Source: http://health-abstracts.com/k/kantorlaw.net1.html
Timestamp: 2019-04-26 07:37:24+00:00

Document:
(2) de novo review applied to claim challenging denial of long-term disability benefits.
claim was closed and the February 12, 2004 date of death].” Aetna did not speak with Dr.
Wallace prior to upholding its denial.
Plaintiff filed a Request for Judicial Notice wherein he asks this Court to take judicial notice of the following: (1) The Opinion Letter of the California Department of Insurance, dated February 26, 2004; (2) The Amazon web page for Dubois' Lupus Erthematosus by Dr. Daniel Wallace et al.; and (3) The Amazon web page for The Lupus Book: A Guide for Patients and Their Families by Dr. Daniel Wallace. He also filed a Supplemental Request for Judicial Notice wherein he asks this Court take judicial notice of a page from the web site of the American Academy of Allergy Asthma & Immunology, located on the Internet at the URL http:// www.aaaai.org/patients/publicedmat/tips/roleoftheallergist.stm. Aetna filed a Request for Judicial Notice wherein it asks this Court to take judicial notice of Memorandum Opinion, Mitchell v. Aetna Life Insurance Co., CV 03-9605 ER (RNBx), filed February 2, 2005. A court must take judicial notice if a party requests it and supplies the court with the requisite information. Fed.R.Evid. 201(d). “A judicially noticed fact must be one not subject to reasonable dispute in that it is either (1) generally known within the territorial jurisdiction of the trial court or (2) capable of accurate and ready determination by resort to sources whose accuracy cannot reasonably be questioned.” Fed.R.Evid. 201(b). A court may take judicial notice of “records and reports of administrative bodies.” Mack, 798 F.2d at 1282 (citing Interstate Natural Gas Co. v. Southern California Gas Co., 209 F.2d 380, 385 (9th Cir.1953)). In addition, this Court may take judicial notice of its own records, and documents that are public records and capable of accurate and ready confirmation by sources that cannot reasonably be questioned. See *966 MGIC Indem. Corp. v. Weisman, 803 F.2d 500, 504 (9th Cir.1986) (courts may take judicial notice of matters of public record outside the pleadings); United States v. Wilson, 631 F.2d 118, 119 (9th Cir.1980)( “In particular, a court may take judicial notice of its own records in other cases, as well as the records of an inferior court in other cases.”). Based on the foregoing, this Court finds that the requests are proper. Aetna objects to Plaintiff's request on the following grounds: hearsay, lack of authentication, certification or verification, and that ERISA limits a Court's review to matter contained in the record at the time of the review. This Court finds that Aetna's objections lack merit as the documents are the proper subject of judicial notice according to Rule 201(b). Furthermore, in determining the standard of review, the Court is permitted to review evidence outside of the administrative record. Tremain v. Bell Industries, Inc., 196 F.3d 970, 976-77 (9th Cir.1999)(“In determining whether a plan administrator's conflict of interest affected its decision to deny benefits, evidence outside the administrative record may be considered.”). Thus, this Court grants said Requests for Judicial Notice and hereby takes judicial notice of the aforementioned documents.
benefits. As such, this Court denies Aetna's Motion to Strike.
show that the declarant or affiant is competent to testify as to the facts at issue. See Fed.R.Civ.P.
of fact. See Taylor v. List, 880 F.2d 1040, 1045 (9th Cir.1989).
In his Motion, Plaintiff seeks summary adjudication on the proper standard of review of the plan administrator's decision to deny Ms. Wible's LTD benefits. More specifically, he asks this Court to determine that the appropriate standard of review on which to decide this case should be de novo. In response, Aetna contends that the appropriate standard of review should be abuse of discretion.FN3 FN3. Thus, the merits of Plaintiff's claim regarding the entitlement to the LTD benefits is not before this Court at this time.
rebutting the presumption, then the de novo standard of review is applied. Id.
breach of its fiduciary obligations to Ms. Wible.
Aetna ignored, or at a minimum discounted, the opinion of Dr. Wallace. For over ten years, Dr. Wallace treated Ms. Wible during her battle with Lupus. Ms. Wible's medial records show that during flares, she would have to be treated with powerful steroids and immunosuppressives, which would manage Ms. Wible's symptoms, but their toxic nature would cause other negative impacts, including a lack of cognitive function and a susceptibility to other illnesses. As an example that Aetna ignored Dr. Wallace's opinion, Plaintiff points to Dr. Wallace's statements about the impact of the drugs Ms. Wible was taking. As Plaintiff argues, Aetna disregarded the impact of Ms. Wible's medication on her mental state. Aetna stated that Dr. Wallace's determination regarding Ms. Wible's mental state was unsupported, that there was “no indication that [Ms. Wible was] being treated for [her] mental health condition” (AR 425; P 21) and that she had not undergone a “mental status exam” or any other psychological testing to determine the scope of her disability. (AR 1318; P 175.) Aetna fails to explain why Dr. Wallace could not opine regarding Ms. Wible's mental difficulties given the fact that degradation of mental facilities in some patients is a documented side effect of the steroids taken as treatment. Indeed, had Aetna believed such tests were necessary before paying continued benefits, it could have ordered them. It did not, and Aetna cannot refuse to credit Dr. Wallace's statements about Ms. Wible's loss of cognitive function, which he stated was obvious during even a short conversation with her, through the absence of tests they never required and Dr. Wallace didn't need. In its Opposition, Aetna contends that there was “substantial evidence in the record contradicting Dr. Wallace's conclusions regarding Ms. Wible's ability to work,” yet it fails to cite to any such evidence. It makes the same assertion that it made at the time of denial-that Dr. Wallace's opinion was not supported by “objective data.” Essentially, then, it ignores unfavorable evidence on the basis that it is not supported by other, non-existent evidence. Aetna fails to provide any evidence contradicting the statements of Drs. Wallace and Damle that Ms. Wible suffered from memory loss and loss of concentration as a result of the drugs she was taking. In sum, as Dr. Wallace states in his response to Dr. Bardana: To conclude, when you have a patient with documented seizures, organic brain syndrome with a mild dementia, hypertension, sun-restrictions, inflammatory arthritis, immune suppression, and scarred-down lungs, it does not take a rocket scientist to ascertain that this patient has significant restrictions.
even been sent to an IME, much less that the IME had concluded she was disabled.
Aetna ignored its own surveillance which showed that Ms. Wible lived the life of a seriously disabled person. In the course of handling this case, Aetna engaged in an intense regimen of covert surveillance. Specifically, for eight full days, Aetna used investigators to watch Ms. Wible. This surveillance demonstrated that Ms. Wible was, in fact, living the life one would expect of a seriously disabled person. A summary of the surveillance is as follows: • October 27, 2001-Ms. Wible was not seen (AR 579; P 76); • November 9, 2001-Ms. Wible left her residence for a brief period to walk a visitor to her car, otherwise stayed in the house all day (AR 580; P 77); *971 • November 10, 2001-Ms. Wible left her residence for a brief period to go through the drive-thru at a Del Taco, otherwise stayed inside her home (AR 58-81; P 77-78); • November 13, 2001-Ms. Wible drove a friend to an AM/PM and waited in the car while the friend shopped. Later, Ms. Wible was driven by her husband to a burger restaurant for lunch, and later she went to a medical appointment (AR 581-83; P 78-80); • March 21, 2002-Ms. Wible was seen going to Vons and then K-Mart with an elderly couple, otherwise she stayed in her home all day (AR 964); • March 22, 2002-Ms. Wible left her home for about two minutes while she talked to a friend on the sidewalk, otherwise she stayed in her home all day (AR 864); • March 23, 2002-Ms. Wible was not seen (AR 965); • April 3, 2002-Ms. Wible stayed inside her home all day (AR 1335-6; P 189-90). These surveillance results were consistent with Ms. Wible's described claims and activities. Instead of finding inconsistent activities because the claimant did not know someone was watching, Aetna found the opposite. As such, it conveniently chose to ignore the results. Aetna did not mention the surveillance either in the denial letter or the uphold letter.
conclusion. However, an SSA determination is evidence of a claimant's disability ( see Kirwan v.
pattern of considering only those few pieces of evidence that supported its claim.
which results it wants to follow, or initiates these actions merely to find a basis to deny benefits.
very condition which Aetna claimed did not prevent her from working.
In sum, this Court concludes that Plaintiff has “come forward with material, probative evidence, beyond the mere fact of the apparent conflict, tending to show that the fiduciary's [Aetna's] self-interest caused a breach of the administrator's fiduciary obligations to the beneficiary,” and Aetna has failed to present any evidence to rebut the resulting presumption. The record reflects that Aetna ignored, or at best, discounted the opinion of Ms. Wible's long-time treating physician, Dr. Wallace. Aetna then sent Ms. Wible for an IME with a physician of its own choosing, Dr. Damle. It proceeded to discount Dr. Damle's opinion. Aetna ordered surveillance of Ms. Wible for eight full days and discounted the results of the surveillance. It ignored the fact that Ms. Wible was found to be disabled by the Social Security Administration. Instead, Aetna chose to focus on the file review of Dr. Bardana, a physician who never met or spoke to Ms. Wible. *975 Significantly, Aetna failed to take the fact of Ms. Wible's death, within six months of the denial of her claim, into account. The sum of this evidence shows that Aetna was “bent on denying [Ms. Wible's] claim” and “oblivious to [its] fiduciary obligations as an administrator of the LTD Plan.” Friedrich v. Intel, 181 F.3d 1105, 1110 (9th Cir.1999). Because Aetna failed to act as a fiduciary, it should not be entitled to a deferential standard of review to which a fiduciary is normally entitled. Accordingly, this Court concludes that the proper standard of review of the plan administrator's decision to deny benefits is de novo as a matter of law.FN8 FN8. As stated above, Plaintiff also asks this Court to find that de novo review is warranted on the basis that the language granting discretion to Aetna in the Policy violates California insurance law. Based on the determinations set forth herein, this Court concludes that it need not address this additional argument.
Wible's Motion for Summary Adjudication on the Proper Standard of Review.

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