Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-azd-2_04-cv-01797/USCOURTS-azd-2_04-cv-01797-0/pdf.json

Nature of Suit Code: 110
Nature of Suit: Insurance
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

Bryan Ritchie, 

Plaintiff, 

vs.

Cox Enterprises Long Term Disability

Plan; Aetna Life Insurance Company, 

Defendants. 

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No. CV-04-1797-PHX-JAT

FINDINGS OF FACT AND

CONCLUSIONS OF LAW

Pending before this Court is a trial on the administrative record pursuant to Kearney v.

Standard Ins. Co., 175 F.3d 1084 (9th Cir. 1999). Both parties have stipulated that a trial of

this action may be conducted on the trial briefs submitted by the parties and the

administrative record. (Stipulation to Waive Pre-Trial Proceedings at 2). The Court has

considered Plaintiff’s Opening Trial Brief (Doc. # 20), Defendant’s Responsive Trial Brief

(Doc. # 22), Plaintiff’s Reply to Defendant’s Responsive Trial Brief (Doc. # 23), and the

administrative record for the case (Doc. # 12). The Court now enters the following Findings

of Fact and Conclusions of Law.

Findings of Fact

1. Pursuant to the terms of the applicable Cox Plan, to be eligible for disability

benefits, a claimant must be totally disabled. Under the terms of the Cox Plan, a claimant

is totally disabled if either of the following apply:

Case 2:04-cv-01797-JAT Document 31 Filed 03/28/06 Page 1 of 9
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In the first 24 months of a period of total disability[, y]ou are not able, solely

because of injury or disease, to work at your own occupation [OR a]fter the

first 24 months of a period of total disability[, y]ou are not able, solely because

of an injury or disease, to work at any reasonable occupation.

(BR 0002).

2. Plaintiff states that he is unable to work at his own occupation as a Field Service

Representative with Cox Communications, due to physical disabilities, including abdominal

pain and back pain, (BR 0071, 0190), and due to mental disabilities, including depression,

agoraphobia, and panic attacks. (BR 0071, 0073, 0170). Plaintiff indicates that he stopped

working with Cox on February 13, 2002 (BR 0188). The administrative record contains a

summary of Plaintiff’s occupation. (BR 0195-200). Plaintiff states that his work entails the

installation and service of cable. (BR 0072). 

3. Dr. Williams’ medical report, dated February 20, 2002, indicates subjective left

groin pain. On exam, there was tenderness over the left pubic tubercle, but no evidence of

an inguinal hernia. Dr. Williams opined that Plaintiff had adductor tendinitis. (BR 0132).

4. Dr. Bollimpalli evaluated Plaintiff on March 22, 2002 and assessed Plaintiff as

having left lower quadrant pain, most likely myofascial in nature, with possible rectus muscle

trigger points. (BR 0126).

5. A radiology report dated June 11, 2002, regarding an abdominal ultrasound,

indicates no definite colon abnormalities, although there was early developing diverticular

disease in the sigmoid area. (BR 0116).

6. A July 12, 2002, report by Beverly A. Collins, N.P.-C., indicates an impression of

left lower quadrant abdominal pain. Ms. Collins questioned whether the pain is of a

gastrointestinal (GI) or intraabdominal source, or is a pulled ligament in the groin area. (BR

0121-23).

7. On August 16, 2002, Dr. Kumar evaluated Plaintiff and indicated that his

symptoms may be GI, renal, or psychosomatic in nature, but no neurological workup was

indicated. (BR 0130-31).

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8. A radiology report dated August 30, 2002, regarding an abdominal CT scan,

indicates no evidence of an abnormal soft tissue mass or intra-abdominal fluid collection.

The scan showed diffuse fatty infiltration of the liver with focal sparing along the interlobar

fissure just superior to the gallbladder fossa. (BR 0120).

9. A September 12, 2002, report by Dr. Kanner, regarding a flexible sigmoidoscopy,

indicates an unremarkable examination with an impression of possible abdominal pain

secondary to Irritable Bowel Syndrome. (BR 0129).

10. Plaintiff filed for long term disability benefits on October 1, 2002, claiming strong

persistent pain in the lower left abdomen as the disabling condition. (BR 0190).

11. An October 14, 2002, report by Dr. Kanner notes left lower quadrant pain of

uncertain etiology. The report states that the pain was not clearly GI in origin. (BR 0128).

12. A radiology report dated October 25, 2002, regarding an intravenous pyelogram,

indicats a normal excretory urogram. (BR 0119).

13. By letter dated January 31, 2003, Aetna requested that Plaintiff complete a

Medical Authorization to Release Information and a Mental Health Provider’s Statement.

(BR 0189). By letter dated March 3, 2003, Aetna requested that Plaintiff return the

Authorization form within thirty days or the claim would be closed. (BR 0173). Plaintiff

completed the Authorization form on May 6, 2003. (BR 0152). 

14. A Mental Health Provider’s Statement was completed by Dr. Pawar on February

28, 2003. In that statement, Dr. Pawar writes that Plaintiff suffers from panic attacks and

agoraphobia, and is markedly limited in each category on the statement. Dr. Pawar notes that

Plaintiff is compliant with his medications and shows some improvement, and describes a

treatment plan of monthly therapy sessions and medication management. (BR 0170-71).

There are no other statements, reports, or notes in the record from Dr. Pawar or any other

mental health provider.

15. By letter dated March 7, 2003, Aetna requested that Plaintiff complete a

supplemental statement. (BR 0172). Plaintiff completed the supplemental statement on May

6, 2003. (BR 0150-51).

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16. Aetna sent letters to Dr. Allen on January 31 and March 2, 2003 requesting

additional information and a physical capacities evaluation. (BR 0161). It appears that these

letters were misaddressed by Aetna, and Dr. Allen did not receive them until May 6, 2003.

Dr. Allen responded to the letters on May 7, 2003, stating that Plaintiff had been off work

on disability because of lower abdominal pain, lower back pain, and depression. In that

response, he states that the physical capacities evaluation requested by Aetna is in excess of

what would normally be conducted in a family physician’s office. (BR 0136).

17. The administrative record contains Dr. Allen’s reports and letters, dated March

31, May 6, May 7, and May 19, 2003. (BR 0165, 0141, 0091, 0095). Dr. Allen’s progress

notes, ranging from August 14, 2002 through June 25, 2003, indicate Plaintiff’s symptoms

of lower abdominal and lower back pain, but do not indicate actual impairment. There is no

indication from Dr. Allen’s reports of a conclusive diagnosis.

18. By letter dated May 15, 2003, Aetna denied Plaintiff’s claim of long term

disability benefits. (BR 0144-47). Aetna based its denial on the following information: (1)

Plaintiff’s Long Term Disability Application (BR 0190); (2) Dr. Pawar’s Mental Health

Provider Statement (BR 0170-71); (3) Dr. Allen’s Physician’s Statements (BR 0165, 0141);

(4) A job description from the employer, Cox Communications (BR 0195-200); and (5) a

review of the file by medical staff. The letter stated that the claim was being denied because

there was not sufficient medical documentation, nor restrictions and limitations, which would

support Plaintiff’s inability to work. (BR 0145-46). The letter stated that Plaintiff was

entitled to a review of Aetna’s decision. (BR 0146).

19. The administrative record shows that a nurse consultant reviewed Plaintiff’s claim

on or about May 23, 2003. Upon a review of the file, the nurse consultant opined that there

is not enough objective medical evidence to support disability. (BR 0279-80).

20. By letter dated June 25, 2003, Aetna upheld its previous denial of benefits to

Plaintiff. (BR 0133-35). Aetna based its denial on all of the information reviewed for the

May 15 denial, plus the letter from Dr. Allen dated May 7, 2003. (BR 0133-34). The letter

stated that the reason for the denial was that the medical documentation does not support

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Plaintiff’s inability to work. (BR 0134). The letter stated that Plaintiff was entitled to a

review of Aetna’s decision. Id.

21. In its denial letters, Aetna identified the additional information, if available, that

would be necessary to support Plaintiff’s claim for disability benefits. (BR 0146, 0134).

Specifically, Aetna requested: (1) a detailed narrative report outlining in objective terms the

specific physical and/or mental limitations and restrictions inherent to Plaintiff’s condition;

(2) any documents or information specific to the condition(s) for which Plaintiff is claiming

total disability, and which would assist in the evaluation of Plaintiff’s disability status; or (3)

any other information or documentation that Plaintiff believed may assist Aetna in reviewing

the claim. (BR 0146, 0134).

22. On or about July 23, 2003, Plaintiff contacted Aetna by phone and was again told

by Aetna’s claim analyst that there was not enough information in his file to support

Plaintiff’s inability to return to work. (BR 0261). The claim analyst asked Plaintiff about

any psychiatric treatment he was receiving, and Plaintiff told the analyst to speak with his

attorney. Id. Plaintiff then ended the call. Id. Aetna’s claim analyst indicated in his notes

that Plaintiff would not cooperate in regards to possible psychiatric treatment, and that

Plaintiff’s claim would again be denied. Id.

23. By letter dated July 23, 2003, Aetna made a “final determination,” upholding the

previous denial of Plaintiff’s claim. (BR 0092). The letter states that Plaintiff was entitled

to another review this decision by submitting a written appeal. Id. 

24. On August 5, 2003, Dr. Barranco, a neurosurgeon, examined Plaintiff for left

lower quadrant pain. (BR 0082-85). Dr. Barranco indicates in his report that he did not have

a neurologic explanation for Plaintiff’s symptoms. (BR 0084). Dr. Barranco states that there

is nothing from the T11 to S1 area of Plaintiff’s spine that would account for Plaintiff’s

symptoms. (BR 0085).

25. By letter dated December 22, 2003, Plaintiff’s counsel submitted an official

request for appeal. (BR 0314). Plaintiff’s counsel requested that he be allowed to

supplement any and all medical records of the Plaintiff. Id.

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26. By letter dated February 6, 2004, Aetna informed Plaintiff’s counsel that they had

not received any additional information. (BR 0324). The letter further states that, because

Aetna was giving Plaintiff’s counsel additional time to submit clinical information, the

decision date would be extended by forty-five days. Id. 

27. By letter dated February 17, 2004, Plaintiff’s counsel informed Aetna that no

additional medical records would be forthcoming. (BR 0315-17). Plaintiff’s counsel stated

that a second decision could take place without updated medical information. (BR 0315).

28. Aetna’s Medical Director, Dr. Hopkins, reviewed Plaintiff’s administrative file

and prepared a report dated February 26, 2004. (BR 0321-22). Dr. Hopkins reviewed

Plaintiff’s medical records from Drs. Williams, Bollimpalli, Allen, Kumar, Kanner, and

Barranco. Id. Dr. Hopkins summarized Plaintiff’s symptoms and treatment in her report, and

concluded that no actual functional impairment was objectively documented. Id. Dr.

Hopkins stated that Plaintiff’s symptoms “appear to be markedly out of proportion to the

exam findings and diagnostic testing.” Id. Dr. Hopkins further concluded that nothing

objectively documented in Plaintiff’s medical records would preclude Plaintiff from

returning to work full-time with no restrictions as of February 13, 2002. Id. 

29. By letter dated March 22, 2004, Aetna upheld its original denial and closed

Plaintiff’s file. (BR 0319-20). In that letter, Aetna summarized the review process and

stated that the clinical evidence failed to support Plaintiff’s claim of total disability. Id.

30. On August 27, 2004, Plaintiff filed a Complaint with this Court, contending that

Aetna has wrongfully denied benefits to the Plaintiff, and breached its duty of good faith and

fair dealing. (Doc. # 1).

Conclusions of Law

Preemption of Plaintiff’s State Law Claims

31. A state law claim for breach of the implied covenant of good faith and fair dealing

in an insurance contract is preempted by ERISA. See, e.g., Pilot Life Ins. Co. v. Dedeaux,

481 U.S. 41, 50-51 (1987); Bast v. Prudential Ins. Co. of Am., 150 F.3d 1003, 1007-08 (9th

Cir. 1998). ERISA’s civil enforcement provisions are the exclusive vehicle for actions by

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plan beneficiaries claiming improper handling of their claims. Crull v. GEM Ins. Co., 58

F.3d 1386, 1390-91 (9th Cir. 1995) (citing Dedeaux, 481 U.S. at 52).

32. Plaintiff’s claims for breach of the implied covenant of good faith and fair dealing

are preempted by ERISA, and are therefore dismissed.

Standard of Review

33. A denial of benefits is reviewed under a de novo standard unless the plan

administrator has discretionary authority to determine eligibility or interpret the terms of the

plan. Kearney v. Standard Ins. Co., 175 F.3d 1084, 1089 (9th Cir. 1999) (citing Firestone

Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989)). Where discretion is conferred upon

the plan administrator, the appropriate standard of review is abuse of discretion. Firestone,

489 U.S. at 111.

34. Under the plan administration agreement between Aetna and Cox

Communications, Aetna is unambiguously given discretion to determine eligibility and

interpret the terms of the plan. (BR 0043). Therefore, the appropriate standard of review in

this case is abuse of discretion.

35. Under an abuse of discretion standard, a reviewing court may only set aside an

administrator’s discretionary decision when it is arbitrary and capricious. Jordan v. Northrop

Grumman Corp. Welfare Benefit Plan, 370 F.3d 869, 875 (9th Cir. 2003). An abuse of

discretion by an ERISA administrator occurs only if it “(1) renders a decision without

explanation, (2) construes provisions of the plan in a way that conflicts with the plain

language of the plan, or (3) relies on clearly erroneous findings of fact.” Boyd v. Bert

Bell/Pete Rozelle NFL Players Ret. Plan, 410 F.3d 1173, 1178 (9th Cir. 2005). “In the

ERISA context, even decisions directly contrary to evidence in the record do not necessarily

amount to an abuse of discretion.” Id.

Review of Aetna’s Denial of Benefits Under the Abuse of Discretion Standard

36. In the denial letters sent to the Plaintiff, Aetna provided an explanation of the

reasons for the denial, and invited the Plaintiff to provide additional documentation for Aetna

to consider. (BR 0144-47, 0133-35). 

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37. There is no evidence in the record to indicate that Aetna interpreted any provision

of the plan in a way that conflicted with the plan’s plain language.

38. Aetna determined that there was insufficient evidence in the administrative record

to support disabling psychiatric illness. Dr. Pawar provided a mental health provider’s

statement asserting that Plaintiff was markedly limited in his abilities (BR 0170-71), but no

progress notes or any other psychiatric medical records are in the administrative record. Dr.

Pawar’s ipse dixit lacks any supporting evidence, and Aetna was within its discretion to

reject Dr. Pawar’s conclusions. See Jordan, 370 F.3d at 878-79.

39. Plaintiff’s claim is based primarily on symptoms, and not on evidence of actual

impairment. At no point did Aetna deny that Plaintiff was having these symptoms, rather

Aetna determined that Plaintiff’s medical records failed to establish that he was unable to

work. The existence of pain is not sufficient to establish disability; the pain must be such

that it disables Plaintiff from working at his job. See id. at 877.

40. Plaintiff’s physician Dr. Allen concluded that Plaintiff was disabled, and Aetna’s

medical director Dr. Hopkins reached the opposite conclusion. Where a plan administrator

is presented with conflicting medical evidence, it is not an abuse of discretion to adopt the

reasonable opinions of one doctor over another. See Boyd, 410 F.3d at 1179-80; Jordan, 370

F.3d at 877-78.

41. Aetna provided Plaintiff with a reasonable basis for its denial, and informed

Plaintiff of what additional evidence would be required to establish disability. Aetna

reasonably concluded that Plaintiff failed to provide adequate evidence of disability.

42. A denial of benefits is not arbitrary or capricious where it is “grounded on any

reasonable basis.” Jordan, 370 F.3d at 875 (emphasis in original) (internal citation omitted).

Therefore, the Court finds that Aetna’s denial was not arbitrary or capricious, and was not

an abuse of discretion. The Court finds that Defendants are entitiled to judgment in this

matter.

Accordingly,

The decision of the plan administrator is AFFIRMED.

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IT IS ORDERED that the Clerk of the Court shall enter judgement in favor of

Defendants.

DATED this 27th day of March, 2006.

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