the claimant from work in his own occupation . . . .” (AR at 822.) Dr. Greenhood also noted that updated clinical information was necessary for further evaluation of Roberts's claim for the period after July 23, 2015. (Opp'n at 4-5.) Under the Plan, Roberts's ninety-day elimination period ended after August 11, 2015. (Opp'n at 5.)

         On October 21, 2015, Anthem denied Roberts's Claim (the “Denial”). (AR at 605-08.) In its Denial, Anthem indicated that it had not received records for Roberts's medical care after June 24, 2015. (AR at 607.) Anthem also provided information for appealing its Denial. (See AR at 608.) On November 9, 2015, Roberts appealed the Denial. (AR at 625-27.) Plaintiff included the following supporting documentation with his appeal: (1) a work release from Peninsula Medical Center for May 13-15, 2015; (2) a work release from Dr. Naik for May 18-30, 2015; (3) an extended work release from Dr. Naik for May 25 to June 15, 2015; (4) a confirmation of Roberts's State Disability Insurance claim with a return to work date of November 1, 2015; and, (5) progress notes from Dr. Aimee Paulson dated June 26, 2015 and August 7, 2015. (AR at 625-35.) In December 2015, Anthem requested additional medical records from Roberts's treating physicians, Dr. Mitchell and Dr. Naik. (Opp'n at 5.) Anthem received medical records from Dr. Mitchell for Plaintiff's evaluations on August 24, October 14, and November 30, 2015. (Opp'n at 5.) Anthem also received medical records for Plaintiff's visits with Dr. Paulson on October 19, 2015. (Opp'n at 5.) On December 17, 2015, Anthem advised Roberts of the status of his appeal. (AR at 659.)

         On January 6, 2016, Anthem consultant Dr. Bruce LeForce reviewed Roberts's records. (See AR at 673.) Dr. LeForce reviewed the following records for periods after July 23, 2015: (1) correspondence from Roberts dated October 29, 2015; (2) a chart of progress notes dated August 6, 2015; (3) correspondence from Dr. Mitchell dated August 24, October 14, and November 30, 2015; (4) progress notes from Dr. Paulson dated August 7 and October 19, 2015; (5) an occupational description from Vindicia; and, (6) a referral form from Anthem. (AR at 673.) Dr. LeForce also considered Dr. Greenhood's October 13, 2015 determination that Roberts was disabled through July 23, 2015. (AR at 673.) Based upon the foregoing materials, Dr. LeForce concluded that “[t]here [were] no findings on examination or imaging studies to support restrictions or limitations that would impede [Roberts] from performing his occupation during the time period under review from 07/14/2015 to present.” (AR at 672.) In light of Dr. LeForce's review, Anthem denied Roberts's appeal on January 7, 2016. (AR at 682-86.) Anthem indicated that a lack of objective findings of cognitive complaints supported its determination. (AR at 684.) Anthem further pointed to a lack of neurocognitive testing. (AR at 685.)

         C. Civil Proceedings

         Plaintiff filed his original Complaint in the Central District of California on March 28, 2016, seeking review of Anthem's adverse claim determination. (See Dkt. No. 1.) Plaintiff filed the operative First Amended Complaint on May 5, 2016. (See FAC.) Plaintiff alleges that Defendant violated its obligations under ERISA as follows: (1) failure to pay disability benefits to Plaintiff when Plaintiff was entitled to benefits; (2) failure to provide a reasonable basis under the terms of the Plan for denial of benefits; (3) failure to specify to Plaintiff what additional material was required “to perfect the claim”; (4) failure to provide a “full and fair review” of Plaintiff's appeal pursuant to 29 C.F.R. § 2560.503-1(h)(2); (5) failure to notify Plaintiff of the need to submit objective neurocognitive testing; and, (6) failure to continue the waiver of life insurance premiums based on Plaintiff's disability. (See FAC at 4.)

         Based upon these alleged violations, Plaintiff seeks: (1) payment of disability benefits due to Plaintiff up to and including the date of Judgment; (2) waiver of Plaintiff's life insurance premiums; (3) a declaratory judgment that Plaintiff is entitled to reinstatement of the Plan; (4) payment of all costs and attorneys' fees pursuant to 29 U.S.C. § 1132(g); and, (5) payment of prejudgment and post-judgment interest. (FAC at 5.) On May 2, 2017, Plaintiff moved to remand the matter to the plan administrator for further development of the factual record. (See Mot. at 1.) On May 16, 2017, Defendant opposed Plaintiff's Motion. (See Opp'n.) On May 22, 2017, Plaintiff replied in support of his Motion. (See Dkt. No. 40 (“Reply”).)


         A. Standard of Review

         ERISA provides that a qualifying ERISA plan “participant” may bring a civil action in federal court “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); Metro. Life Ins. Co. v. Glenn, 554 U.S. 105, 108 (2008) (ERISA “permits a person denied benefits under an employee benefit plan to challenge that denial in federal court.”). The Supreme Court established a de novo standard of review for denial of benefits under an ERISA plan, except for plans that give the administrator discretion to determine benefits eligibility. Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989); see also Kearney v. Standard Ins. Co., 175 F.3d 1084, 1089 (9th Cir. 1999).

         B. ...

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