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Elliott v. Life Insurance Company of North America, Inc.

United States District Court, N.D. California

July 9, 2019

EDWARD ELLIOTT, Plaintiff,
v.
LIFE INSURANCE COMPANY OF NORTH AMERICA, INC., Defendant.

          ORDER GRANTING PLAINTIFF'S MOTION FOR JUDGMENT; DENYING DEFENDANT'S CROSS-MOTION FOR JUDGMENT; FINDINGS OF FACT AND CONCLUSIONS OF LAW RE: DKT. NO. 56

          MAXINE M. CHESNEY, UNITED STATES DISTRICT JUDGE

         Before the Court are (1) plaintiff Edward Elliott's ("Elliott") "Rule 52 Motion for Judgment," filed October 2, 2018, and (2) defendant Life Insurance Company of North America's ("LINA") "Cross-Motion for Judgment Under F.R.C.P. Rule 52," filed October 29, 2018. The motions have been fully briefed. Having read and considered the parties' respective arguments as well as the applicable administrative record, the Court rules as follows.[1]

         BACKGROUND[2]

         Elliott was formerly employed as a Vice President with BTIG LLC ("BTIG"), a brokerage firm. (Administrative Record ("AR") 1074, 1328-1329.)[3] Through his employer, Elliott was a participant in a "Group Policy" issued by LINA that provides for payments to participants who become "Disabled" within the meaning of the policy. (AR 1008-1033.) In September 2014, Elliott submitted to LINA a claim for disability benefits (AR 233, 273), in which he listed September 5, 2014, as his last day of work and stated he was unable to return to work due to a "nerve condition - severe face pains - twitching in the face" (AR 333). Thereafter, in support of his claim, he submitted, inter alia, a letter from his treating physician, who provided a diagnosis of "trigeminal neuralgia." (AR 233, 429).

         LINA initially approved Elliott's claim as one for "Short Term Disability (STD) benefits" under a separate policy (AR 314) and paid benefits for approximately three months, after which the claim was denied (AR 271).[4] With respect to Elliott's claim for "Long Term Disability (LTD)" benefits, said claim was denied on February 26, 2015 (AR 232), after which, on June 9, 2015, and, again, on January 14, 2016, the denial was upheld (AR 210-211, 229).

         On March 21, 2016, Elliott filed the instant action pursuant to the Employee Retirement Income Security Act ("ERISA"), seeking judicial review of the denial of his claim for LTD benefits and requesting an award of such benefits or, in the alternative, an order remanding his claim to the plan administrator for further proceedings.

         Thereafter, on October 20, 2016, Elliott filed with the Social Security Administration ("SSA") an application for disability benefits, in which he alleged an "inability to function and/or work" as a result of the following impairments: "trigeminal neuralgia; chronic migraine headaches; severe facial pain; poor sleep; [and] difficulty talking due to trigeminal neuralgia." (AR 790.) On February 26, 2017, the SSA granted Elliott's application, finding he was disabled (AR 837), based on its determination that he was "[u]nable to sustain work due to pain from trigeminal neuralgia" and his medication's "side effects of sedation and cognitive slowing" (AR 796).

         On March 23, 2017, the Court approved the parties' stipulation to stay the instant action to afford LINA, in light of the SSA's decision, the opportunity to conduct further administrative proceedings. Thereafter, Elliott, in addition to submitting to LINA the SSA's decision and documents the SSA had considered in making its determination, provided LINA with his updated medical records and other evidence. (See Joint Status Report, filed June 21, 2017, at 2:10-13; AR 181, 195, 390, 835.) On July 6, 2017, LINA advised Elliott that its prior denial of his claim for LTD benefits was "unchanged" (AR 196), and, on April 10, 2018, upon reconsideration, upheld its decision not to reconsider said denial (AR 181).

         On May 29, 2018, the Court, upon joint request of the parties, lifted the stay, and the parties subsequently filed the instant motions for judgment.

         LEGAL STANDARD

         Under ERISA, a plan participant may bring a civil action "to recover benefits due to him under the terms of his plan," see 29 U.S.C. § 1132(a)(1)(B), in which action the plaintiff has the burden to establish his entitlement to benefits, see Muniz v. Amec Construction Management, Inc., 623 F.3d 1290, 1294 (9th Cir. 2010).

         Where, as here, a court's review of a decision to deny benefits is de novo, [5]disputes of fact are "resolved by trial." See Kearney v. Standard Ins. Co., 175 F.3d 1084, 1094 (9th Cir.), cert. denied, 528 U.S. 964 (1999). "Although Rule 43(a) requires that 'testimony' be taken in open court, the record [in an ERISA case] should be regarded as being in the nature of exhibits, which are routinely a basis for findings of fact even though no one reads them out loud." Id. Specifically, the district court tries the case "on the record that the administrator had before it." Id. at 1095. "In a trial on the record, ... the judge can evaluate the persuasiveness of conflicting [evidence] and decide which is more likely true." Id. In so doing, the district court "consider[s] anew both the legal and factual aspects of [the plaintiff's] claim." See Thomas v. Oregon Fruit Products Co., 228 F.3d 991, 995 (9th Cir. 2000). In other words, the district court "does not give deference to the claim administrator's decision, but rather determines in the first instance if the claimant has adequately established that he or she is disabled under the terms of the plan." See Muniz, 623 F.3d at 1295-96.

         DISCUSSION

         In his motion for judgment, Elliott states he seeks an order "overturn[ing] [LINA's] denial of his short term disability, long term disability, and life insurance waiver of premium benefit claims." (See Pl.'s Mot., first unnumbered page at line 21.) As LINA points out, however, Elliott's complaint only seeks relief with respect to the denial of benefits under the LTD policy and, further, that Elliott has not alleged he exhausted his administrative remedies as to any claim other than the claim for LTD benefits. See Vaught v. Scottsdale Healthcare Corp. Health Plan, 546 F.3d 620, 626 (9th Cir. 2008) (holding "an ERISA plaintiff claiming a denial of benefits must avail himself or herself of a plan's own internal review procedures before bringing suit in federal court") (internal quotation and citation omitted).[6] Consequently, any challenge to the termination of Elliott's claim for short-term disability benefits, as well as any challenge to any decision by LINA regarding life insurance premiums, [7] is not properly before the Court and will not be further addressed herein.

         The Court next turns to the issue before it, i.e., whether Elliott is entitled to LTD benefits and/or an order remanding his claim for such benefits to LINA for further consideration.

         The Group Policy, i.e., the policy that sets forth the circumstances under which a plan participant is entitled to LTD benefits, defines "Disability/Disabled" as follows:

The Employee is considered Disabled if, solely because of Injury or Sickness, he or she is:
1. unable to perform the material duties of his or her Regular Occupation; and
2. unable to earn 80% or more of his or her Indexed Earnings from working in his or her Regular Occupation.
After Disability Benefits have been payable for 24 months, the Employee is considered Disabled if, solely due to Injury or Sickness, he or she is:
1. unable to perform the material duties of any occupation for which he or she is, or may reasonably become, qualified based on ...

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