Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-cand-3_18-cv-04394/USCOURTS-cand-3_18-cv-04394-2/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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United States District Court

Northern District of California

IN THE UNITED STATES DISTRICT COURT

FOR THE NORTHERN DISTRICT OF CALIFORNIA

ANIS SHAIKH,

Plaintiff,

v.

AETNA LIFE INSURANCE COMPANY,

Defendant.

Case No. 18-cv-04394-MMC 

ORDER GRANTING PLAINTIFF'S 

MOTION FOR JUDGMENT; DENYING

DEFENDANT'S CROSS-MOTION FOR 

JUDGMENT; FINDINGS OF FACT AND 

CONCLUSIONS OF LAW

Re: Doc. Nos. 37, 38

Before the Court are (1) plaintiff Anis Shaikh’s (“Shaikh”) “Motion for Judgment,” 

filed August 16, 2019, and (2) defendant Aetna Life Insurance Company’s (“Aetna”) 

“Cross-Motion Under FRCP 52,” filed September 6, 2019. 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

BACKGROUND2

Shaikh was formerly employed as a Senior Manufacturing Test Development 

Engineer with Zonare Medical Systems, Inc. (“Zonare”), a company that develops and 

manufactures medical ultrasound imaging systems. (See Administrative Record (“AR”) 

413-14).3 Through his employer, Shaikh was a participant in a “Group Plan,” issued by 

Aetna, that provides for payments to participants who become disabled within the 

1 By order filed October 21, 2019, the Court took the matters under submission.

2 This section and the following sections constitute the Court's findings of fact and 

conclusions of law. See Fed. R. Civ. P. 52(a)(1).

3 The Administrative Record was filed September 16, 2019 as Exhibit A to the 

Supplemental Declaration of Rebecca A. Hull.

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meaning of the policy. (AR 1-37). On January 11, 2016, Shaikh’s car “inexplicably went 

off [an exit] ramp and rolled over downwards 20 feet,” resulting in a “left nondisplaced 

clavicle fracture.” (AR 164). On January 20, 2016, Shaikh had surgery, namely, a “[l]eft 

clavicle open reduction and internal fixation with demineralized bone matrix 

augmentation,” to repair the fracture. (AR 146). On February 3, 2016, Shaikh submitted 

to Aetna a claim for disability benefits, in which he listed January 8, 2016 as his last day 

of work (AR 534), and stated he was unable to return to work due to “[s]evere pain” 

(AR 540) in his “neck, shoulder and arm” (AR 323). 

Aetna initially paid Shaikh “Short Term Disability (STD)” benefits for approximately 

three months, from January 18, 2016 to April 10, 2016 (AR 437), and then paid “Long 

Term Disability (LTD)” benefits for approximately eleven months, from April 10, 2016 

(AR 485), to March 16, 2017, on which date his benefits were terminated (AR 517). 

Shaikh appealed the termination, and, on May 25, 2017, his appeal was denied. 

(AR 529).

Subsequently, on July 6, 2017, Shaikh filed with the Social Security Administration 

(“SSA”) an application for disability benefits. On October 31, 2017, the SSA granted 

Shaikh’s application, finding he “became disabled under [its] rules on January 8, 2016.” 

(AR 302).4

Thereafter, on July 19, 2018, Shaikh 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 along with

“such other relief as the Court deems equitable and just.” (See Compl. at 14:1-3,14:9). 

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 

4 The record contains the SSA’s award letter but not the administrative record on 

which its decision was based. 

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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, Shaikh states he seeks “an award of all disability 

benefits owed through the date of judgment, pre-judgment interest on his awarded 

disability benefits, and a declaration that he is entitled to benefits on an on-going basis.” 

(See Mot. at 4:21-23). 

The Group Plan, i.e., the plan that sets forth the circumstances under which a plan 

participant is entitled to LTD benefits, provides the following “Test of Disability”:

From the date that you first become disabled and until Monthly Benefits are 

payable for 24 months, you will be deemed to be totally disabled on any day 

if, as a result of a disease or injury, you are unable to perform with 

reasonable continuity the substantial and material acts necessary to pursue 

5 On October 22, 2018, the parties stipulated the appropriate standard of review is 

de novo. 

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your own occupation and you are not working in your own occupation.

After the first 24 months that any Monthly Benefit is payable during a period 

of disability, you will be deemed to be totally disabled on any day if, as a 

result of a disease or injury, you are not able to engage with reasonable 

continuity in any occupation in which you could reasonably be expected to 

perform satisfactorily in light of your age, education, training, experience, 

station in life, and physical and mental capacity that exists within any of the 

following locations:

• a reasonable distance or travel time from your residence in light of the 

commuting practices of your community; or

• a distance or travel time equivalent to the distance or travel time you 

traveled to work before becoming disabled; or

• the regional labor market, if you reside or resided prior to becoming 

disabled in a metropolitan area.

(AR 31).

Aetna argues that, “although [Shaikh] reported subjective symptoms,” the medical 

records “reflected steady improvement in his actual physical condition during the eleven 

months he received LTD benefits” and, by March 2017, “no longer supported functional 

limitations of such severity as to preclude him from sedentary work in his Own 

Occupation.” (See Cross-Mot. at 5:15-20). 

In support of its argument, Aetna relies primarily on the results of two diagnostic 

tests pertaining to Shaikh’s shoulder. In particular, on October 17, 2016, neurologist 

Prabhjot Singh Khalsa, M.D. (“Dr. Khalsa”), performed “electrodiagnostic studies” based 

on “clinical suspicion of a brachial plexopathy” (AR 362), and found such “studies . . .

failed to document any abnormalities to confirm the diagnosis of brachial plexopathy.” 

(AR 365).6 Thereafter, on March 7, 2017, radiologist Karim Taghaddos, M.D., performed 

an “MRI Left Shoulder” and found “[m]inimal degenerative changes at the 

[acromioclavicular] joint” along with a “5 mm bone spur” at the acromion,”

7 and a “[v]ery 

6 Brachial plexopathy “occurs when there is damage to the brachial plexus[,] . . . 

an area on each side of the neck where nerve roots from the spinal cord split into each 

arm's nerves,” which damage “results in pain, decreased movement, or decreased 

sensation in the arm and shoulder.” See Brachial plexopathy, MEDLINEPLUS, 

https://medlineplus.gov/ency/article/001418.htm (last visited Mar. 24, 2020). 

7 The acromioclavicular joint “is the point where the . . . clavicle meets the 

acromion, which is the tip of the shoulder blade.” See Shoulder Osteoarthritis 

(Degenerative Arthritis of the Shoulder), WEBMD, 

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small interstitial tear at the footprint of infraspinatus.”8 (AR 331-32). 

The Court finds Aetna has focused overly on the objective evidence. First, as Dr. 

Khalsa himself reported, “nerve conduction and electromyography studies may be normal 

in mild brachial plexopathy” (AR 365), and, as noted above, brachial plexopathy is a 

disorder occurring where there is nerve damage. 

Moreover, with respect to Shaikh’s cervical spine, X-rays and an MRI did show

structural changes, including “posterior spondylosis” (AR 394)9 and “[s]ignificant . . . 

neuroforaminal narrowing” (AR 329).10 Although Aetna argues Shaikh’s “treating doctors 

. . . did not attribute Shaikh’s reported symptoms to cervical spine issues” (see CrossMot. at 9:21-22), Shaikh’s primary care physician and specialist in internal medicine, 

Karim Hussain, M.D. (“Dr. Hussain”), appears to have done so. (See AR 335) 

(“Capabilities and Limitations Worksheet” dated March 7, 2017, grouping together 

shoulder and cervical conditions).

Lastly, and of particular importance, Aetna has essentially disregarded Shaikh’s 

complaints of severe pain, which, as set forth below, have persisted over an extended 

period of time. See, e.g., Saffon v. Wells Fargo & Co. Long Term Disability Plan, 522 

F.3d 863, 872 n.3 (9th Cir. 2008) (noting “the factual observation that disabling pain 

shoulder#1 (last visited Mar. 24, 2020). Degenerative joint disease is commonly found at 

the acromioclavicular joint and “occurs when the cartilage that covers the tops of bones

. . . degenerates or wears down[;] [t]his causes swelling, pain, and sometimes the 

development of . . . bone spurs.” See id. 

8 The infraspinatus covers the back of the shoulder blade and “is the main muscle 

responsible for lateral rotation of [the] arm away from the centerline of [the] body.” See

Rotator Cuff Anatomy Explained, HEALTHLINE, https://www.healthline.com/health/bonehealth/rotator-cuff-anatomy (last visited Mar. 24, 2020). 

9

“Cervical spondylosis is the degeneration of the bones and disks in the neck, 

which can lead to a variety of problems[.]” See Cervical spondylosis, MAYO CLINIC, 

https://www.mayoclinic.org/diseases-conditions/cervical-spondylosis (last visited Mar. 24, 

2020). 

10 Neural foraminal stenosis, or narrowing, is a condition wherein “[t]he nerve roots 

that exit the spinal column . . . become compressed,” which may cause “neck pain” and

“shooting pain going down the arm.” See Neural Foraminal Stenosis, HEALTHLINE,

https://www.healthline.com/health/neural-foraminal-stenosis (last visited Mar. 24, 2020). 

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cannot always be measured objectively . . . is as true for ERISA beneficiaries as it is for 

Social Security claimants”). 

On March 3, 2016, orthopedic surgeon Soheil Motamed, M.D. (“Dr. Motamed”), 

while noting “the fracture appear[ed] to be healing well,” further noted Shaikh “continue[d] 

complaining of left shoulder and left arm pain,” for which Dr. Motamed prescribed

Percocet, an opioid pain medication. (AR 143). Thereafter, as set forth below, four

additional treating physicians, specifically, another orthopedic surgeon, a family 

physician, a neurologist, and an internist, recorded Shaikh’s use of various types of

prescription pain medications, the most successful of which only partly alleviated 

Shaikh’s pain. 

First, on April 4, 2016, orthopedic surgeon Co Banh, M.D. (“Dr. Banh”) noted 

Shaikh had been using Percocet and Norco, another opioid pain medication, yet 

“continued to have severe pain in the left upper shoulder with radiation down the left 

arm,” which Shaikh rated 9/10 on a numeric scale. (AR 393). Dr. Banh prescribed

Naprosyn, an anti-inflammatory drug. (AR 395). Thereafter, on May 26, 2016, family 

physician Dr. Khalid Baig, M.D. (“Dr. Baig”), while noting Shaikh had switched from opioid 

pain medication to Naprosyn and that his pain was “now down to scale 5” (AR 387),

advised against the use of such medication “due to renal function compromise” (AR 389). 

Although, as Aetna points out, Dr. Baig, on July 12, 2016, under “Subjective Complaints,” 

noted “[a] little pain on [left] shoulder” (AR 383), Dr. Khalsa, on September 8, 2016, noted 

Shaikh’s complaint of “[m]oderate to severe” pain that was “[s]harp and prickling” and of 

“[i]ntermittent to constant” duration (AR 359), for which Dr. Khalsa prescribed 

Gabapentin, a non-opioid pain medication (AR 360). On November 3, 2016, Dr. Baig, in 

the most recent treating physician’s note contained in the administrative record, reported

Shaikh’s pain had been reduced with his use of Gabapentin, but was still “at 5-6,” i.e., still 

ranging from moderate to severe. (AR 352).

11

 Lastly, Dr. Hussain, in the “Capabilities 

11 In December 2016 and January 2017, Shaikh received physical therapy (AR 

346-48); the record, however, does not suggest his pain was reduced further during such 

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and Limitations Worksheet” referenced earlier herein, noted Shaikh was still using

Gabapentin in March 2017. (AR 335).

Additionally, Shaikh has repeatedly complained that, as a result of pain, he has

difficulty lifting items. On July 25, 2016, in a “LTD Claimant Interview” with Aetna, Shaikh 

reported he experienced “a lot of pain” when “lifting objects in certain positions,” which

pain he described as “shooting and sometimes pinching.” (AR 657). On September 30, 

2016, in another “LTD Claimant Interview,” Shaikh reported he was still “having pain in 

his shoulder” and was “unable to reach behind him or to lift anything over a couple of 

pounds.” (AR 667-68). On May 2, 2017, in an “Appeal Request Form” provided by 

Aetna, Shaikh reported he was unable to “move[ ] heavy equipment due to pain & 

weakness in neck, shoulder & arm.” (AR 324). 

Moreover, in other forms provided by Aetna, Shaikh’s treating physicians opined

that he could only lift items weighing no more than five pounds. On March 3, 2016, for 

example, Dr. Motamed, Shaikh’s orthopedic surgeon, opined that Shaikh could “no[t] 

lift . . . greater than 2 lbs.” (AR 138). Thereafter, on May 26, 2016, Dr. Baig, Shaikh’s 

family physician, noting Shaikh’s “severe left shoulder pain” (AR 398), opined Shaikh

could “[o]ccasional[ly]” lift a “[m]aximum weight” of “1-5 lbs.” (AR 399). Lastly, on March 

7, 2017, Dr. Hussain, Shaikh’s primary care physician, similarly opined Shaikh could 

“[o]ccasional[ly]” lift a “[m]aximum weight” of “1-5 lbs.,” and further specified the duration 

of such restriction was “one year” (AR 335).

Aetna, relying on a “Physician Review,” dated May 8, 2017, and prepared by 

occupational medicine specialist Timothy Craven, M.D., M.P.H. (“Dr. Craven”) (AR 315),

contends Shaikh is not limited to the above-described extent. Dr. Craven, at the request 

of Aetna, reviewed Shaikh’s medical records and consulted with Dr. Hussain. (AR 318). 

Based on the medical records, Dr. Craven opined that from November 3, 2016, through 

March 7, 2017, Shaikh could “lift[ ]” items weighing “up to 20 lbs[.],” and, that, after March 

period.

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7, 2017, “[t]here was no support in [Shaikh’s] medical records for a functional 

impairment.” (AR 318-19). As to the period ending March 7, 2017, Dr. Craven offered no 

explanation as to why he disagreed with Dr. Hussain, in whose opinion, as noted, Shaikh 

could only lift items weighing far less than 20 pounds, nor did he elaborate as to his 

conclusion that no restriction for the period after March 7, 2017, was necessary. 

For purposes of ERISA, although the opinion of a treating physician “gets no 

special weight,” see Jordan v. Northrop Grumman Corp. Welfare Benefit Plan, 370 F.3d 

869, 879 (9th Cir. 2004), the district court may “take cognizance of the fact (if it is a fact in 

a particular case) that a given treating physician has a greater opportunity to know and 

observe the patient than a physician retained by the plan administrator,” see Jebian v. 

Hewlett-Packard Co. Employee Benefits Org. Income Prot. Plan, 349 F.3d 1098, 1109 

n.8 (9th Cir. 2003) (internal quotation and citation omitted).

As Shaikh’s treating physicians had a greater opportunity to know and observe 

him than Aetna’s retained physician, Dr. Craven, they had a greater opportunity to assess 

his credibility, and one would expect any doubts as to whether Shaikh in fact suffered the 

pain he alleged, or the effect thereof, would be reflected in the medical records. Nothing

in those records suggests any treating physician ever questioned the effect of Shaikh’s 

pain. To the contrary, over an extended period of time, each physician who examined 

Shaikh, and who opined as to his lifting capabilities, agreed he could only lift items 

weighing no more than five pounds. (AR 138, 335, 398). Dr. Craven did not examine 

Shaikh, although, under the terms of the Group Plan, he could have done so (see AR 22)

(providing Aetna “ha[s] the right and opportunity to examine and evaluate any person 

who is the basis of any claim at all reasonable times while that claim is pending or 

payable”), and, indeed, Dr. Craven does not opine, nor does Aetna argue, Shaikh is

malingering. 

Accordingly, the Court finds Shaikh could lift items weighing no more than five 

pounds.

The Court next considers whether, as a result of such functional limitation, Shaikh,

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for the remainder of the twenty-four month “Own Occupation” period following Aetna’s 

termination of benefits, i.e., from March 16, 2017, through April 10, 2018, was unable to 

perform “the substantial and material acts” of his “own occupation.” (AR 31).

Shaikh’s position as a Senior Manufacturing Test Development Engineer at 

Zonare entailed his “designing, building, and programming automated test fixtures . . . to 

validate medical ultrasound imaging systems.” (AR 413). On April 10, 2017, Shaikh 

submitted to Aetna a letter from Zonare’s “Manager of Human Resources,” stating “he 

was required to frequently lift pans weighing up to 51 lbs.” (AR 327).12 Thereafter, on 

April 19, 2017, at Aetna’s request, a vocational rehabilitation counselor performed an 

“Occupation Analysis,” and found Shaikh’s position, as performed in the national 

economy, correlated with the “Light” strength occupation of “Electronics Test Engineer” 

and also with the “Sedentary” strength occupation of “Software Engineer.” (AR 724-25). 

Although Aetna initially determined the former more accurately represented Shaikh’s 

position (AR 721), Aetna, as noted, now argues Shaikh’s position correlates with a 

“Sedentary” strength occupation (see Cross-Mot. at 5:20). 

According to the Department of Labor, “Electronics Test Engineer” requires

“[e]xerting up to 20 pounds of force occasionally,” see Dict. of Occ. Titles 

(4th ed. 1991) § 003.061-034, and “Software Engineer” requires “[e]xerting up to 10 

pounds of force occasionally,” see id. § 030.062-010. As Shaikh could only lift items 

weighing no more than five pounds, the Court finds Shaikh has shown he was unable to 

perform “the substantial and material acts” of his “own occupation.”

The Court now turns to whether Shaikh is entitled to an award of benefits. “[A] 

plan administrator will not get a second bite at the apple when its first decision was 

simply contrary to the facts.” Grosz–Salomon v. Paul Revere Life Ins. Co., 237 F.3d 

12 Although Aetna now contends “there is serious doubt that Shaikh’s former job 

ever actually included a requirement that he must be able to lift more than 50 pounds” 

(see Cross-Mot at 14:2-3), Aetna, in various notes in its claim file, conceded Shaikh’s 

position “involve[d] . . . lifting up to 50 pounds” (AR 107, 108, 124). 

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1154, 1164 (9th Cir.2001) (affirming district court's award of benefits and denial of 

request to remand for determination thereof where plan administrator “applied the right 

standard, but came to the wrong conclusion”); cf. Saffle v. Sierra Pacific Power Co. 

Bargaining Unit Long Term Disability Income Plan, 85 F.3d 455, 460 (9th Cir.1996) 

(remanding for determination on merits where plan administrator “ha[d] not yet had the 

opportunity of applying the [p]lan, properly construed”).

Accordingly, the Court finds it appropriate to award benefits corresponding to the 

remainder of the twenty-four month “Own Occupation” period.

The Court next addresses Shaikh’s claim for LTD benefits under the “Any 

Occupation” provision of the Group Plan. (AR 31). 

Where, as here, a court has found a plan administrator erred in determining a 

claimant is unable to perform his “own occupation,” district courts commonly have found it 

appropriate to remand the matter to the plan administrator to determine whether the 

claimant is entitled to benefits under an “any occupation” provision. See Lavino v. 

Metropolitan Life Ins. Co., 2010 WL 234817, at *13 (C.D. Cal. January 13, 2010) (holding, 

where plan administrator erroneously terminates LTD benefits under an “own occupation”

provision, “[r]emand is proper” for determination of whether claimant satisfies an “anyoccupation standard” in plan); Minton v. Deloitte & Touche USA LLP Plan, 631 F. Supp. 

2d 1213, 1221 (N.D. Cal. 2009) (holding, where plan administrator erroneously finds 

claimant ineligible for LTD benefits under an “own occupation” provision, claimant's claim 

for benefits under an “any occupation” provision is properly remanded to plan 

administrator for consideration).

Similarly, in this instance, the Court finds it appropriate to remand the matter to 

Aetna for a determination of whether Shaikh can demonstrate he is entitled to LTD 

benefits under the “Any Occupation” provision, particularly given the absence, both in the 

record presented to Aetna and the record before the Court, of any medical evaluation

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later than March 7, 2017.

13

Lastly, the Court addresses Shaikh’s claim, made in his complaint and reiterated in 

his motion for judgment, that he is entitled to an award of prejudgment interest. In his 

motion, Shaikh does not set forth any argument as to why he is entitled to such award.

Under the circumstances, the Court makes no determination at this time as to Shaikh’s

entitlement, if any, to an award of prejudgment interest.

CONCLUSION

For the reasons stated above:

1. Shaikh’s motion for judgment is hereby GRANTED, and the matter is 

REMANDED to Aetna to (a) determine the amount of LTD benefits to which Shaikh is 

entitled under the “Own Occupation” provision of the Group Plan, from March 16, 2017,

through April 10, 2018, and (b) consider whether Shaikh is entitled to benefits under the 

“Any Occupation” provision of the Group Plan.

2. Aetna’s cross-motion for judgment is hereby DENIED.

IT IS SO ORDERED.

Dated: March 24, 2020

MAXINE M. CHESNEY

United States District Judge

13 Shaikh argues the SSA’s award letter “is evidence of his disability from any 

occupation under the [Group] Plan’s definition.” (See Pl.’s Reply at 21:23-25). Although 

“not bind[ing] on plan administrators,” SSA awards “are evidence of disability.” See

Salomaa v. Honda Long Term Disability Plan, 642 F.3d 666, 679 (9th Cir. 2011). Here, 

however, the letter was not available at the time Aetna made its decision.

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