Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-cand-3_03-cv-04387/USCOURTS-cand-3_03-cv-04387-1/pdf.json

Nature of Suit Code: 791
Nature of Suit: Employee Retirement Income Security Act (ERISA)
Cause of Action: 28:1132 E.R.I.S.A.

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IN THE UNITED STATES DISTRICT COURT

FOR THE NORTHERN DISTRICT OF CALIFORNIA

RICHARD H. AGUILAR,

Plaintiff,

 v.

NEW UNITED MOTOR

MANUFACTURING, INC. DISABILITY

INSURANCE INCOME PLAN,

Defendant.

 /

NO. C 03-04387 WWS

FINDINGS OF FACT AND

CONCLUSIONS OF LAW

I. INTRODUCTION

Plaintiff Richard H. Aguilar brings this action, arising under the Employee Retirement

Income Security Act of 1974 (“ERISA”), 29 U.S.C. § 1132, against Defendant New United

Motor Manufacturing, Inc. Disability Insurance Income Plan (“the Plan”), challenging the denial

of his claim for short-term and long-term disability benefits that he alleges are due to him under

the terms of the Plan. 

A pretrial conference was held on October 25, 2004, at which the Court (White, J.)

appropriately determined – and the parties conceded – that Plaintiff’s claim would be reviewed

de novo because the Plan contains no language delegating authority to the Plan Administrator to

interpret the terms of the Plan. See Kearney v. Standard Ins. Co., 175 F.3d 1084, 1089 (9th Cir.

1999) (citing Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 109 (1989)). The Court
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additionally held that it would not exercise its discretion to admit evidence outside of the

administrative record in its evaluation of the Plan Administrator’s decision. See id. at 1090-91. 

The parties submitted trial briefs and proposed findings of fact and conclusions of law,

and made arguments at a bench trial hearing on February 4, 2005. The case was reassigned to

the undersigned on June 27, 2005. 

The Court, having reviewed the administrative record, the hearing transcripts, and the

papers submitted by the parties, now finds for Defendant and against Plaintiff. 

II. JURISDICTION

The action arises under ERISA, 29 U.S.C. § 1132, and this Court has jurisdiction over

Plaintiff’s claim pursuant to 29 U.S.C. § 1132(e) .

III. FINDINGS OF FACT

The following facts are taken from the administrative record (“PLAN”) submitted by the

parties, which contains the only relevant and admissible evidence in the trial of this matter. See

Kearney, 175 F.3d at 1090-91. 

Plaintiff was employed by New United Motor Manufacturing, Inc. (“NUMMI”) from

February 1985 to December 2000, as a production line inspector. PLAN 0284-85. As an

employee of NUMMI, Plaintiff was a participant in NUMMI’s employee welfare benefit Plan,

which was funded through the purchase of a group insurance policy issued by the Life Insurance

Company of North America (“LINA”). PLAN 0001-32. 

A. The NUMMI Disability Income Insurance Plan

The Plan provides for disability benefits if, because of injury or sickness, an employee is

unable to perform all the material duties of any occupation available at the Plant for which he is

or may reasonably become qualified based on his education, training or experience. PLAN

0005, 0309. 

Under the Plan, short-term disability benefits are payable for a maximum of 52 weeks

after a seven-day benefit waiting period during which the participant must be continuously and

totally disabled. PLAN 0027. Long-term disability benefits are payable after 52 weeks of

continuous disability. PLAN 0009. If a participant is 50 or older when the disability began,
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28 1There is no evidence to indicate that Plaintiff’s time off after December 1, 2000, was due to

holiday, vacation or employer-approved paid leave. See PLAN 0305.

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long-term benefits are payable until the earlier of (a) the participant’s sixty-fifth birthday or (b)

the date the participant ceased to be disabled. PLAN 0015. 

The Plan agrees to pay benefits for “Eligible Employees,” which include: 1) all active

full-time hourly employees of NUMMI working a minimum of 40 hours per week and 2) all

active full-time salaried employees of NUMMI working a minimum of 40 hours per week. 

PLAN 0290. 

The Plan provides for the termination of insurance on the date that an employee’s

“Active Service” ends. PLAN 0295. An employee is considered to be in Active Service under

the terms of the Plan on a scheduled work day if: 1) the employee is “performing in the usual

way all of the regular duties” of work for the employer on a full time basis that day, or 2) the

day is a scheduled holiday, vacation day or period of employer-approved paid leave of absence.

PLAN 0305. The Plan provides that if an employee is not in Active Service on the date the

coverage would otherwise become effective, it will become effective on the date the employee

returns to Active Service. PLAN 0295. The Plan states that if Active Service ends due to

disability for which benefits are or may become payable, an employee’s insurance will continue

as long as the benefits are payable for the disability. PLAN 0295. 

B. Plaintiff’s Claim for Disability Benefits

Plaintiff’s last day of work at NUMMI was December 1, 2000, PLAN 0285-86, and it is

undisputed that Plaintiff was an eligible Plan participant on that date. The record provides no

reason given by Plaintiff or noted by NUMMI on or around December 1, 2000, why Plaintiff did

not return to work.1 See Hearing Transcript at 17, lines 13-25. 

On January 22, 2002, Plaintiff initiated a claim for disability benefits by telephone to

LINA. PLAN 0281-91. This telephone call was followed by an integrated application for shortterm and long-term benefits on or about February 12, 2002. PLAN 0199-0200. 

On January 23, 2002, in response to Plaintiff’s claim, LINA sent a request for Plaintiff’s

medical records to Vasdeep Kahlon, M.D., a psychiatrist identified by Plaintiff as his treating
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Plaintiff was being treated by both Dr. Kahlon and Dr. Rennert for a certain period of time, but did not

begin seeing Dr. Rennert until January 29, 2001. PLAN 0081, 0083.

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physician. PLAN 0274-76. By letter dated March 15, 2002, LINA advised Plaintiff that it had

not received any medical records from Dr. Kahlon and requested Plaintiff’s assistance in

obtaining such records. PLAN 0273. LINA also notified Plaintiff that if no medical

information was received by April 28, 2002, a decision on his claim for benefits would be made

based on the information in his administrative record. PLAN 0273. 

By letter dated March 28, 2002, LINA advised Plaintiff that it was still awaiting medical

records and information from Dr. Kahlon and again told Plaintiff that it would make a decision

based on the available information on April 28, 2002. PLAN 0271. 

By letter dated April 29, 2002, LINA denied Plaintiff’s short-term disability benefit

claim because it had not received any records from Plaintiff or Plaintiff’s medical providers

upon which to base an evaluation of Plaintiff’s claim. PLAN 0265-67. In this letter, LINA

noted that it had requested, unsuccessfully, records from Dr. Kahlon on February 6 and 21, and

March 7, 2002. PLAN 0265-67. 

On April 29, 2002, LINA received an Attending Physician’s Statement from James

Rennert, M.D., dated April 29, 2002, wherein Dr. Rennert stated that Plaintiff suffered from

major depressive disorder and panic disorder and that he was disabled from working. PLAN

0268-70. Dr. Rennert stated that Plaintiff had been disabled since December 1, 2000. PLAN

0268-70. LINA subsequently received an Attending Physician’s Statement from Dr. Kahlon,

dated May 20, 2002, wherein Dr. Kahlon diagnosed Plaintiff with major depression and panic

disorder. PLAN 0260. Dr. Kahlon noted that he treated Plaintiff from December 1, 2000 to

January 15, 2002, after which time Plaintiff transferred exclusively to Kaiser and Dr. Rennert

for further treatment.2 PLAN 0260. Dr. Kahlon stated that Plaintiff was currently under the

care of Dr. Rennert and that Plaintiff was still on disability, but he did not specify when Plaintiff

became disabled. PLAN 0260. 

Plaintiff appealed LINA’s denial of benefits by letter dated July 16, 2002. PLAN 0259. 

By letter dated July 26, 2002, LINA advised Plaintiff that a decision to overturn its prior denial
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could not be made based upon the statements in the Attending Physician’s Reports alone. 

PLAN 0255. 

By letter dated August 19, 2002, LINA affirmed its denial of Plaintiff’s claim, noting

that Plaintiff had failed to submit any additional medical evidence in support of his claim and

that Plaintiff had failed to submit a signed authorization to LINA so that LINA could obtain

further medical information on its own. PLAN 0253. LINA subsequently obtained Plaintiff’s

signed authorization and agreed to re-review Plaintiff’s claim. PLAN 0170. 

By letter dated November 1, 2002, LINA notified Plaintiff that he had failed to

demonstrate that he was totally disabled as of December 1, 2000, but stated that it would request

records from Dr. Kahlon. PLAN 0195. LINA received Dr. Kahlon’s records on December 18,

2002. PLAN 0176-87. Dr. Kahlon’s records showed that Dr. Kahlon evaluated Plaintiff on

December 1, 2000, and filled out a mental evaluation form on that date. PLAN 0178-81. Dr.

Kahlon noted that Plaintiff was irritable, restless, and hypoactive, but in the section entitled

“Liabilities and Special Needs,” Dr. Kahlon marked only that Plaintiff had “poor coping skills.” 

PLAN 0181. At the end of the form, Dr. Kahlon prescribed the antidepressant Paxil for

Plaintiff, but nowhere indicated that Plaintiff was disabled and/or unable to perform any work at

the NUMMI Plant. PLAN 0178-81. 

By letter dated January 6, 2003, LINA reconfirmed its denial of Plaintiff’s claim for

benefits because the medical records failed to establish that Plaintiff was totally disabled as of

December 1, 2000. PLAN 0150-53.

LINA received a letter, dated March 12, 2003, from Dr. Rennert, challenging the denial

of Plaintiff’s claim for benefits and stating that Plaintiff’s treatment at Kaiser indicates that he

had a “difficult treatment-resistant case of Panic Disorder and Depression.” PLAN 0143. LINA

also received a letter, dated March 12, 2003, from Dr. Diane Enos, a psychologist, who first

treated Plaintiff on February 11, 2002, and who stated that Plaintiff’s condition made him

unable to return to work. PLAN 0145-46. 

On April 14, 2003, LINA received a third appeal from Plaintiff. PLAN 0142. By letter

dated April 21, 2003, LINA reconfirmed its denial of Plaintiff’s claim, noting that the reports
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from Dr. Rennert and Dr. Enos, relating to treatment provided after February 11, 2002, did not

show that Plaintiff was disabled as of December 1, 2000. PLAN 0140-41. LINA also notified

Plaintiff that he had exhausted all administrative levels of appeal. PLAN 0140-41. 

By letter dated April 29, 2003, Plaintiff objected to LINA’s April 21, 2003, denial and

requested a copy of his claim file. PLAN 0113-14. With this letter, Plaintiff sent LINA

additional records, including copies of “disability slips” from Drs. Kahlon and Rennert that

advise medical leave for Plaintiff. PLAN 0116-0139. The records indicate that although Dr.

Kahlon was treating Plaintiff as of December 1, 2000, the first disability slip available shows

that Dr. Kahlon did not put Plaintiff on medical leave until December 20, 2000. PLAN 0116-

35. The records also indicate that Dr. Rennert certified that Plaintiff was disabled as of

December 1, 2000, even though Dr. Rennert’s first evaluation of Plaintiff did not occur until

January 29, 2001. PLAN 0083.

LINA did not treat Plaintiff’s April 29, 2003 letter as an appeal because Plaintiff had

been previously notified that he had exhausted all appeals. PLAN 0140-41. By letter dated May

27, 2003, LINA sent Plaintiff a copy of his file. PLAN 0112. 

This litigation ensued. 

III. CONCLUSIONS OF LAW

Plaintiff bore the burden of providing evidence to LINA showing that he is entitled to

disability benefits under the Plan. See Kearney, 175 F.3d at 1091 (stating that if claimant

believed particular medical data should have been reviewed by the Plan administrator, the

claimant “should have sent it to [the administrator]”); Chamberlain v. Allstate Ins. Co., 931

F.2d 1361, 1364 (9th Cir. 1991) (holding that under California law, “[a]n insured bears the

burden of proving that a claim falls within the scope of the policy”); Jordan v. Northrop, 63 F.

Supp. 2d 1145, 1150 n.2 (C.D. Cal. 1999) (stating that in determining a claim for disability

benefits under ERISA, “it is not the duty of the administrator to seek out evidence which is not

before them”) aff’d, 370 F.3d 869 (9th Cir. 2004); PLAN 0313 (requiring plaintiff to submit

proof of loss in order to receive benefits).
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3Both parties agree that Plaintiff’s last day of work was Friday, December 1, 2000. PLAN

0285-86. The Plan provides that an employee is deemed to be in “Active Service” on the day which

is one of the employer’s scheduled work days if the employee is performing in the usual way all of

the regular duties of employment on a full time basis that day. PLAN 0305. If the day is not a

scheduled work day, the employee is deemed to be in Active Service if the employee was in Active

Service on the preceding scheduled work day. PLAN 0305. The Court is unaware of any record

evidence establishing that Saturday and Sunday, December 2 and 3, 2000, were scheduled work days

for Plaintiff. Because Plaintiff cannot show disability as of December 1 or December 4, 2000, the

precise date that Active Service ceased is irrelevant. The Court will use December 4, 2000, because

Active Service ceased, at the latest, on that date when Plaintiff failed to return to work. See PLAN

0305.

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The medical records provided by Drs. Kahlon, Rennert, and Enos support Plaintiff’s

argument that he is or was disabled and unable to work at some point in time. However, under

the terms of the Plan, Plaintiff must establish that he was totally disabled as of December 4,

2000,3 because Plaintiff’s coverage under the Plan terminated on December 4, 2000, when he

ceased to be in “Active Service.” PLAN 0295. The Plan provides for the continuation of

insurance if Active Service ceases due to a “Disability for which Monthly Benefits are or may

become payable.” PLAN 0295. This means, again, that Plaintiff must establish that he was

disabled and unable to perform the duties of any occupation available at the Plant as of

December 4, 2000. PLAN 0309. Plaintiff has failed to present evidence to prove disability as

of that date.

The only record evidence reflecting Plaintiff’s claim that he was disabled as of

December 4, 2000, is: 1) a “Visit Verification/Family Leave” form filled out by Dr. Rennert on

February 13, 2002, stating that Plaintiff is disabled and unable to work, and has been so disabled

since December 1, 2000, PLAN 0136; and 2) an Attending Physician Statement filled out by

Dr. Rennert on April 29, 2003, again commenting that Plaintiff has been disabled since

December 1, 2000. PLAN 0270. Dr. Rennert does not provide any support for his finding that

Plaintiff was disabled as of December 1, 2000, however, and the record indicates that

Dr. Rennert first evaluated Plaintiff on January 29, 2001, at the earliest. PLAN 0083, 0136.

The most relevant medical records with regard to the date of Plaintiff’s disability are

those of Dr. Kahlon, who evaluated Plaintiff on December 1, 2000. PLAN 0178-81. During

this evaluation, Dr. Kahlon noted that Plaintiff had poor eye contact and was irritable,

hypoactive, restless, depressed, and anxious. PLAN 0180-81. Dr. Kahlon’s assessment was
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that Plaintiff has “poor coping skills” and that Plaintiff should be treated with the antidepressant

Paxil. PLAN 0180-81. However, Dr. Kahlon nowhere noted on any of the relevant forms that

Plaintiff was disabled or that he was unable to perform his duties at NUMMI. PLAN 0178-81. 

Moreover, the disability slips that Plaintiff submitted to LINA – after LINA had already denied

his third appeal – show that the first date for which Dr. Kahlon advised medical leave for

Plaintiff was December 20, 2000. PLAN 0116. 

Therefore, although the record presents what may be viewed as conflicting evidence on

the issue of Plaintiff’s date of disability, the Court is charged with evaluating the persuasiveness

of conflicting evidence and deciding which is more likely true. See Kearney, 175 F.3d at 1095. 

Although Dr. Rennert stated that Plaintiff was disabled as of December 1, 2000, the Court must

evaluate the credibility of Dr. Rennert’s statement by looking at the basis upon which

Dr. Rennert rendered his conclusion. See id. It is undisputed that Dr. Rennert did not evaluate

Plaintiff on December 1, 2000. The first evaluation by Dr. Rennert appears to have been on

January 29, 2001. PLAN 0083. Therefore, Dr. Rennert had no personal knowledge of

Plaintiff’s condition on December 1, 2000, and provides no other basis for reaching his

conclusion regarding Plaintiff’s date of disability. PLAN 0083. Plaintiff argues that a doctor

may make a diagnosis without having observed a disability on a particular day, and that Dr.

Rennert looked at Dr. Kahlon’s notes from the December 1, 2000, evaluation and was able to

reach a conclusion even though Dr. Kahlon made no comment regarding disability. Hearing

Transcript at 6, lines 16-21. However, the fact that Dr. Rennert first evaluated Plaintiff two

months after the alleged onset of the disability – coupled with the fact that Dr. Rennert’s report

was sent to LINA only after Plaintiff’s claim for benefits had already been denied – weakens the

credibility of Dr. Rennert’s conclusion regarding the onset date of disability. 

The treating physician who saw Plaintiff on December 1, 2000, Dr. Kahlon, gave no

indication that Plaintiff was disabled and unable to work as of that date, PLAN 0178-81, and

first advised Plaintiff to take medical leave from work on December 20, 2000. PLAN 0116. 

Therefore, the earliest date that Plaintiff can show evidence of disability under the Plan is

December 20, 2000. 
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28 4Again, the record does not show that Plaintiff was on holiday, vacation, or employerapproved paid leave, thus enabling him to remain in Active Service. PLAN 0305.

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Plaintiff ended Active Service, as defined under the Plan, on December 4, 2000, at the

latest, because on that scheduled day of work, Plaintiff was not “performing in the usual way all

of the regular duties” of his work.4 PLAN 0295, 0305. Insurance therefore terminated as of

December 4, 2000, unless Plaintiff returned to work – which he never did – or unless Plaintiff

proved that his Active Service ended due to an eligible disability, which he has not. PLAN

0295.

Because short-term and long-term disability benefits require Plaintiff to have shown

disability at the time he ceased Active Service and during the relevant waiting periods, PLAN

0292, 0295, Plaintiff has not shown that he is entitled to such benefits.

IV. CONCLUSION

A review of the administrative record indicates that Plaintiff has failed to establish that

he was disabled as of the date required in order to receive short-term and long-term disability

benefits. The denial of his claim for disability benefits was therefore appropriate. For the

reasons set forth above, the Court finds for Defendant and against Plaintiff.

IT IS SO ORDERED.

Dated: August 29, 2005 

WILLIAM W SCHWARZER

SENIOR UNITED STATES DISTRICT JUDGE