Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-azd-2_14-cv-01808/USCOURTS-azd-2_14-cv-01808-0/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 

Smail Yaakoubi, 

Plaintiff, 

v. 

Aetna Life Insurance Company; Marriott 

International Inc. Long-Term Disability 

Plan, 

Defendants. 

No. CV-14-01808-PHX-NVW 

ORDER 

Before the Court is Plaintiff’s Motion for Judgment on the Administrative Record 

(Doc. 34), Defendants’ Opposing Trial Brief (Doc. 35), and Plaintiff’s Reply to 

Defendants’ Opposing Trial Brief (Doc. 42). Plaintiff seeks judicial review of 

Defendant’s denial of long-term disability benefits effective August 24, 2012. 

I. LEGAL STANDARD 

This action is brought under the Employee Retirement Income Security Act of 

1974 (“ERISA”), which permits a participant or beneficiary to bring a civil action to 

recover benefits due to him under the terms of his plan, to enforce his rights under the 

terms of the plan, or to clarify his rights to future benefits under the terms of the plan. 29 

U.S.C. § 1132(a)(1)(B). The term “plan” includes any plan, fund, or program established 

or maintained by an employer for the purpose of providing its participants medical care 

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or benefits in the event of sickness, accident, disability, death, or unemployment. Id.

§ 1002(1), (3). 

“Every employee benefit plan shall be established and maintained pursuant to a 

written instrument” that “provides for one or more named fiduciaries who jointly or 

severally shall have authority to control and manage the operation and administration of 

the plan.” Id. § 1102(a)(1). Every plan must “describe any procedure under the plan for 

allocation of responsibilities for the operation and administration of the plan” and 

“provide a procedure for amending such plan, and for identifying the persons who have 

authority to amend the plan.” Id. § 1102(b). Further, every plan must “specify the basis 

on which payments are made to and from the plan.” Id. In addition, a plan may provide 

“that any person or group of persons may serve in more than one fiduciary capacity with 

respect to the plan (including service both as trustee and administrator).” Id.

§ 1102(c)(1). 

The plan administrator must provide each participant a summary plan description, 

which is “sufficiently accurate and comprehensive to reasonably apprise such participants 

and beneficiaries of their rights and obligations under the plan.” Id. § 1022(a). The 

summary plan description also must “be written in a manner calculated to be understood 

by the average plan participant.” Id. 

“A district court must review a plan administrator’s denial of benefits de novo 

‘unless the benefit plan gives the administrator or fiduciary discretionary authority to 

determine eligibility for benefits.’” Prichard v. Metro. Life Ins. Co., 783 F.3d 1166, 

1168-69 (9th Cir. 2015) (quoting Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 

115 (1989)). The administrator bears the burden of proving the plan’s grant of 

discretionary authority. Id. at 1169. An administrator has discretion only where a plan 

document unambiguously grants the administrator discretionary authority to grant or 

deny benefits under the plan. Ingram v. Martin Marietta Long Term Disability Income 

Plan, 244 F.3d 1109, 1113-14 (9th Cir. 2001). “An allocation of decision-making 

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authority to [the administrator] is not, without more, a grant of discretionary authority in 

making those decisions.” Id. at 1112-13. If the language only arguably confers 

discretion, it does not unambiguously confer discretion, and the court must review the 

administrator’s decision de novo. Feibush v. Integrated Device Tech., Inc., Employee 

Benefit Plan, 463 F.3d 880, 884 (9th Cir. 2006). When a court reviews a plan 

administrator’s decision de novo, the claimant bears the burden of proving he is entitled 

to benefits. Muniz v. AMEC Constr. Mgmt., 623 F.3d 1290, 1294 (9th Cir. 2010). The 

burden of proof remains with the claimant when disability benefits are terminated after an 

initial grant. Id. 

Where a plan document unambiguously grants the administrator discretionary 

authority to grant or deny benefits under the plan, the court reviews the administrator’s 

decision for abuse of discretion. “A plan administrator abuses its discretion if it renders a 

decision without any explanation, construes provisions of the plan in a way that conflicts 

with the plain language of the plan, or fails to develop facts necessary to its 

determination.” Pacific Shores Hosp. v. United Behavioral Health, 764 F.3d 1030, 1042 

(9th Cir. 2014). A plan administrator abuses its discretion if it relies on clearly erroneous 

findings of fact in its determination. Id. 

Where the plan administrator both evaluates claims and pays benefits claims, a 

reviewing court should consider that structural conflict of interest as a factor, among 

many, in determining whether the plan administrator abused its discretion in denying 

benefits. Metro. Life Ins. Co. v. Glenn, 554 U.S. 105, 108, 116 (2008). A conflict may 

be given more weight where circumstances suggest a greater likelihood that it affected 

the benefits decision and less weight where the administrator has taken active steps to 

reduce potential bias and to promote accuracy. Id. at 117. In the absence of a conflict, 

the administrator’s decision can be upheld if it is grounded on any reasonable basis, but 

where the administrator is also the insurer, the abuse of discretion standard requires a 

more complex analysis. Montour v. Hartford Life & Acc. Ins. Co., 588 F.3d 623, 630 

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(9th Cir. 2009). The analysis requires the court to consider numerous case-specific 

factors including, but not limited to, the extent to which a conflict of interest appears to 

have motivated an administrator’s decision. Id. The court may also consider the quality 

and quantity of medical evidence, whether the plan administrator required an in-person 

medical examination or relied on the review of existing medical records, and whether the 

administrator provided its independent experts with all of the relevant evidence. Id. 

In assessing the effect of a conflict of interest, the court must view evidence of 

bias in the light most favorable to the claimant. Stephan v. Unum Life Ins. Co., 697 F.3d 

917, 930 (9th Cir. 2012). The plan administrator bears the burden of proving that its 

decision was not improperly influenced by its dual role as administrator and insurer. 

Muniz, 623 F.3d at 1295. Regardless of whether an administrator’s conflict of interest is 

a factor, however, an abuse-of-discretion review requires consideration of all the 

circumstances. Pacific Shores Hosp., 764 F.3d at 1042. 

II. FACTUAL BACKGROUND 

Plaintiff was born and raised in Morocco where he worked as a chef. He may 

have had polio as a child. When he was 27 years old, he emigrated from Morocco and 

shortly thereafter began working for Marriott International Inc. as a chef. When Plaintiff 

was 36 years old, in approximately March 2009, he developed pain and swelling in his 

right foot. In October 2009, he became unable to continue working as a specialty 

restaurant chef, a job for which he was paid approximately $57,500/year, because it 

required long periods of standing and walking, which resulted in swelling and pain in his 

right ankle and foot. 

Marriott hired Plaintiff October 25, 2000. Marriott is the plan administrator of 

Defendant Marriott International Inc. Long-Term Disability Plan (the “Plan”). Defendant 

Aetna Life Insurance Company insures the Plan and is the claim administrator for the 

Plan. Plaintiff was a participant in the Plan as a result of his employment with Marriott. 

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The Plan’s long-term disability coverage pays a monthly benefit to an employee 

who is disabled and unable to work because of an illness, injury, or disabling pregnancyrelated condition, after the first 182 days of a period of disability. Under the Plan’s test 

of disability, monthly benefits are payable for the first 24 months if the employee cannot 

perform the material duties of his “own occupation” solely because of an illness, injury, 

or disabling pregnancy-related condition and his earnings are 80% or less of his adjusted 

pre-disability earnings. The Plan defines “own occupation” as the occupation the 

employee is routinely performing when his period of disability begins, viewed as it is 

normally performed in the national economy. 

The Plan’s test of disability changes from “own occupation” to “any occupation” 

after the first 24 months that monthly benefits are payable. After 24 months, the 

employee meets the Plan’s test of disability on any day that he is unable to work “at any 

reasonable occupation” solely because of an illness, injury, or disabling pregnancyrelated condition. The Plan defines “reasonable occupation” as any gainful activity for 

which the employee is, or may reasonably become, fitted by education, training, or 

experience, and which results in, or can be expected to result in, an income of more than 

60% of the employee’s adjusted pre-disability earnings. 

Initially, Plaintiff received short-term disability benefits. Plaintiff’s first day 

absent from work was October 25, 2009, and his date of disability under the Plan was 

November 5, 2009. In September 2009, Plaintiff reported right foot pain and swelling 

that had begun approximately six months before. In February 2010, he had surgery to 

relieve tightness in his right calf and subsequently reported dramatic improvement with 

minor pain when walking. In March 2010, Plaintiff had surgery to increase the range of 

motion in his right ankle and subsequently reported pain-free range of motion in his right 

ankle. In April 2010, Plaintiff reported swelling in his right foot after standing on it for a 

long period of time. He returned to work, but after ten continuous hours of being on his 

feet, the swelling increased dramatically and was very painful. On May 4, 2010, Plaintiff 

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was treated with a local block of the right common peroneal nerve, which significantly 

reduced, but did not eliminate, his right ankle pain. 

Also on May 4, 2010, Plaintiff’s treating orthopedist Ralph N. Purcell, M.D., 

wrote to Aetna that on April 22, 2010, he advised Plaintiff not to work because of 

swelling and pain over his right tibia at the site of his surgery. Dr. Purcell said Plaintiff 

reported the swelling occurred after being on his feet for ten hours at work, but Plaintiff 

“had done extraordinarily well without any symptoms prior to his being on his feet for 

such a protracted period of time.” Dr. Purcell also stated that Plaintiff “was doing 

wonderfully postoperatively and his dramatic improvement postoperatively was the basis 

for his return to work.” He recommended ankle support for protracted weight bearing. 

In an Attending Physician Statement dated April 26, 2010, Dr. Purcell opined that 

Plaintiff was able to do sedentary work activity 8 hours/day, 5 days/week, but should do 

no prolonged standing and no pushing, pulling, or lifting. He attributed Plaintiff’s 

impairment to pain and swelling of the right ankle. 

From May 8, 2010,1

 through August 23, 2012, Plaintiff received long-term 

disability benefits under the Plan’s “own occupation” test of disability, based on a 

determination that Plaintiff was unable to work as a specialty restaurant chef. On June 

26, 2010, Aetna sent a letter to Plaintiff explaining that he was eligible to receive 

monthly benefits effective May 8, 2010, and continuing for up to 24 months as long as he 

remained disabled from his own occupation. The letter further explained that if he was 

still disabled from his own occupation and eligible for disability benefits on May 8, 2012, 

the Plan would require him to meet a more strict definition of disability. It informed 

Plaintiff that to qualify for monthly benefits, he would be required to provide medical 

evidence that he was unable to perform any reasonable occupation for which he was 

 1

 Although initially his long-term disability benefit was to be effective May 6, 

2010, it was adjusted to May 8, 2010, because he had returned to work on April 21 and 

22, 2010. 

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qualified or could become qualified as a result of his education, training, or experience. 

If he qualified for continuation of benefits, Aetna would periodically review his 

eligibility by requesting updated medical information from Plaintiff’s medical providers, 

independent physicians, or vocational specialists. 

In July 2010, Plaintiff received peripheral nerve decompression and neurolysis of 

the right common peroneal nerve. In September 2010, Plaintiff underwent right hip 

arthroscopic surgery. In October 2010, he reported to Aetna that he was in a cast from 

his hip surgery and would have another surgery in December 2010. The record does not 

show that Plaintiff had surgery in December 2010. 

In May 2011, an Aetna representative interviewed Plaintiff by telephone regarding 

his current status. Plaintiff reported experiencing a lot of pain in his right ankle that 

radiated to his back. He said he could not be on his feet more than 30 minutes and had 

difficulty sleeping. He said that his wife did most of the housework, but he was able to 

prepare meals and do home exercises. Plaintiff said that it had been about three months 

since his last office visits with his treating providers. The Aetna representative’s notes 

regarding the telephone interview do not indicate that Plaintiff had any difficulty 

communicating in English. 

In June 2011, Plaintiff reported difficulty walking, swelling in his ankle, tingling 

near his toes, and radiating pain up his leg into his buttocks. He said any standing 

exacerbated his symptoms greatly and that he had recently received a burning treatment 

to his lower leg while in Morocco. In July 2011, MRIs of Plaintiff’s right knee, right hip, 

and lumbar/cervical spine and x-rays of lumbar spine and right hip were not clinically 

significant regarding his symptoms except for a new right hip labral tear. Plaintiff 

reported pain and swelling between his ankle and heel on his right foot. 

On July 28, 2011, treating podiatrist Stephen L. Barrett, D.P.M., completed an 

Attending Physician Statement. Dr. Barrett opined that Plaintiff was able to do sedentary 

work, but unable to continuously stand/walk more than one hour at a time. He reported 

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that Plaintiff had presented with swelling of the right ankle on July 25, 2011, and an MRI 

had been ordered. Dr. Barrett assessed Plaintiff as able to perform occasional climbing, 

crawling, kneeling, carrying, bending, twisting, standing, stooping, and walking. He 

assessed Plaintiff as able to perform continuous (5.1-8 hours/day) lifting, pulling, 

pushing, reaching above shoulder, and forward reaching while sedentary. Dr. Barrett said 

that Plaintiff could not drive because his prescribed pain medication could cause 

drowsiness. 

On August 2, 2011, a clinical consultant for Aetna reviewed the medical records in 

support of Plaintiff’s claim. She concluded that the restrictions and limitations of no 

standing or walking for more than an hour at a time were supported and would likely be 

ongoing. She opined that the restrictions and limitations did not appear to preclude the 

performance of full-time sedentary work activities. The clinical consultant recommended 

confirming her opinion with Dr. Barrett and Dr. Purcell and obtaining updated medical 

records. 

On September 27, 2011, Aetna’s vocational counselor spoke by telephone with 

Plaintiff, who said that his work history was limited to cooking. Plaintiff expressed 

interest in participating in vocational rehabilitation services to assist him in identifying 

alternate job goals, assess his interests and areas of strength, and discuss possible 

retraining and job placement options. That same day the vocational counselor completed 

a Transferable Skills Analysis based only on Plaintiff’s predicted sedentary work 

capacity, work history as a chef, and education consisting of one year of college. She did 

not find any sedentary occupations that were a “good” match for Plaintiff’s transferable 

skills. She concluded that the occupation of hotel sales representative was a 

“fair/limited” match for Plaintiff’s transferable skills because Plaintiff lacked any sales 

experience and his computer skills were limited. Although the vocational counselor had 

spoken with Plaintiff at least two times, she did not note any limitation in his ability to 

communicate in English. 

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On September 21, 2011, Plaintiff began treatment at the Arizona Center for Pain 

Relief and was seen by Brittany Jones, P.A., for pain of the low back, right hip, and right 

leg, which reportedly had occurred in an intermittent pattern for ten years. Pain 

medications were prescribed. On October 19, 2011, Plaintiff was seen by J. Julian 

Grove, M.D., of the Arizona Center for Pain Relief, who noted that Plaintiff had 

experienced significant relief and slight functional improvement, but also noted that 

Plaintiff reported no change in pain. 

On October 28, 2011, Dr. Grove completed an Attending Physician Statement, in 

which he opined that Plaintiff had “no ability to work” and stated that “Patient has only 

been seen twice but he came in on a 0 work status.”2

 Dr. Grove indicated that Plaintiff 

can never perform climbing, crawling, kneeling, lifting, pulling, pushing, reaching above 

shoulder, forward reaching, carrying, bending, or twisting. He further indicated that 

Plaintiff can occasionally perform sitting, standing, stooping, or walking. Dr. Grove also 

opined that Plaintiff can frequently carry 1-5 pounds, occasionally carry 6-20 pounds, and 

never carry more than 20 pounds. He identified Plaintiff’s primary diagnosis as 

lumbosacral neuritis and his secondary diagnosis as “pain in joint ankle/foot.” 

On November 30, 2011, an investigator interviewed Plaintiff at his home and 

reported that Plaintiff was wearing pajamas at 11:00 a.m. and sat with his right leg 

elevated on the sofa. Plaintiff reported that he does not often leave home and his wife 

does all of the household chores, shopping, and driving. On December 13, 2011, an 

investigator videotaped about two minutes of Plaintiff walking in his driveway, speaking 

with someone, returning to the residence, and driving away in a vehicle. The investigator 

noted that Plaintiff walked with a slight limp. The investigator followed Plaintiff driving 

for about 30 minutes. On December 14, 2011, the investigator observed Plaintiff driving 

 2

 At that point Plaintiff had been seen twice at the Arizona Center for Pain 

Relief—once by Dr. Grove and once by PA Jones. 

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the same vehicle with children in the back seat. On two other days, surveillance efforts 

were continued, but Plaintiff was not observed outside of or departing his home. 

Plaintiff was seen by PA Brittany Jones of the Arizona Center for Pain Relief on 

November 16, 2011, December 15, 2011, and January 10, 2012, for routine medical 

follow up and pain medicine prescriptions. 

In January 2012, Plaintiff underwent left knee ACL reconstruction. In a February 

2012 follow-up visit, Plaintiff reported that he had no complaints with his left lower 

extremity, but his right knee, hip, and foot had been giving him “some problems.” He 

was progressing well with physical therapy and home exercises and was referred to a foot 

and ankle specialist, Dr. Michael Castro. 

On March 6, 2012, Plaintiff told PA Brittany Jones that his knee was feeling well, 

but his altered gait had increased his right lower extremity pain. On April 4, 2012, 

Plaintiff appeared at Dr. Grove’s office, but the doctor was delayed and could not see 

Plaintiff. Medication refills were ordered and Plaintiff was directed to return in one 

month. 

The record includes a facsimile of an Attending Physician Statement with Dr. 

Grove’s signature dated April 6, 2012. Except for the dates next to Dr. Grove’s 

signature, the two pages with signatures are identical—same handwriting, same 

comments, and same marginal notations—to the corresponding two pages of the 

Attending Physician Statement dated October 28, 2011. Both the October 28, 2011 

statement and the April 6, 2012 statement include the handwritten comment that “Patient 

has only been seen twice but he came in on a 0 work status.” These pages with 

signatures both indicate that Plaintiff has “no ability to work” and is capable of working 

zero hours/day zero days/week. Instead of stating prescribed restrictions on work 

activities and an estimated return to work date, both statements say only that “Patient is 

not working.” The first pages of the statements, which describe diagnoses, medications, 

and office visit dates, are not identical and do not include a signature. 

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In March 2012, three months before the Plan’s test of disability would change 

from “own occupation” to “any reasonable occupation,” Aetna began attempting to 

obtain updated medical records from Plaintiff’s treating physicians for clinical review by 

a nurse consultant. On May 8, 2012, after 24 months of long-term disability benefits, the 

test for evaluating Plaintiff’s claim changed from whether he was capable of performing 

the material duties of his “own occupation” to whether he could perform the material 

duties of “any reasonable occupation.” On May 8, 2012, after repeated requests, Aetna 

received the records requested from Dr. Grove and referred Plaintiff’s claim to a nurse 

consultant for a clinical review on May 9, 2012. On May 9, 2012, the nurse consultant 

reviewed clinical information from December 2011 through April 2012. She noted that 

Plaintiff appeared to be recovering well from left knee surgery, but continued to have 

chronic pain from his right knee and ankle. She noted that Dr. Grove opined that Plaintiff 

was unable to work. The nurse consultant opined that the current records supported 

finding functional impairment, but recommended obtaining updated medical records in 

about four months from pain management, orthopedics, and Dr. Castro, the foot/ankle 

specialist, if Plaintiff had been seen by him.3

 

On June 1, 2012, an investigator observed Plaintiff leave his home alone, drive to 

a store where he met two men and entered the store with the men. He stood and talked to 

the men inside the store. After leaving the store, Plaintiff drove to a convenience store, 

entered, departed carrying items, and drove home. On June 2, 2012, the investigator 

observed Plaintiff drive to a bank, park the car, get out of the car, use the automatic teller 

machine, enter the bank, exit the bank, and drive home. On his way home, Plaintiff 

stopped several times in different parking lots and appeared to be texting on his cell 

phone.4

 3

 The record does not show that Plaintiff ever saw Dr. Castro. 

4

 The private investigation firm also found Internet videos of televised cooking 

segments performed by Plaintiff while he worked for Marriott, a web site for Plaintiff’s 

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On June 26, 2012, Aetna requested peer review of Plaintiff’s claim by Malcom 

McPhee, M.D., Board Certified in Physical Medicine and Rehabilitation, to assess the 

effect that any physical conditions would have on Plaintiff’s functionality for the period 

May 8, 2012, through May 7, 2013. Dr. McPhee reviewed the records provided, 

including operative notes, radiology reports, and office notes from February 2010 

through April 2012. He reviewed the July 28, 2011 Attending Physician Statement by 

treating podiatrist Stephen L. Barrett, D.P.M., which stated that Plaintiff was capable of 

performing sedentary work, but unable to continuously stand/walk more than one hour at 

a time. He viewed the surveillance video from June 1 and 2, 2012. Dr. McPhee observed 

Plaintiff on June 1 walking from his car to a store “with an equal stride length and no 

limp while wearing flip flops.” He observed Plaintiff on June 2 walking from his car and 

back “without any observable gait difficulty.” Dr. McPhee noted that Plaintiff’s file did 

not include details of when he became infected with the polio virus, a detailed 

neurological examination, or a detailed neuromuscular exam of the lower right extremity. 

Nevertheless, Dr. McPhee found general evidence of right lower extremity atrophy, 

which would reasonably limit walking to an occasional basis and short distances. He 

further concluded it would be reasonable to limit Plaintiff’s standing to no more than a 

frequent basis for 30–60 minutes at a time followed by a brief five-minute break to sit. 

Dr. McPhee’s peer review included peer-to-peer consultation. On July 2, 2012, he 

attempted to contact treating orthopedist Dr. Stacey McClure, who performed Plaintiff’s 

left knee arthroscopy in January 2012. Dr. McPhee spoke with Dr. McClure’s medical 

assistant, who indicated that Plaintiff’s left knee was fully functional and would not 

preclude work activity. Dr. McPhee also attempted to contact Dr. Grove and spoke with 

PA Brittany Jones, who had treated Plaintiff multiple times. She said that Plaintiff’s left 

leg and foot muscles were very functional, but his right leg and foot had functional 

 

catering business that appeared to be inactive, and a LinkedIn account. 

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limitations. She advised limiting Plaintiff to changing to a seated position after standing 

for 30–60 minutes. 

On July 5, 2012, Dr. McPhee completed his initial peer review. He opined that, 

based on the provided documentation and telephonic consultation, Plaintiff’s functional 

impairments from May 8, 2012, through May 7, 2013, would limit standing to 30–60 

minutes before changing positions and limit walking to short distances such as 50 feet at 

any one time. He further opined that a reasonable estimate of physical demand level 

would be a light level with the additional restrictions of limiting walking to short 

distances such as 50 feet at any one time and limiting standing to 30–60 minutes and then 

changing positions for five minutes. He opined that Plaintiff could lift/carry up to 10 

pounds frequently and 20 pounds occasionally and that sitting would be unrestricted. Dr. 

McPhee also stated, “There were no providers advising restrictions or limitations for the 

time period in question.” On July 10, 2012, copies of Dr. McPhee’s peer review report 

were mailed to Dr. Grove and Dr. McClure. 

On July 11, 2012, Aetna requested that a Telephonic Evaluation and Transferable 

Skills Analysis be conducted by Coventry Health Care, vocational rehabilitation 

consultants. On July 13, 2012, Maria Provini-Salas, Coventry Vocational Case Manager, 

spoke with Plaintiff by telephone. She said that Plaintiff reported he had received the 

equivalent of a high school diploma, was able to use a computer for Internet and email 

use, enjoyed occasional swimming, and received on-the-job training to eventually 

become a chef. She did not document any difficulty communicating with Plaintiff in 

English. 

To determine Plaintiff’s transferable skills, Ms. Provini-Salas reviewed, among 

other things, the job description of Plaintiff’s last position, specialty restaurant chef, 

which was provided by Plaintiff’s employer and dated April 2009. The job summary 

states: 

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Accountable for the quality, consistency and production of the specialty 

restaurant kitchen. Exhibits culinary talents by personally performing tasks 

while leading the staff and managing all food related functions. 

Coordinates menus, purchasing, staffing and food preparation for the 

property’s specialty restaurant. Works with team to improve guest and 

associate satisfaction while maintaining the operating budget. Must ensure 

sanitation and food standards are achieved. Develops and trains team to 

improve results. 

Core work activities include, among many others: 

 Plans and manages food quantities and plating requirements for the 

specialty restaurant. 

 Ensures compliance with all local, state and federal (e.g., OSHA, 

ASI and Health Department) regulations. 

 Supervises and coordinates activities of cooks and workers engaged 

in food preparation. 

 Utilizes interpersonal and communication skills to lead, influence, 

and encourage others; advocates sound financial/business decision 

making; demonstrates honesty/integrity; leads by example. 

 Ensures associates are cross-trained to support successful daily 

operations. 

 Ensures associates understand expectations and parameters. 

 Sets and supports achievement of kitchen goals including 

performance goals, budget goals, team goals, etc. 

 Improves service by communicating and assisting individuals to 

understand guest needs, providing guidance, feedback, and 

individual coaching when needed. 

 Handles guest problems and complaints. 

 Interacts with guests to obtain feedback on product quality and 

service levels. 

 Identifies the developmental needs of others and coaching, 

mentoring, or otherwise helping others to improve their knowledge 

or skills. 

 Manages associate progressive discipline procedures. 

 Participates in the associate performance appraisal process, 

providing feedback as needed. 

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 Assists as needed in the interviewing and hiring of associate team 

members with appropriate skills. 

Additional responsibilities include: “Provides information to supervisors, co-workers, 

and subordinates by telephone, in written form, e-mail, or in person.” Basic 

competencies, i.e., “fundamental competencies required for accomplishing basic work 

activities,” include: 

 Basic Computer Skills – Using basic computer hardware and 

software (e.g., personal computers, word processing software, 

Internet browsers, etc.). 

 Mathematical Reasoning – The ability to add, subtract, multiply, or 

divide quickly, correctly, and in a way that allows one to solve 

work-related issues. 

 Oral Comprehension – The ability to listen to and understand 

information and ideas presented through spoken words and 

sentences. 

 Reading Comprehension – Understanding written sentences and 

paragraphs in work related documents. 

 Writing – Communicating effectively in writing as appropriate for 

the needs of the audience. 

On July 18, 2012, Ms. Provini-Salas reported to Aetna that Plaintiff has a variety 

of transferable skills and abilities, which include thinking creatively; making decisions 

and solving problems; coordinating the work and activities of others; getting information; 

inspecting equipment, structures or material; establishing and maintaining interpersonal 

relationships; resolving conflicts and negotiating with others; monitoring and controlling 

resources; and communicating with supervisors, peers, or subordinates. Ms. ProviniSalas concluded that the following occupations are consistent with Plaintiff’s transferable 

skills and the functional capacities and restrictions identified in Dr. McPhee’s July 5, 

2012 peer review: food/beverage controller, supervisor order taker, hotel sales 

representative, repair order clerk, timekeeper, and referral clerk for a temp agency. Each 

of the positions was classified as sedentary with a wage of more than the target wage of 

$17.19 per hour. Ms. Provini-Salas reported that she had used the following resources: 

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Bureau of Labor statistics, OASYS software, the Occupational Outlook Handbook, the 

Dictionary of Occupational Titles, and O*NET. 

On July 20, 2012, Dr. Grove wrote a letter to Aetna stating that Plaintiff “suffers 

from chronic and long-standing right lower extremity radiating pain.” He said that 

Plaintiff’s symptoms had “been going on for more than 20 years” and had “led to surgical 

intervention in the right knee and right foot and ankle.” He stated that Plaintiff “has been 

evaluated for a postpolio syndrome, as this was prevalent where he grew up in the middle 

east.” Dr. Grove opined that Plaintiff “cannot sit for longer than 20 minutes to an hour 

and has to get up and walk around due to the right lower extremity radiating pain.” He 

further opined that Plaintiff “can stand for approximately 5-10 minutes at a time.” He 

also noted that Plaintiff requires medications due to the severity of his pain, but “has 

unfortunately suffered many side effects with current pain medications, including 

Percocet and Lyrica, which make him dizzy.” Dr. Grove’s letter does not refer to Dr. 

McPhee’s July 5, 2012 peer review report or specifically address any of Dr. McPhee’s 

findings. 

On August 1, 2012, Aetna requested additional peer review by Dr. McPhee based 

on Dr. Grove’s July 20, 2012 letter. On August 8, 2012, Dr. McPhee spoke by telephone 

with Dr. Grove, who had personally seen Plaintiff once. In response to Dr. McPhee’s 

questions, Dr. Grove said he had not restricted Plaintiff’s driving, he had based his 

limitations regarding Plaintiff’s ability to stand only for 10-15 minutes on what Plaintiff 

had told him, and he believed Plaintiff could work with restrictions. Dr. McPhee asked 

Dr. Grove whether certain walking, standing, and lift/carry restrictions and unrestricted 

sitting with change of position for five minutes every hour would be reasonable. Dr. 

Grove agreed with the restrictions and limitations Dr. McPhee posed. Dr. McPhee also 

reported, “I described the video surveillance that I viewed and Dr. Grove was pleased 

with his functioning.” 

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On August 8, 2012, Dr. McPhee submitted his additional peer review in which he 

addressed the opinions expressed in Dr. Grove’s July 20, 2012 letter. Dr. McPhee noted 

that the letter explained that Plaintiff’s symptoms had been going on for more than 20 

years and had received surgical interventions to address right lower extremity concerns 

due to the effects of polio. Dr. McPhee further noted that after these procedures, Dr. 

Barrett reported Plaintiff was unable to stand/walk for more than an hour at a time. In 

Dr. McPhee’s opinion, the residual right lower extremity problems would not prevent 

Plaintiff from all work activity. Dr. McPhee also noted that the video surveillance 

showed that Plaintiff was able to walk with an equal stride length and no limp or 

observable gait difficulty while wearing flip-flops. Dr. McPhee noted that the video 

surveillance indicated that any chronic swelling that may have been present appeared 

mild and would not prevent all work activity. Regarding the duration of sitting, standing, 

and walking, Dr. McPhee noted that Dr. Grove based his opinion on Plaintiff’s selfreport. Finally, although Dr. Grove’s July 20, 2012 letter reported dizziness caused by 

Percocet and Lyrica, Dr. Grove’s office visit records did not mention dizziness, and 

Plaintiff’s driving and walking as captured on video did not indicate any dizziness. Dr. 

McPhee concluded that Dr. Grove’s letter did not include any new information that 

would cause Dr. McPhee to alter his prior opinion. 

In a letter dated August 23, 2012, Aetna notified Plaintiff that his long-term 

disability benefits were being terminated effective August 24, 2012. The letter explained 

that Plaintiff’s long-term disability policy provided benefits for 24 months if he could not 

“perform the material duties of his own occupation” solely because of illness or injury 

and his earnings were 80% or less of his adjusted pre-disability earnings. It further 

explained that after the first 24 months of disability benefits, he would meet the plan’s 

test of disability if he was “unable to work at any reasonable occupation” solely because 

of illness or injury. It defined “reasonable occupation” as “any gainful activity: 

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 For which you are, or may reasonable [sic] become, fitted by education, 

training, or experience; and 

 Which results in, or can be expected to result in, an income of more than 

60% of your adjusted pre-disability earnings.” 

The August 23, 2012 letter stated that Plaintiff’s benefits began on May 8, 2010, the first 

24 months of benefits ended as of May 7, 2012, and benefits were paid beyond the initial 

24 months while Aetna completed its review. It further stated that Aetna had recently 

completed its review and concluded that Plaintiff no longer met the policy’s test of 

disability. It then stated the sources of medical documentation reviewed, how the peer 

review was conducted, and the occupations it had determined would satisfy the “any 

reasonable occupation” criteria, i.e., for which Plaintiff would have the necessary skills 

and earn a reasonable wage of $17.19 per hour. The letter further stated that Aetna would 

review any additional information Plaintiff cared to submit. 

On October 25, 2012, Plaintiff saw Lisa Piccione, M.D., of Desert Ridge Family 

Physicians for left knee pain. Upon physical examination, Dr. Piccione found moderately 

reduced range of motion in the left knee and atrophic right quadriceps and hamstring. 

She reported his primary language as English. 

On November 7, 2012, Plaintiff began treatment at Valley Pain Consultants. The 

office note does not identify whether he was seen by an anesthesiologist or a physician 

assistant. The office note states that Plaintiff presented with pain in the right lumbar area, 

right buttock, right thigh, right lower leg, and the right foot. Pain scores included a 

current level of 8/10, average level of 5/10, minimum pain level of 2/10, and maximum 

pain level of 8/10. Plaintiff reported that symptoms are exacerbated by standing and 

walking, but are relieved by opioid analgesics. It appears that pain medications were 

prescribed. On November 7, 2012, Nikesh Seth, M.D., of Valley Pain Consultants wrote 

to Dr. Piccione that Plaintiff had been “getting good relief with opioids which allows him 

to maintain functionality.” 

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On November 13, 2012, Dr. Cory Nelson of Spine Orthopedic Specialists 

evaluated Plaintiff for left knee pain. He noted that Plaintiff said he had had symptoms 

and weakness in his right lower extremity for several years, developed instability in his 

left knee, had left ACL reconstruction, and continued to experience pain and weakness. 

After physical examination, Dr. Nelson opined that the left knee instability was related to 

left quadriceps weakness and atrophy. Dr. Nelson recommended that Plaintiff resume 

physical therapy for knee extension, quadriceps strength, and gait training. 

On December 5, 2012, Plaintiff was seen at Valley Pain Consultants. The 

provider noted a current pain level of 4/10, symptoms as unchanged, and pain as 

constant. The provider consulted with Dr. Seth, who advised changing one of the pain 

medications. 

On January 8, 2013, Plaintiff was seen again at Valley Pain Consultants. The 

provider reported a current pain level of 4/10. Plaintiff reported unchanged symptoms 

and constant pain, and the provider noted “good tolerance of treatment and good 

symptom control.” The provider further noted that the opioid side effects did not include 

dizziness, drowsiness, or constipation. 

On February 5, 2013, Plaintiff was seen by Dr. Seth at Valley Pain Consultants. 

Dr. Seth wrote that Plaintiff was a high school graduate who reported constant low back 

and right lower extremity pain, exacerbated by standing and walking. Plaintiff also 

reported swelling in his left knee and pain on movement and swelling in his right ankle. 

Plaintiff reported a current pain level of 6/10. Dr. Seth’s physical examination findings 

included no edema in either lower extremity, normal muscle strength and tone in upper 

and lower extremities, some decreased sensation along the dorsum of the right foot, 

walking on toes impaired, and tandem gait mildly antalgic on the right side. 

Musculoskeletal findings included mildly positive straight leg raising on the right side, 

mild tenderness in the back and knees, and moderate tenderness with mild swelling along 

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the right lower ankle. Dr. Seth also wrote that Plaintiff reported “pain relief with current 

medication regimen without side effects or impairments.” 

On February 19, 2013, Plaintiff appealed Aetna’s August 23, 2012 termination of 

Plaintiff’s long-term benefits. With the letter of appeal, Plaintiff’s attorney included 

Valley Pain Consultants’ records of office visits dated November 7, 2012, through 

February 5, 2013, and a short statement written by Plaintiff dated February 15, 2013. 

The statement reported that Plaintiff went to elementary school from age 6 to 13, lived in 

Morocco until age 27, worked as a gardener until age 20, worked as a dish washer until 

age 23, and then began cooking. Plaintiff’s attorney stated, “Mr. Yaakoubi is 

demonstrably unable to write English with any degree of proficiency.” The attorney’s 

letter also reported that Plaintiff “continues to suffer from fatigue, swelling of the 

extremities, dizziness, numbness, trouble walking, and constant burning, stabbing pains 

in the right lumbar area and throughout the right leg and foot.” The attorney asserted that 

with limited education and lack of computer skills and English proficiency, Plaintiff is 

unable to work in the white-collar office, sales, and managerial occupations identified by 

Aetna. 

On February 20, 2013, Dr. Seth provided Plaintiff with a “left knee injection in 

office to help with some mild arthritis.” Plaintiff asked Dr. Seth to provide a statement 

regarding his diagnoses and the impact on his ability to work. Dr. Seth recommended 

that Plaintiff obtain a Functional Capacity Exam by his physical therapist. On February 

28, 2013, Dr. Seth performed a right L2 lumbar sympathetic block “to help with vague 

nerve type pain” in his right lower extremity. 

On March 13, 2013, Aetna requested that Plaintiff provide updated medical 

records. On March 20, 2013, Plaintiff was seen at Valley Pain Consultants. He reported 

a current pain level of 8/10 and that relief provided by a lumbar nerve block was only 

temporary. The provider ordered a lumbar MRI and pain medications. 

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On April 11, 2013, Plaintiff’s attorney provided Aetna with updated medical 

records, a statement by Plaintiff regarding his attempt to return to work in March 2013, 

and a photograph of Plaintiff’s swollen ankle taken on March 18, 2013. Plaintiff said that 

he was hired as a Banquet Sous Chef at the Phoenician Resort in Phoenix, he completed a 

two-day orientation involving mostly sitting, but on subsequent days he had to take 

breaks and leave early because of pain, swelling, and occasional inability to move his 

legs. He said that at the end of each hour he would sit in the office and then go back to 

work in the kitchen where after four hours his leg would get really tired and after six 

hours his foot would begin to swell. He did not return to work after March 18, 2013. 

On appeal, Aetna asked Edward Klotz, M.D., Board Certified in Internal Medicine 

and Pulmonology, to review the Aetna Transferrable Skills Analysis Report dated July 

18, 2012. On May 14, 2013, Dr. Klotz concluded that the documents provided to him 

showed no functional impairment from an internal medicine point of view and no 

physical or cognitive examination findings of any functional impairment suggesting that 

Plaintiff’s ability to work had been directly impacted by an adverse medication effect 

during the period from August 24, 2012, through May 31, 2013. He stated that his 

review was not sufficient to evaluate the transferable skills analysis from an internal 

medicine point of view. 

Aetna also asked Stuart Rubin, Board Certified in Physical Medicine and 

Rehabilitation, to review the Aetna Transferrable Skills Analysis Report dated July 18, 

2012. On May 21, 2013, Dr. Rubin concluded that the documents provided to him did 

not support finding Plaintiff had functional impairments from August 24, 2012, through 

May 31, 2013, despite multiple abnormal findings. Dr. Rubin commented that some 

findings were inconsistent, such as right quadriceps atrophy on October 25, 2012, left 

quadriceps atrophy on November 13, 2012, and no musculoskeletal abnormalities noted 

on March 20, 2013.5

 Other abnormal findings were mild or moderate. Dr. Rubin opined 

 5

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that Plaintiff can work at the light level with standing limited to 30-60 minutes at one 

time. He noted that on July 20, 2012, Dr. Grove wrote that Percocet and Lyrica had 

made Plaintiff dizzy. Dr. Rubin reviewed O*NET Online job descriptions for nine 

occupations and found no specific physical demands that would preclude Plaintiff from 

performing those jobs. He concluded that all of the occupational alternatives identified in 

the Transferrable Skills Analysis were appropriate, including food beverage controller, 

supervisor order taker, hotel sales representative, repair order clerk, timekeeper, and 

referral clerk for a temp agency. 

In a letter to Plaintiff’s attorney dated June 18, 2013, Aetna notified Plaintiff that 

after its appeal review of the termination of Plaintiff’s long-term disability benefits, the 

original decision, effective August 23, 2012, was upheld. The letter described the 

reviews by Dr. Klotz and Dr. Rubin, the video surveillance performed on June 1 and 2, 

2012, and Dr. Nelson’s treatment notes. Regarding the video surveillance, the letter 

stated: “On both occasions, your client was observed walking with an equal stride length 

and did not exhibit a limp and/or any observable gait difficulty.” The letter concluded: 

In summary, although your client has multiple abnormal findings, that 

include moderately reduced range of motion of uncertain knee, atrophic 

right quadriceps and hamstrings, decreased right hip flexor strength and 

decreased quadriceps compared to the left as of October 25, 2012, mildly 

positive straight leg raise on the right on February 05, 2013, and received a 

right knee injection on February 20, 2013, for osteoarthritis of the left knee, 

and it was also noted that there was a suspicion of complex region[al] pain 

syndrome of the left lower extremity, however, physical examination 

findings to correlate with this assessment was not proven. As of March 20, 

2013, there were no notations of any musculoskeletal abnormalities. In 

addition, although there was notation that the medications Percocet and 

Lyrica were making your client dizzy, the provided documentation does not 

reflect that there were any physical or cognitive examination findings of 

any functional impairment suggesting that your client’s ability to work has 

been directly impacted by an adverse medication effect as of August 24, 

2012. 

 

which there was no record, but Dr. Rubin actually referred to March 20, 2013. 

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The letter stated that Plaintiff’s file had been referred to a vocational specialist, who 

identified several occupational alternatives for which Plaintiff was qualified based on his 

education, training, experience, and physical capabilities. Finally, the June 18, 2013 

letter informed Plaintiff that the original decision to terminate long-term disability 

benefits effective August 24, 2012, was final and he had the right to bring a civil action 

under ERISA within one year. 

On August 14, 2014, Plaintiff filed his complaint in this action. He seeks recovery 

of long-term disability benefits from August 23, 2012, through the present and until such 

time as he is no longer disabled under the terms of the Plan. 

III. ANALYSIS 

A. Standard of Review 

The Plan is established by the Policy, an agreement entered into by and between 

Aetna and Marriott. Among other things, the Policy incorporates the Booklet-Certificate, 

which is the Certificate of Coverage and includes the Schedule of Benefits. In the Policy, 

Aetna and Marriott agreed that Aetna is “a fiduciary with complete authority to review all 

denied claims for benefits under this Policy” and “shall have discretionary authority to 

determine whether and to what extent eligible employees and beneficiaries are entitled to 

benefits and to construe any disputed or doubtful terms under this Policy, the Certificate 

or any other document incorporated herein.” (Doc. 33-1 at 30.) Moreover, Aetna and 

Marriott agreed that Aetna shall be deemed to have properly exercised such authority 

unless Aetna abuses its discretion by acting arbitrarily and capriciously. (Id.) Aetna and 

Marriott also agreed that Aetna would pay benefits in accordance with the terms of the 

Policy and the reasonable exercise of Aetna’s business judgment. (Doc. 33-1 at 14.) 

Because the Plan unambiguously grants Aetna discretionary authority to grant or 

deny benefits, the Court reviews Aetna’s benefit decisions for abuse of discretion, 

considering all the circumstances. Because Aetna both evaluates claims and pays 

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benefits claims under the Plan, the Court considers that structural conflict of interest and 

views evidence of bias in the light most favorable to Plaintiff. 

B. Viewing Evidence of Bias in the Light Most Favorable to Plaintiff, the 

Evidence Does Not Show that Aetna’s Conflict of Interest Improperly 

Influenced Its Decision to Terminate Plaintiff’s Long-Term Disability 

Benefits. 

Plaintiff contends that Aetna’s bias is demonstrated by its use of “paper 

reviewers,” “Dr. McPhee’s purported success in changing Dr. Grove’s mind,” “Dr. 

McPhee’s misrepresentation of the surveillance,” and Aetna’s “focus on surveillance.” 

Plaintiff concedes Aetna was not required to evaluate Plaintiff in person, but 

contends that relying on paper reviews by Dr. McPhee, Dr. Klotz, and Dr. Rubin “raises 

questions about Aetna’s accuracy and thoroughness in reviewing [Plaintiff’s] claim.” 

(Doc. 42 at 6.) Plaintiff argues that Dr. McPhee’s paper review cannot establish 

Plaintiff’s true functional abilities because he did not review records dated before 

February 4, 2010. However, Plaintiff was able to work until October 25, 2009, and Dr. 

McPhee reviewed the operative notes for Plaintiff’s surgeries in February, March, July 

and September 2010. Office notes from before multiple surgeries would not have shed 

light on Plaintiff’s true functional abilities after recovery from the surgeries. 

Plaintiff also contends that Dr. Rubin’s opinions do not constitute substantial 

evidence because he did not cite many of the records he reviewed and he focused on 

records dated after Dr. McPhee’s review. Plaintiff ignores the fact that Aetna asked Dr. 

Rubin in May 2013 to review the July 2012 Transferable Skills Analysis Report, in 

response to Plaintiff’s appeal, to determine whether Plaintiff had functional impairments 

from August 2012 through May 2013—not to repeat Dr. McPhee’s medical records 

review. 

Further, Plaintiff contends that Dr. McPhee misrepresented the video surveillance 

and described it to Dr. Grove, thereby tainting Dr. Grove’s opinion. Dr. McPhee reported 

that he viewed the June 2012 video surveillance and observed Plaintiff driving a car to a 

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store, walking from his car to the store “with an equal stride length and no limp while 

wearing flip-flops,” driving to a bank and convenience store, and walking from and to his 

car “without any observable gait difficulty.” Dr. McPhee’s report does not state exactly 

what Dr. McPhee said to Dr. Grove about the video surveillance, only that he described it 

and Dr. Grove was pleased with Plaintiff’s functioning. If Dr. Grove’s independent 

opinion conflicted with Dr. McPhee’s description of the video, he likely would have 

expressed surprise or disbelief, not that he was pleased with Plaintiff’s functioning. 

But it is unlikely that Dr. Grove actually held an independent opinion regarding 

Plaintiff’s functionality. Dr. Grove saw Plaintiff once in October 2011 for pain 

treatment, did not assess Plaintiff’s functionality, and wrote an office note stating 

Plaintiff had experienced significant relief and slight functional improvement. Nine days 

later he completed an Attending Physician Statement opining that Plaintiff had no ability 

to work based only on the fact that Plaintiff was not working. In April 2012, Dr. Grove 

had not seen Plaintiff since October 2011, but a second Attending Physician Statement 

substantially identical to the first was created with his signature. In July 2012, Dr. 

McPhee spoke with PA Jones, who had treated Plaintiff multiple times and described his 

left leg and foot as very functional, right leg and foot as limiting, and ability to stand as 

limited to 30-60 minutes at a time with 5-minute seated breaks. Aetna provided Dr. 

Grove with opportunity to review and respond to Dr. McPhee’s initial report. On July 20, 

2012, Dr. Grove wrote that Plaintiff had chronic swelling and pain in his right lower 

extremity, which prevented him from sitting more than 20-60 minutes before standing 

and walking for no more than 5-10 minutes at a time. After Aetna received Dr. Grove’s 

letter, it requested additional review by Dr. McPhee. When Dr. McPhee spoke with Dr. 

Grove about the letter, Dr. Grove stated that he had not restricted Plaintiff’s driving, he 

had relied on what Plaintiff told him, he believed Plaintiff could work with restrictions, 

and he agreed with the restrictions Dr. McPhee suggested, such as sitting with change of 

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position for 5 minutes every hour and standing limited to 30-60 minutes. There is no 

evidence that Dr. McPhee tainted Dr. Grove’s opinion. 

Finally, Plaintiff contends that “Aetna’s focus on surveillance demonstrates its 

bias” and “giving surveillance inordinate weight is improper.” However, the record does 

not show that Aetna gave the surveillance inordinate weight. Plaintiff states that Aetna 

did not mention video surveillance in its August 23, 2012 letter explaining Aetna’s 

rationale for determining that Plaintiff was no longer eligible for long-term disability 

benefits and did mention the June 2012 video in its June 18, 2013 letter upholding the 

original determination. Plaintiff also states that neither the peer reviewers nor the letters 

refer to the December 2011 video surveillance showing Plaintiff walking with a slight 

limp as though Aetna should have given greater weight to video surveillance, not less. 

Further, Plaintiff states, “Dr. McPhee briefly mentioned the June 2012 surveillance in his 

first report; however, his addendum focuses on the surveillance as the reason to reject 

[Plaintiff’s] complaints and Dr. Grove’s position on [Plaintiff’s] restrictions.” In fact, the 

description of the June 2012 video is identical in both reports. In the addendum Dr. 

McPhee also referred to it in the context of Dr. Grove’s July 20, 2012 letter mentioning 

that Plaintiff had been evaluated for post-polio syndrome. Moreover, Plaintiff’s medical 

records are consistent with the video surveillance showing that Plaintiff is able to walk 

short distances without assistance, stand for short periods of time, and drive without 

restriction and with no observable dizziness from pain medications. Aetna did not rely 

on surveillance while minimizing contrary medical evidence. 

Viewing the evidence in the light most favorable to Plaintiff, the evidence shows 

that Aetna’s structural conflict of interest as both claims administrator and insurer did not 

improperly influence its decision to terminate Plaintiff’s long-term disability benefits. 

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C. Aetna Did Not Abuse Its Discretion by Terminating Plaintiff’s LongTerm Disability Benefits. 

Plaintiff seeks to recover long-term disability benefits under the Plan from the date 

they were terminated, August 24, 2012, to the date of judgment and to have his long-term 

disability benefits reinstated. There is no dispute about Plaintiff’s medical condition or 

benefit status before August 24, 2012. The only question is whether Aetna abused its 

discretion in terminating Plaintiff’s long-term disability benefits on August 24, 2012, 

based on finding a lack of medical evidence showing that a functional impairment 

precluded Plaintiff from performing work at any reasonable occupation as of August 24, 

2012. Plaintiff contends he is, and has been, unable to work “at any reasonable 

occupation.” As explained below, Aetna did not abuse its discretion to terminate 

Plaintiff’s benefits because it fully explained its determination, developed facts necessary 

to its determination, and did not rely on clearly erroneous findings of fact in its 

determination. See Pacific Shores Hosp. v. United Behavioral Health, 764 F.3d 1030, 

1042 (9th Cir. 2014). 

1. The Record Supports Aetna’s Determination that Plaintiff 

Could Perform Light Work with Limited Standing and Walking 

As of August 24, 2012. 

Aetna determined that Plaintiff was unable to work as a specialty restaurant chef 

from November 5, 2009, through August 23, 2012. His multiple surgeries during this 

period precluded performing the material duties of his “own occupation,” i.e., specialty 

restaurant chef, which requires standing and walking for many hours. For example, in 

April 2010, Plaintiff returned to work as a chef, but experienced swelling in his right 

lower extremity after being on his feet for ten hours. As a result, his treating orthopedist 

opined that Plaintiff could perform full-time sedentary work, but not work involving 

prolonged standing. In July 2011, his treating podiatrist also opined that Plaintiff could 

perform sedentary work, but he could not continuously stand/walk for more than one 

hour at a time. 

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Plaintiff’s medical records after August 23, 2012, do not show that he became 

unable to perform sedentary work. During multiple office visits with pain management 

providers from November 2012 through February 2013, Plaintiff reported receiving pain 

relief from oral pain medications without side effects or impairments. In November 

2012, Plaintiff’s treating orthopedist evaluated Plaintiff for left knee pain. Based on 

physical examination, the orthopedist opined that Plaintiff’s left knee instability was 

related to left quadriceps weakness and atrophy, and he recommended physical therapy. 

In February 2013, upon physical examination, Plaintiff’s treating pain management 

specialist found Plaintiff had normal muscle strength and tone in upper and lower 

extremities, mild tenderness in the back and knees, and moderate tenderness with mild 

swelling along the right ankle. The specialist observed that Plaintiff walked with a slight 

limp on the right side. Two weeks later, the specialist injected Plaintiff’s left knee for 

what he described as “mild arthritis.” A week later, the specialist performed a lumbar 

nerve block for “vague nerve type pain” in his right lower extremity. In March 2013, 

Plaintiff reported that the relief provided by the lumbar nerve block had been temporary, 

and he was prescribed oral pain medications. There is no medical evidence in the record 

that shows that Plaintiff was unable to perform sedentary work after August 23, 2012. 

Plaintiff reported that in March 2013 he tried to return to work as chef. His ability 

to complete a two-day orientation that involved mostly sitting indicates that he was 

capable of performing sedentary work. His inability to work in the kitchen, which 

required standing with only brief breaks, does not show that he could not perform 

sedentary work. 

Aetna did not reject reliable evidence from Plaintiff and did not rely on clearly 

erroneous findings of fact in its determination. Plaintiff’s evidence does not contradict 

Aetna’s determination that Plaintiff was capable of performing light work with 

unrestricted sitting, standing limited to 30-60 minutes before changing positions for 5 

minutes, and walking limited to no more than 50 feet at a time. 

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2. The Record Supports Aetna’s Determination that “Reasonable 

Occupations” that Plaintiff Was Capable of Performing Existed 

as of August 24, 2012. 

The Plan defines “reasonable occupation” as any gainful activity for which the 

employee is, or may reasonably become, fitted by education, training, or experience, and 

which results in, or can be expected to result in, an income of more than 60% of the 

employee’s adjusted pre-disability earnings. Aetna determined that the following 

occupations could be performed with Plaintiff’s skills and functional limitations and 

would produce a reasonable wage of $17.19 per hour: food/beverage controller, 

supervisor order taker, hotel sales representative, repair order clerk, timekeeper, and 

referral clerk for a temp agency. Plaintiff contends the 2012 Transferable Skills Analysis 

by Coventry Health Care, vocational rehabilitation consultants, was flawed because (1) it 

relied on Plaintiff’s reported level of education; (2) it assumed that Plaintiff possessed the 

skills and abilities required for the position he had successfully performed for many 

years; (3) it used $17.19/hour instead of $17.48/hour as the target wage; and (4) it 

conflicted with the 2011 Transferable Skills Analysis by an Aetna vocational counselor. 

Aetna’s records and Plaintiff’s medical records consistently indicated that Plaintiff 

had at least a high school education. It is possible that when Plaintiff reported how many 

years of education he had completed, Plaintiff said “13,” but meant until the age of 13 

years, not 13 years of education. In the fall of 2011, Aetna’s vocational counselor spoke 

with Plaintiff at least twice in the fall of 2011 and continued to think Plaintiff had 

completed one year of college when she discussed with him seeking a new line of work. 

In July 2012, Plaintiff reported that he did not have one year of college education when 

an Aetna employee spoke with Plaintiff by telephone: 

EDUCATION/TRAINING: Mr. Yaakoubi reports to have the equivalent 

of a high school diploma in this country that he obtained in his native 

Morocco. He reportedly did not complete a year of college level work as 

indicated in his work history/education questionnaire but rather completed 

his high school education. He reportedly received on the job training to 

eventually become a chef. 

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In February 2013, Plaintiff’s pain specialist noted that Plaintiff was a high school 

graduate. About the same time, Plaintiff’s attorney told Aetna that Plaintiff “left school 

at age 13.” Plaintiff’s attorney attached a statement from Plaintiff that stated he went to 

elementary school from the age of 6 until the age of 13. The attorney also attached 

materials from O*NET related to the six occupations identified by Aetna. The O*NET 

documents show that most of the occupations usually require a high school diploma or 

equivalent, and some require additional vocational training, on-the-job training, or 

experience. They do not show, however, that if Plaintiff did not complete high school, it 

would preclude his ability to perform any of the six occupations. It was not necessary for 

Aetna to determine whether Plaintiff’s on-the-job training and experience constituted the 

equivalent of a high school education because the job description for his last position 

provided a detailed explanation of its requisite skills and competencies. 

Plaintiff worked as a chef for about fourteen years, the last nine of which for the 

Marriott. By October 2009, he earned approximately $57,500 annually and was 

responsible for planning, management, supervision, legal compliance, guest relations, and 

maintaining the operating budget for a specialty restaurant kitchen. His job description 

required basic computer skills, mathematical reasoning, oral comprehension, reading 

comprehension, and writing skills.6

 Aetna did not abuse its discretion by identifying as 

transferable skills and abilities the fundamental competencies required for accomplishing 

the basic work activities of the job he had successfully performed for many years. 

To identify reasonable occupations, Aetna used a target wage of $17.19/hour, 

calculated as 60% of Plaintiff’s last wage adjusted for cost-of-living changes. Aetna 

determined the target wage in July 2012. Plaintiff incorrectly contends that 60% of 

Plaintiff’s last wage, i.e., $16.60, should have been adjusted by 1.7% for 2012 as well as 

0% for 2010 and 3.6% for 2011, even though the 2012 year had not ended. Nevertheless, 

 6

 Plaintiff does not contend that the job description for Specialty Restaurant Chef 

that Marriott provided to Aetna is incorrect. 

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even if Aetna should have used $17.48 as the target wage, five of the six occupations 

would have produced a wage greater than $17.48. 

Finally, Plaintiff contends that Aetna should not have relied on the 2012 

Transferable Skills Analysis by Coventry Health Care instead of the 2011 Transferable 

Skills Analysis performed by Aetna’s vocational counselor. The vocational counselor 

called Plaintiff September 27, 2011, to discuss vocational rehabilitation and to ask 

whether he thought he would be able to participate in vocational rehabilitation services. 

Plaintiff said his doctor told him he would need to seek a new line of work based on his 

standing and walking restrictions. Plaintiff said he was interested in participating in 

vocational rehabilitation services. The vocational counselor encouraged Plaintiff to 

address vocational rehabilitation services with his doctor. She recommended that 

Plaintiff be referred to a local rehabilitation counselor for assistance with vocational 

exploration, possible retraining, and job placement options after obtaining a functional 

capacity assessment from his pain management specialist. Plaintiff did not tell her that 

he was unable to write correct sentences in English as he now contends, and she did not 

note any difficulty communicating with Plaintiff in English. 

After the telephone conversation, on the same day, the vocational counselor 

performed a preliminary Transferable Skills Analysis, based on limited and somewhat 

hypothetical information. The vocational counselor assumed that eventually Plaintiff 

would be able to perform a full-time sedentary job although at the time he was released to 

work only one hour a day. The vocational counselor did not have the Marriott job 

description for Specialty Restaurant Chef or a functional capacity assessment by a 

treating provider. Using only his work history as a chef and education as one year of 

college, the vocational counselor found one occupation, which she considered to be a 

“fair/limited,” not “good,” match for his transferable skills because Plaintiff lacked sales 

experience and had only limited computer skills. Aetna was not required to rely on the 

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internal 2011 Transferable Skills Analysis based on incomplete and hypothetical 

information. 

Thus, Aetna did not abuse its discretion by determining that Plaintiff was capable 

of performing a reasonable occupation as of August 24, 2012. 

3. Aetna Fully Explained Its Benefits Determination. 

Aetna’s August 23, 2012 letter stated the terms of the long-term disability policy, 

including the test of disability that applied after 24 months and the definitions of 

“reasonable occupation” and “adjusted pre-disability earnings.” It explained that 

although the initial 24 months of long-term disability benefits ended May 7, 2012, Aetna 

paid benefits beyond the initial 24 months while it completed review of Plaintiff’s claim. 

The letter identified the doctors from whom Aetna had obtained medical documentation, 

summarized the medical records, described the peer review process, and stated its 

conclusions regarding Plaintiff’s capabilities and limitations. It then identified 

occupations for which Plaintiff had the necessary skills that would produce a reasonable 

wage. The letter stated that Plaintiff’s claim was terminated and no further benefits were 

payable beyond August 23, 2012. The letter informed Plaintiff, however, that Aetna 

would review any additional information Plaintiff cared to submit and described in detail 

the type of information needed. It also informed Plaintiff of his right to seek a review of 

the decision with specific information regarding how to do so. 

Aetna’s June 18, 2013 letter explained the test of disability Plaintiff was required 

to meet to obtain long-term disability benefits after the initial 24 months and stated that, 

effective August 24, 2012, Plaintiff’s benefits were terminated due to a lack of medical 

evidence to support a functional impairment that precluded Plaintiff from performing 

work at any reasonable occupation as of August 24, 2012. The letter stated that Aetna 

forwarded Plaintiff’s file to independent physician reviewers who specialized in internal 

medicine and rehabilitation and summarized their findings, which supported the initial 

termination decision. The letter stated that Aetna’s original decision to terminate 

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Plaintiff’s long-term disability benefits was upheld, final, and not subject to further 

review. It also explained that if Plaintiff disagreed with the determination, Plaintiff had 

the right to bring a civil action under ERISA within one year of the final decision of his 

claim. 

Considering all the circumstances, the Court finds that Aetna did not abuse its 

discretion to terminate Plaintiff’s long-term disability benefits effective August 24, 2012. 

IT IS THEREFORE ORDERED that Plaintiff’s Motion for Judgment on the 

Administrative Record (Doc. 34) is denied. 

IT IS FURTHER ORDERED that the Clerk enter judgment in favor of Defendant 

and against Plaintiff. The Clerk shall terminate this case. 

 Dated this 9th day of December, 2015. 

Neil V. Wake

United States District Judge

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