Source: https://case-law.vlex.com/vid/williby-v-aetna-life-691571509
Timestamp: 2019-04-22 18:05:57+00:00

Document:
Opinion Judge: FEINERMAN, DISTRICT JUDGE.
Party Name: Yvette Williby, Plaintiff-Appellee, v. Aetna Life Insurance Co., Defendant-Appellant.
Judge Panel: Before: Milan D. Smith, Jr. and N. Randy Smith, Circuit Judges, and Gary Feinerman, District Judge.
Aetna Life Insurance Co., Defendant-Appellant.
Plaintiff-Appellee Yvette Williby worked for The Boeing Company, which provided her with short-term disability payments through a plan that it self-funded. Defendant-Appellant Aetna Life Insurance Company administered the plan. After Aetna determined that Williby was not disabled and terminated her benefits, Williby brought suit under the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. §§ 1001-1461. Applying de novo review, the district court held that Aetna improperly denied Williby's claim. See Williby v. Aetna Life Ins. Co., No. 2:14-CV-042032015 WL 5145499 (C.D. Cal. Aug. 31, 2015). Aetna appeals, contending that the district court should have reviewed the denial only for abuse of discretion. Aetna is correct, so we vacate and remand to the district court for reconsideration under the proper standard of review.
Boeing's short-term disability (STD) benefit plan for its employees pays them between sixty and eighty percent of their salary if, because of a disability, they cannot perform their usual job responsibilities or other similar work at Boeing. The STD plan is self-funded, meaning that Boeing does not purchase an insurance policy to cover its plan obligations; rather, Boeing pays benefits from its own coffers, and retains Aetna to administer the plan. See FMC Corp. v. Holliday, 498 U.S. 52, 54 (1990) (describing self-funded ERISA plans). There is a 26-week limit on STD benefits, after which the employee must apply for long-term disability (LTD) benefits.
The STD plan expressly provides Aetna with "full discretionary authority to determine all questions that may arise, " including whether and to what extent a plan participant is entitled to benefits. This provision is known as a "discretionary clause." See Standard Ins. Co. v. Morrison, 584 F.3d 837, 840-41 (9th Cir. 2009) (describing discretionary clauses). The presence of a discretionary clause typically means that a court reviewing an adverse benefits determination will do so only for abuse of discretion. See Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989); Abatie v. Alta Health & Life Ins. Co., 458 F.3d 955, 963 (9th Cir. 2006) (en banc).
Williby worked for Boeing as a Supply Chain Specialist, a position that required her to problem-solve, interact with customers and vendors, conduct research, and assess technical issues. In September 2011, she was briefly hospitalized after suffering either a stroke or a stroke-like episode. In November 2012, Williby found herself experiencing chronic headaches and other problems that caused her difficulty at work. In December 2012, she saw a neurologist, Dr. David Edelman, who performed various assessments. Computerized cognitive tests showed that Williby's overall cognitive function fell within a normal range, and an MRI revealed no "acute infarct"-brain tissue damage-and no hemorrhage. But Williby's executive functions-the ability to organize information and to respond quickly and accurately-"predicted a moderate likelihood of 'mild cognitive impairment.'" Dr. Edelman found that Williby suffered from "migraine, acute but ill-defined cerebrovascular disease, and vascular dementia uncomplicated, " and on those premises concluded that she should go on disability "pending further testing." On December 12, 2012, Williby left her employment at Boeing, never to return.
Aetna approved Williby for STD benefits from December 20, 2012 through February 28, 2013 based on Dr. Edelman's testing and conclusions. However, Aetna denied Williby STD benefits for the period from February 28, 2013 through June 2013. Dr. Vaughn Cohan, the Aetna-retained neurologist responsible for the denial, reviewed the file, spoke with Dr. Edelman by telephone, and concluded that Williby could still work because, despite her executive function impairments, her cognitive function was normal overall, the MRI showed no "acute" abnormalities, and she had not undergone formal neuropsychological testing to follow up on Dr. Edelman's initial tests.
After Aetna terminated Williby's STD benefits, she appealed the decision within Aetna, armed with the additional doctors' reports. Aetna hired an occupational medicine specialist and a neuropsychologist to review the case. Both reviewers concluded that there was insufficient objective documentation of Williby's disability, with the occupational medicine specialist explaining that any impairment was "self-reported" and "primarily based on mood disorder/behavioral issues, " and the neuropsychologist concluding that "the provided information did not include sufficient findings to corroborate" Williby's claimed cognitive impairments or their interference with her work. Aetna upheld its decision to deny benefits in February 2014, determining that "there was insufficient medical evidence to support continued disability" after February 28, 2013.
Williby then sued Aetna in the Central District of California for "breach of plan and recovery of plan benefits" under ERISA, invoking ERISA's jurisdictional provision, 29 U.S.C. § 1132(e). A bench trial ensued, based on the administrative record.

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