Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-azd-2_05-cv-02867/USCOURTS-azd-2_05-cv-02867-2/pdf.json

Nature of Suit Code: 791
Nature of Suit: Employee Retirement Income Security Act (ERISA)
Cause of Action: 29:1132 E.R.I.S.A.-Employee Benefits

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WO

IN THE UNITED STATES DISTRICT COURT

FOR THE DISTRICT OF ARIZONA

Ron TAVOR, 

Plaintiff, 

vs.

AETNA LIFE INSURANCE COMPANY,

et al., 

Defendants. 

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No. CIV 05-2867-PHX-SMM

FINDINGS OF FACT, CONCLUSIONS OF

LAW, AND ORDER

The Court granted the parties’ request to render a decision based on the pleadings to

date. (See Dkt. 33, Order dated Aug. 8, 2007.) Having reviewed the pleadings and briefs

filed in this matter, the Court now issues this ruling.

FINDINGS OF FACT

A. Factual Background

Plaintiff Ron Tavor (“Plaintiff”) was an employee of Kodak Polychrome Graphics,

LLC (“Kodak”), and a participant in Kodak’s employee welfare benefit plan (“the Plan”).

The Plan included short-term disability (“STD”) and long-term disability (“LTD”) benefits.

Defendant Aetna Life Insurance Company (“Aetna”) processes claims, pays benefits, and

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1

 The Plan refers to Kodak as the “Plan Administer,” rather than the more common

“plan administrator.”

2

 The record is unclear as to the exact date on which Plaintiff’s STD benefits ceased.

The letter upholding denial states that Plaintiff is “not eligible for any further payment of

STD benefits after February 24, 2002.” (AET 00088.) That same letter states that Plaintiff

was paid another eight weeks of STD benefits from January 25, 2002 through February 24,

2002—a period of approximately four weeks. The initial letter approving STD benefits

states that the eight weeks of remaining STD payments would end March 31, 2002—a period

of approximately nine weeks from January 25, 2002. (AET 00201; see also AET 00212.)

As Plaintiff’s claim is for termination of LTD benefits and not STD benefits, the Court need

not resolve this ambiguity. (See Dkt. 14, First Am. Compl. ¶ 12 (acknowledging that STD

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makes benefit determinations under the Plan. (Dkt. 16, Answer ¶ 5.) Kodak is the Plan

Administer.1

B. Payment and Termination of STD Benefits

On December 17, 2001, Plaintiff undertook an initial consultation with Dr. Lawrence

Metrick regarding lower back pain down Plaintiff’s left leg. An x-ray revealed degenerative

spur changes and decreased curve lumbosacral spine. (AET 00169-00170.) A cortisone shot

received by Plaintiff a few days later improved the pain, but Plaintiff still experienced

discomfort while walking. (AET 00170.) A MRI taken January 16, 2002 indicated that

Plaintiff suffered from avascular necrosis. (AET 00171.) A subsequent bone scan was

consistent with the MRI. (AET 00172.) Plaintiff continued to experience discomfort when

he attempted to walk. (Id.) Dr. Metrick prepared a noted dated January 28, 2002 stating that

Plaintiff could not return to work for six weeks. (AET 00222.)

Plaintiff submitted an application for STD benefits to Aetna on January 29, 2002.

(See AET 00220.) After requesting and receiving additional information, Aetna approved

STD benefits effective February 4, 2002 through February 24, 2002. (AET 00201.) STD

benefits were later extended through March 31, 2002; due to a previous disability claim, no

further STD payments would be made after that date. (AET 00212.) Plaintiff appealed that

decision (see AET 00093), but Aetna upheld the original decision to deny further STD

payments.2

 (AET 00088-00089.)

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benefits “ceased due to [Plaintiff] having exhausted the STD Plan’s provision for . . . STD

benefits.”).)

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C. Payment and Termination of LTD Benefits

On March 13, 2002, Plaintiff faxed Aetna a note indicating he had been diagnosed

with “AVN left hip” and that Plaintiff was unable to work for three months. (AET 00210.)

Aetna advised Plaintiff that LTD benefits required a waiting period of 26 weeks, retroactive

to the date of his disability—January 28, 2002. (AET 00103.) After that waiting period,

Aetna would request and review Plaintiff’s medical information to determine whether he

remained totally disabled. (Id.) Plaintiff continued to see Dr. Metrick and was also

examined by an orthopedic surgeon in Israel. (AET 00174-00175, 00187.) Both stated that

Plaintiff could not return to work for a period of time.

On June 13, 2002, Dr. Metrick signed a “Disability Attending Physician’s Statement,”

diagnosing Plaintiff with “aseptic necrosis of [left] hip.” (AET 00153-00154.) Dr. Metrick

assessed Plaintiff as “improved” and “ambulatory,” but that Plaintiff should use a cane or

crutch. (AET 00153-00154.) Dr. Metrick classified Plaintiff’s physical impairment at a

“Class 4” level on a scale of increasing severity from Class 1 to Class 5: “[m]oderate

limitation of functional capacity; capable of clerical/administrative (sedentary) activity. (60-

70%),” with no stress to be placed on his left hip. (AET 00154.) Dr. Metrick indicated that

Plaintiff’s prognosis was “fair,” but deferred any prognoses on when Plaintiff’s maximum

medical improvement would be reached, the estimated date of Plaintiff’s return to work, and

whether Plaintiff was a viable candidate for vocational rehabilitation (job retraining). (Id.)

On July 24, 2002, Aetna determined that Plaintiff was totally disabled from his usual

occupation under the terms of the Plan, and was eligible for monthly disability payments of

$3,414 per month beginning July 29, 2002. (AET 00110-00111.) Plaintiff would remain

eligible for payments for up to 24 months so long as he remained disabled from his usual

occupation. (AET 00110.) After 24 months of LTD payments the Plan requires that a

participant meet a stricter “any occupation” definition of totally disabled, defined as “unable

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to perform all the material duties of any job” for which the participant is qualified for, or may

become qualified for by training, education, or experience. (Id.) The Plan authorizes

payment of LTD benefits to a disabled participant until the participant reaches the age of 65,

or is no longer disabled for purposes of LTD benefits. Plaintiffs condition would be assessed

to determine whether, after 24 months of receiving LTD benefits, Plaintiff’s condition

prevented him from performing the duties of “any occupation” and not just his usual

occupation. Aetna also informed Kodak that Plaintiff’s claim for LTD benefits had been

approved. (AET 00094.)

Plaintiff continued to seek medical treatment for his left hip and other ailments. Dr.

Metrick signed another Disability Attending Physician’s Statement on September 5, 2002

repeating the diagnosis, assessments, and prognoses found in the June 13, 2002 Statement.

(AET 00152.) Dr. Metrick referred Plaintiff for another MRI, conducted September 26,

2002. (AET 00180.) The results of that MRI showed significant improvement since the

previous MRI taken January 16, 2002, and suggested “that the findings may have been due

to transient osteoporosis at the left hip and/or insufficiency of fracture/osteochondral injury

(rather than avascular necrosis).” (Id.) 

Dr. Metrick reviewed the MRI results with Plaintiff during a October 24, 2002 visit.

 (AET 00177.) Despite the significant improvement indicated by the MRI report, Plaintiff

stated that his hip was hurting more. (Id.) Dr. Metrick referred the MRIs and other

documents to Dr. Marty Lazarus for his opinion. (Id.) On October 28, 2002, Dr. Lazarus

agreed with the September 26, 2002 findings of significant improvement, and felt that the

findings represented “cessation/resolution of AVN as opposed to transient osteoporosis,” and

that osteochondral fracture was less likely. (AET 00184.) Dr. Metrick discussed Dr.

Lazarus’s report with Plaintiff during a December 2, 2002 visit. (AET 00177.) Plaintiff felt

“improved,” but could not stand for any length of time and twisting his leg still caused

discomfort. (Id.) Plaintiff stated that he had considered going on some job interviews, but

that “he just can’t do it” because of the travel requirements. (AET 00178.) Dr. Metrick

continued to believe that Plaintiff was not ready to return to work. (Id.)

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Plaintiff visited Dr. Metrick again on April 11, 2003 and reported greatly increased

pain in his left hip radiating down the anterior thigh toward the knee. (AET 00178.) An xray taken that day showed no evidence of an acute fracture, subluxation, or asymmetric hip

joint effusion. (AET 00183.) Plaintiff had lost a significant amount of weight, and was

disappointed that the weight loss did not relieve the pain. (AET 00178-00179.) Dr. Metrick

advised Plaintiff that the weight loss could be beneficial if he required a hip replacement.

(AET 00179.) Dr. Metrick signed another Disability Attending Physician Statement dated

April 13, 2003, reiterating the same findings: diagnosis of aseptic necrosis in the left hip;

improved progress, ambulatory; Class 4 physical impairment, capable of

clerical/administrative (sedentary) activity with no undue stress on the left hip; fair prognosis

with other prognoses deferred. (AET 00205-00206.)

On May 14, 2003, Plaintiff submitted a “Work History and Education Questionnaire”

to Aetna. (AET 00195 (double sided document).) Plaintiff indicated that he had received

a degree in computer science and had worked as a Senior Application Specialist since his

hiring date of August 1990. (Id.) Plaintiff’s condition prevented him from performing job

duties of “computer hookup, networking, training, calibration.” (Id.) Plaintiff had previously

been employed as a tech support and quality control manager at Price Electronic, where he

had been trained in computer installations. (Id.) Plaintiff’s disability prevented him from

engaging in tennis, sailing, and softball—activities he had engaged in before the disability.

(Id.) Plaintiff also submitted an “Other Income Questionnaire” certifying that he was

receiving no other income. (AET 00196.) 

Plaintiff underwent another MRI on August 16, 2003 which revealed “a small focus

of abnormal signal intensity involving the left femoral head consistent with a small focus [of]

osteonecrosis.” (AET 00438.) Plaintiff visited Dr. Metrick on August 18, 2003, complaining

of discomfort in his left hip. (AET 00462.) Plaintiff stated that acupuncture received at the

weight reduction facility tended to reduce the pain. (Id.) Plaintiff’s treatment remained the

same and Plaintiff was instructed to be cautious with activities. (AET 00463.)

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Dr. Metrick submitted another evaluation form to Aetna on September 25, 2003.

(AET 00126-00128; AET 00707-710.) Dr. Metrick stated that Plaintiff was able to do

sedentary work activity with moderate limitation of functional capacity, exerting up to ten

pounds of force occasionally, with no stress, bending, or kneeling. (AET 00709.) Dr.

Metrick further stated that Plaintiff was capable of working four hours per day, four to five

days a week, divided between two hours sitting, one hour standing, and one hour walking.

(Id.) Plaintiff’s status was again listed as “improved.” (Id.)

On October 27, 2003, Aetna submitted a “Disability SIU Request” asking for

surveillance of Plaintiff. (AET 00079-00081.) Crawford Investigation Services performed

a three-day surveillance of Plaintiff at Plaintiff’s residence in Arizona from November 20,

2003 to November 22, 2003. Plaintiff had recently moved to Arizona from North Carolina

to see if the change in weather would improve his condition. (See AET 00464.) The

investigator watched Plaintiff’s residence from 7:00 am to 4:00 pm each day. (AET 00077-

00078.) Plaintiff was in the residence during the surveillance, but the investigator did not

observe any activity; the investigator noted that Plaintiff “might have been conscious of

surveillance efforts.” (AET 00077-00078.)

On January 21, 2004, Aetna informed Plaintiff that it was investigating whether

Plaintiff would remain disabled from any reasonable occupation after July 29, 2004. (AET

00072.) Aetna also asked Plaintiff to complete a Functional Capacity Evaluation (“FCE”)

to determine his level of physical impairment. (AET 00074.) Plaintiff expressed concern

about having a physical therapist rather than a medical doctor perform the FCE, and objected

to the proposed FCE date. (AET 00524-00525.) On March 23, 2004, Plaintiff sent a letter

to Aetna’s president indicating that he lacked confidence in Aetna and its representatives, and

believed Aetna was trying to deny Plaintiff benefits to which he was entitled. (AET 00494-

00495.) 

On April 30, 2004, Plaintiff signed a Long Term Disability Employee Questionnaire

and advised Aetna that he was represented by counsel. (AET 00013-00014, 00365-68.)

Plaintiff indicated that he could not perform any of the tasks of his previous occupation and

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relied on a friend to assist with errands. (AET 00013.) Plaintiff further indicated that he

could handle 30-45 minutes of sitting, 15-30 minutes of walking, and 30 minutes of grocery

shopping per day. (Id.) Plaintiff expressed his intention to return to work upon improvement

of his condition and physician’s approval. (AET 00014.)

On May 20, 2004, Plaintiff reported to Dynamic Rehab Physical Therapy for his FCE.

(AET 00129-00130.) Plaintiff reportedly gave a “self-limited effort,” and declined to

perform the following exercises due to his reported hip pain: climb stairs, stoop, crouch,

kneel, and shoulder to overhead. (AET 00129.) Plaintiff’s hip pain also caused him to

complete only one of three trials of carrying an empty crate weighing one pound, and of

immediate reaching with to his right side. (AET 00146, 00149.) The physical therapist who

conducted the FCE concluded that Plaintiff’s functional capacities were “within the

Sedentary physical demand classification for a standard eight-hour day.” (AET 00130.)

However, Plaintiff’s condition limited his ability to sustain a sitting position for greater than

10 to 15 minutes at a time and Plaintiff demonstrated difficulty standing due to an inability

to bear weight evenly on his legs and feet. (Id.) Plaintiff’s duration of function decreased

during testing, pain complaints remained constant, and as a result Plaintiff requested more

frequent rest breaks. (Id.) Dr. Metrick’s requests for a copy of the FCE report were denied

on the grounds that the case was still open.

On June 8, 2004, Plaintiff met with Dr. Metrick. (AET 00465.) Plaintiff felt better

due to the weather in Phoenix, but was still limited physically. (Id.) When Plaintiff walked

3,000 paces, his pain increased and caused him to stop or sit down. (Id.) Plaintiff knew he

was improved, but did not want surgery; Dr. Metrick stated that Plaintiff was not a candidate

for surgery. (Id.) Plaintiff knew he could not stand or sit all day and would have to alternate,

and the question remained whether Plaintiff could work four-, six-, or eight-hour days. (Id.)

Plaintiff was “apprehensive as to what he could or could not do. He certainly knows at this

point he is most likely unable to put in a decent day’s work in a structured environment.”

(Id.)

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On June 29, 2004, Aetna sent Plaintiff a letter advising him that his LTD benefits were

being terminated effective July 28, 2004. (AET 00422-00424.) Aetna identified the

following occupations available within Plaintiff’s geographic area and physical limitations:

Sales Manager; Computer Systems Analyst; Network and Computer Systems Administrator;

and Production Planning and Expediting Clerk. (AET 00423.) A registered nurse employed

by Aetna reviewed Plaintiff’s records and concurred with the FCE that Plaintiff was able to

perform sedentary work. (AET 00509-00510.) 

Plaintiff retained counsel and requested an appeal of the LTD benefits termination.

 (AET 00005-00006.) Aetna forwarded a copy of Plaintiff’s file, but did not provide a copy

of the Plan or the FCE. (AET 00007.) Aetna stated that it was not the Plan Administer and

recommended contacting Kodak for a complete copy of the Plan. (Id.) Aetna provided a

copy of the FCE report on December 29, 2004. Plaintiff then served a formal notice of

appeal to Aetna’s Central Appeals Unit. (AET 00471.) After reviewing the records,

including additional records submitted by Plaintiff, Aetna notified Plaintiff’s counsel of its

decision to uphold termination of LTD benefits. (AET 00474.) Aetna also advised Plaintiff

of his right to bring an action under Section 502(a) of ERISA.

B. Procedural Background

Plaintiff commenced this action against Aetna and Kodak on September 19, 2005. 

(Dkt. 1, Compl.) Plaintiff then filed a First Amended Complaint (“FAC”) which

dismissed Kodak as a defendant, eliminated a claim for breach of fiduciary duty, and

withdrew Plaintiff’s demand for a jury trial. (Dkt. 14, FAC at 1.) The Court

subsequently granted the parties’ request to vacate oral argument and submit the matter

based on the pleadings filed to date. (Dkt. 33.)

This Court has jurisdiction pursuant to section 502(e) of the Employee Retirement

Income Security Act of 1974 (“ERISA”), 29 U.S.C. § 1132(e), (f). Venue in the District

of Arizona is proper under 29 U.S.C. § 1132(e)(2) because the alleged breach occurred in

Arizona and because Aetna conducts business and may be found in Arizona.

//

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STANDARD OF REVIEW

The standard of review in ERISA claims depends on the role of the plan

administrator or fiduciary. When a plan does not confer discretion upon a plan

administrator or fiduciary to determine eligibility for benefits or to construe the terms of

the plan, district courts should review the denial of benefits de novo. Firestone Tire &

Rubber Co. v. Brush, 489 U.S. 101, 115 (1989). If the benefit plan gives the

administrator or fiduciary discretionary authority to determine eligibility for benefits or to

construe the terms of the plan, denial of benefits should be reviewed for abuse of

discretion. Id. 

ERISA defines a fiduciary as one who “(I) exercises any discretionary authority or

discretionary control respecting management of [a] plan or exercises any authority or

control respecting management or disposition of its assets, (ii) renders investment advice

for a fee or other compensation . . ., or (iii) has any discretionary authority or

discretionary responsibility in the administration of [the] plan.” 29 U.S.C. § 1102(21)(A). 

An entity or person is thus a fiduciary to the extent it exercises any discretionary authority

or control. Firestone, 489 U.S. at 113. A plan administrator or fiduciary has discretion

only where discretion is “unambiguously retained” by the administrator or fiduciary. 

Kearney v. Standard Ins. Co., 175 F.3d 1084, 1090 (9th Cir. 1999) (en banc); Abatie v.

Alta Health & Life Ins. Co., 458 F.3d 955, 963 (9th Cir. 2006) (en banc).

CONCLUSIONS OF LAW

A. The Appropriate Standard of Review

The parties dispute which standard of review should be applied in this case. 

Plaintiff asserts that the appropriate standard of review is de novo because Aetna’s role is

ambiguous. (Dkt. 26, Pl.’s Trial Br. 22-24.) Aetna stated that it was “not the Plan

Administer” (AET 00007), and thus it is uncertain who functioned in the capacity of Plan

Administrator. (Pl.’s Trial Br. at 23:16-24.) Aetna concedes that Kodak is the Plan

Administrator, but argues that abuse of discretion applies because Aetna is nonetheless a

“fiduciary” as defined by ERISA. (Dkt. 27, Def.’s Resp. Trial Br. 2-4.) Abuse of

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discretion therefore applies, Aetna asserts, because the Plan unambiguously delegates

authority to Aetna. (Dkt. 25, Def.’s Trial Br. 26; Def.’s Resp. Trial Br. at 3-4.) The

Court finds that although Aetna is a fiduciary under ERISA, the Plan does not

unambiguously grant Aetna discretionary authority. Therefore de novo review applies. 

Firestone, 489 U.S. at 115.

“When an insurance company administers claims for an employee welfare benefit

plan and has authority to grant or deny the claims, the company is an ERISA ‘fiduciary’

under 29 U.S.C. § 1002(21)(A)(iii).” Aetna Life Ins. Co. v. Bayona, 223 F.3d 1030, 1033

(9th Cir. 2000) (citations omitted). In Bayona, Aetna was found to be a fiduciary because

it made decisions regarding claims to life insurance money and because the claimant

directed her correspondence concerning the policy to Aetna, rather than any other plan

entity. Id. In the instant case, Aetna approved payments, arranged for the FCE,

determined whether Plaintiff was unable to perform the duties of his employment,

terminated LTD benefits, and reviewed Plaintiff’s records. (Pl.’s Trial Br. at 9-10, 15, 16,

19.) Additionally, Plaintiff’s correspondence regarding the Plan were directed to Aetna. 

(Id. at 9-10.) Furthermore, the Plan documents state that “[Kodak] hereby delegates to

Aetna U.S. Healthcare authority to make determinations on behalf of [Kodak] with

respect to disability certifications under the Plan. In connection with such determinations,

[Aetna] acknowledges that it is acting as a fiduciary solely for benefit determinations and

review of denied claims for benefits under ERISA.” (AET 00063.) Aetna is accordingly

an ERISA fiduciary.

Determining that Aetna is a fiduciary does not end the analysis regarding the

appropriate standard of review. De novo review is still the default setting and applies if a

plan does not confer “discretionary authority to determine eligibility for benefits or to

construe the terms of the plan.” Firestone, 489 U.S. at 115. A court reviews for abuse of

discretion only when discretionary authority is “unambiguously retained.” Kearney, 175

F.3d at 1090.

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Plan language is insufficient to confer discretionary authority when it does not

grant any power to construe the terms of the plan. Abatie, 458 F.3d at 964 (citing Ingram

v. Martin Marietta Long Term Disability Income Plan, 244 F.3d 1109 (9th Cir. 2001)). In

Ingram, the plan stating “the carrier will make all decisions on claims” only allocated

responsibility for administrative decisions. 244 F.3d at 1112. “An allocation of decisionmaking authority . . . is not, without more, a grant of discretionary authority in making

those decisions.” Id. at 1112-13. The further statement granting authority over “the

review and payment or denial of claims and the full and fair review of claim denial” was

found to “add[] nothing.” Id. at 1113. The court held that the text of the plan did not

unambiguously state that the plan administrator had discretionary authority to grant or

deny benefits. Id.

On the other hand, plans which grant the power to interpret plan terms and to make

final benefits determinations confer discretionary authority on the fiduciary. Abatie, 458

F.3d at 963. In Abatie, the plan bestowed the responsibility to interpret the terms of the

plan and to determine eligibility for benefits. Id. at 965 (emphasis original). The plan

gave the administrator “full and final” authority, and cautioned that the authority “rests

exclusively” with the plan administrator. Id. These provisions “clearly gave to the

administrator the power to decide according to its own judgment.” Id.

Under these precedents, the Plan does not unambiguously retain discretion on the

part of Aetna. The Plan states that “[Kodak] hereby delegates to Aetna U.S. Healthcare

authority to make determinations on behalf of [Kodak] with respect to disability

certifications under the Plan.” (AET 00063.) The import of Ninth Circuit precedent is

that a plan must either confer power to interpret the terms of the plan, or must confer

plenary authority over benefits determinations. See, e.g., Abatie, 458 F.3d at 965; see

also Firestone, 489 U.S. at 115. In either case, the discretionary authority must be

unambiguously retained. Kearney, 175 F.3d at 1090. 

Conferring discretionary authority does not require the invocation of certain

“magic” words. Abatie, 458 F.3d at 963. But the Plan language is insufficient to warrant

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a deferential abuse of discretion standard of review. The Plan does not confer to Aetna

the power to interpret any of its terms of the Plan. Cf. id. at 964 (“We have held that

ERISA plans are insufficient to confer discretionary authority on the administrator when

they do not grant any power to construe the terms of the plan.”). Therefore the Plan must

confer discretionary authority to determine eligibility to avoid de novo review. The

language delegating “authority to make determinations . . . with respect to disability

certifications” parallels the language which encompassed only “administrative decisions.” 

Ingram, 244 F.3d at 1112-13. Thus a delegation of decision-making authority to Aetna is

not, without more, a grant of discretionary authority in making those decisions. Id. 

At best, the Plan is ambiguous as to the whether Aetna’s authority is discretionary

or administrative. Accordingly, the Court will review denial of Plaintiff’s LTD benefits

de novo because the Plan does not unambiguously retain discretionary authority on the

part of Aetna. The standard of review does not affect the outcome in this case because

even under de novo review Plaintiff is not entitled to relief.

B. Termination of Benefits

A de novo review of the administrative record and the parties’ trial briefs confirms

that termination of Plaintiff’s LTD benefits was justified. Plaintiff was not “totally

disabled” as defined by the Plan. This finding is supported by the FCE and evaluations

by Plaintiff’s treating physicians. Plaintiff fails to provide any evidence that he is unable

to perform the duties of “any occupation.” 

After 24 months of receiving LTD benefits, the Plan defines “total disability” as

being unable, “solely because of injury or disease, to work at any reasonable occupation.” 

(AET 00057.) A “reasonable occupation” is defined as a position for which the

participant is qualified, or may become qualified by training, education, or experience. 

(Id.) Under ERISA, Aetna was required to apply the terms of the Plan in handling

Plaintiff’s claim. See 29 U.S.C. § 1104(a)(1)(D). Plaintiff’s argument that total disability

should be defined according to Hangarter v. Provident Life & Accident Ins. Co., 373 F.3d

998, 1006 (9th Cir. 2004) is misguided. Hangarter did not involve a claim for ERISA

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benefits. Rather, it required the application of California law in a diversity suit for breach

of contract and other state law claims. Hangarter, 373 F.3d at 1003. In contrast, “the

interpretation of ERISA insurance policies is governed by a uniform federal common

law.” Evans v. Safeco Life Ins. Co., 916 F.2d 1437, 1439 (9th Cir. 1990); see also

McClure v. Life Ins. Co. of N. Am., 84 F.3d 1129, 1133 (9th Cir. 1996)(“Under ERISA,

state law does not control the construction of the [benefits] policy.”). Therefore the

definition applied in Hangarter is not relevant to this decision. Aetna’s use of the Plan

definition was therefore proper. Cf. Madden v. ITT Long Term Disability Plan for

Salaried Employees, 914 F.2d 1279, 1286 n.6 (9th Cir. 1990). As Plaintiff had received

LTD benefits for 24 months, continued benefits payments require that he be “totally

disabled” as defined by the Plan.

The results of the FCE state that Plaintiff is capable of sedentary work, alternating

between sitting and standing. (AET 00130.) This is consistent with Dr. Metrick’s

follow-up evaluation of June 8, 2004. Dr. Metrick noted the same limitations, but did not

opine as to whether Plaintiff could work a four-, six-, or eight-hour day. (AET 00465.) 

Dr. Metrick further stated that Plaintiff was capable of working four hours per day, four

to five days a week, divided between two hours sitting, one hour standing, and one hour

walking. (Id.) Throughout Plaintiff’s treatment, Dr. Metrick’s evaluations consistently

classified Plaintiff’s condition as capable of sedentary work activity with moderate

limitation of functional capacity. (AET 00154 (evaluation dated June 13, 2002); AET

00205-00206 (evaluation dated Apr. 13, 2003); AET 00709 (evaluation dated Sept. 25,

2003).) Other doctors who reviewed Plaintiff’s records and MRIs, such as Dr. Lazarus,

also noted significant improvement in Plaintiff’s condition. (E.g., AET 00184.) 

Although Dr. Metrick stated in June 2004 that Plaintiff could not work a full day in a

“structured work environment” (AET 00465), Plaintiff has not provided evidence that the

potential jobs identified by Aetna entail such an environment.

Under the Plan, Plaintiff must be unable to perform the material duties of any

reasonable occupation for which he is qualified or could become qualified through

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education, training or experience. (AET 00057.) Aetna noted four jobs for which

Plaintiff is capable of performing: sales manager; computer systems analyst; network and

computer systems administrator; and production planning and expediting clerk. (AET

00423.) Plaintiff states that he was not able to secure any position as a sales manager

because he has virtually no sales experience. (Pl.’s Trial Br. 29:1-3.) However, Plaintiff

fails to show that he could not become qualified through education or training. Plaintiff

states that he could not secure work as a computer systems analyst or administrator

because “he has no computer systems experience and has no aptitude for computer

systems analysis.” (Id. at 29:3-5.) This contradicts the Work History and Education

Questionnaire signed by Plaintiff, in which he states that he received a degree in

computer science, that his responsibilities at Kodak included “computer hookup,

networking, calibration, training,” and that his previous job at Price Electronic provided

training in computer installations. (AET 00195.) Moreover, Plaintiff could become

qualified for those jobs by further education or training. Finally, Plaintiff states that work

as a production planning and expediting clerk is not feasible because “in any industry . . .

these positions always require extreme mobility.” Plaintiff does not provide any support

for this contention.3

 Regardless, Plaintiff is or could become qualified for the computer

and sales manager positions.

Plaintiff obliquely references Aetna’s failure to determine whether Plaintiff

suffered “partial disability.” (See Pl.’s Trial Br. 27:1-4, 27:28-28:3, 29:15-17.) Plaintiff

seems to be arguing that Aetna should have determined whether Plaintiff remained

partially disabled before terminating his LTD benefits. The Plan states that a participant

may become eligible for LTD benefits if the participant meets the Plan’s definition of

partially disabled. (AET 00025.) However, the Plan states that LTD benefits will end on

the date that the participant is no longer totally disabled (AET 00032); thus a participant’s

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partial disability will not qualify them for continued benefits. Plaintiff was notified upon

approval of his application for LTD benefits that he would need to meet the more strict

“any occupation” definition of disability in order to receive LTD benefits after July 29,

2004. (AET 00110.) Moreover, Plaintiff sought and received LTD benefits on the

grounds that he was totally disabled, not partially disabled.

ORDER

Based on the foregoing de novo review of the administrative record in this case,

the Court finds that Plaintiff was not entitled to continue receiving LTD benefits after

July 28, 2004. The FCE and other medical information indicates that Plaintiff was not

“totally disabled” as defined by the Plan, and Plaintiff failed to provide any evidence that

he is unable to perform the duties of “any occupation.” Therefore Aetna did not violate

ERISA or the terms of the Plan when it terminated Plaintiff’s LTD benefits. Judgment

shall be entered in favor of Aetna.

Accordingly,

IT IS HEREBY ORDERED entering judgment in this matter in favor of

Defendant Aetna Life Insurance Company. Plaintiff shall take nothing, and the Clerk of

the Court shall terminate this matter.

DATED this 4th day of March, 2008.

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