United States District Court, N.D. California
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
M. CHESNEY, UNITED STATES DISTRICT JUDGE
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.
was formerly employed as a Vice President with BTIG LLC
("BTIG"), a brokerage firm. (Administrative Record
("AR") 1074, 1328-1329.) 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).
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). 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).
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.
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"
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).
29, 2018, the Court, upon joint request of the parties,
lifted the stay, and the parties subsequently filed the
instant motions for judgment.
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).
as here, a court's review of a decision to deny benefits
is de novo, 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
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). 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,  is not properly before the
Court and will not be further addressed herein.
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
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
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 ...