Silver v. Executive Car Leasing Long-Term

• Decision Date: 07 August 2006
• Docket Number: No. 04-55747.,04-55747.
• Citation: 466 F.3d 727
• Parties: Marc S. SILVER, Plaintiff-Appellant, v. EXECUTIVE CAR LEASING LONGTERM DISABILITY PLAN, an employee welfare benefits plan under ERISA, Defendant-Appellee.
• Court: U.S. Court of Appeals — Ninth Circuit

466 F.3d 727

Marc S. SILVER, Plaintiff-Appellant, v. EXECUTIVE CAR LEASING LONGTERM DISABILITY PLAN, an employee welfare benefits plan under ERISA, Defendant-Appellee.

No. 04-55747.

United States Court of Appeals, Ninth Circuit.

Argued and Submitted February 14, 2006.

Filed August 7, 2006.

Amended October 6, 2006.

Lyle R. Mink, Esq., Los Angeles, CA, for the plaintiff-appellant.

Stacey R. Turner, Esq., Los Angeles, CA, for the defendant-appellee.

Appeal from the United States District Court for the Central District of California; Stephen V. Wilson, District Judge, Presiding. D.C. No. CV-02-05279-SVW.

Before: B. FLETCHER, FERGUSON, and CALLAHAN, Circuit Judges.

ORDER

The opinion filed August 7, 2006 at slip op. 8907 is amended as follows:

The final paragraph of the Standard of Review Section at slip op. 8918-19 is deleted and replaced by the following:

We note that scrutiny is especially warranted when, after conducting de novo review of a decision by an ERISA plan administrator, a district court adopts verbatim the administrator's proposed factual findings and legal conclusions. We have previously emphasized that, when they conduct de novo review, district courts have a responsibility under the ERISA framework to undertake an independent and thorough inspection of an administrator's decision. See Mongeluzo, 46 F.3d at 943 (emphasizing the obligation of the district court to conduct a sufficiently thorough review of the record, as well as its authority to introduce additional evidence into the record, in order to "enable the full exercise of informed and independent judgment"). When a district court adopts wholesale and verbatim the findings and conclusions of an ERISA plan administrator, it behooves us to review the district court's findings carefully to ensure that the trial court has adequately discharged its responsibility. Wariness of a district court's verbatim adoption of a plan administrator's proposed findings is especially warranted in the ERISA context because of the complex and sometimes conflicting roles of plan administrators. See Abatie v. Alta Health & Life Ins. Co., 458 F.3d 955, 959 (9th Cir.2006) (noting that a district court's review of an administrator's decision must be "tempered by skepticism commensurate with the plan administrator's conflict of interest"); In re T.H. Richards Processing Co., 910 F.2d 639, 643 n. 2 (9th Cir.1990) (noting that courts must be wary of borrowed findings in any event); Sealy, Inc. v. Easy Living, Inc., 743 F.2d 1378, 1385 n. 3 (9th Cir.1984) (same).

With that amendment we reinstate the mandate.

OPINION

BETTY B. FLETCHER, Circuit Judge:

Marc Silver claims that he is disabled due to the deteriorating condition of his heart. He argues that, as a result of his disabling heart condition, he is entitled to benefits under an insurance policy issued by the UNUM Life Insurance Company of America ("UNUM"). UNUM claims that Silver recovered from his disability and that under the terms of the policy he is therefore not entitled to benefits. Following a bench trial, the district court upheld UNUM's decision to deny Silver's claim. We now reverse.

I. FACTUAL AND PROCEDURAL BACKGROUND

Since 1974, Executive Car Leasing has provided coverage for its employees under a long-term disability insurance policy ("Policy"). The Policy is administered by UNUM and governed by the Employee Retirement Income Security Act ("ERISA"), 29 U.S.C. §§ 1001 et seq. It provides benefits to Executive Car Leasing employees who suffer a loss of earnings due to disability. To qualify as disabled under the Policy, a claimant must demonstrate that "because of injury or sickness ... [he] cannot perform each of the material duties of his regular occupation." Also, because the Policy covers only long-term disabilities, it establishes a 90-day "elimination period," during which time no benefits are payable. Thus, to receive benefits under the UNUM Policy, a claimant must establish not only that he is disabled, but also that he is disabled continuously for 90 days following the initial date on which he claims disability. If the claimant fails to show that he is continuously disabled throughout this elimination period and does not return to work after those 90 days, coverage under the Policy terminates.

Silver, an Executive Car Leasing employee who was covered under the UNUM Policy, has a lengthy history of severe heart disease. He is a long-time smoker— medical records indicate that he smoked up to one and a half packs a day for as many as 30 years—and for nearly as long he has suffered from claudication, or cramping, in his legs, which is a symptom of peripheral heart disease. In 1980, he suffered a myocardial infarction (a heart attack). Doctors discovered that 17350 three vessels in his heart were blocked, and he underwent triple-bypass surgery to circumvent the obstructions. In 1983, he suffered another heart attack when one of the grafts from his bypass surgery became completely obstructed. He returned to the hospital complaining of chest pain in 1989 and 1991, and when he returned yet again in 1992, cardiologists found multiple pathways obstructed and conducted another triple-bypass surgery. In November of 1998, doctors again found that several of Silver's blood vessels were partially or entirely occluded. This time, they performed angioplasty—a procedure in which a small balloon is first inserted into the obstructed blood vessel and then inflated to clear the obstruction.

Despite these medical problems, Silver continued to work as a sales manager at Executive Car Leasing. His job generally required him to work around nine hours a day and demanded that he fulfill sales quotas for the company. Silver claims that the work was stressful for him, and UNUM has conceded that his employment at Executive Car Leasing required him to work under stressful conditions.

The events giving rise to this lawsuit started to unfold when, in December of 2000, he once again started having chest pain. On December 14, 2000, Silver sought treatment at Western Medical Center in Santa Ana, California, after experiencing acute chest pain and angina, or shortness of breath. An initial examination excluded the possibility of another heart attack, but concluded that Silver would require a cardiac catheterization (his fifth such procedure) and possibly another angioplasty procedure. Further examination revealed that there were lesions in two of his blood vessels and that several other vessels were occluded, or blocked, with the openings in some of these vessels narrowed by as much as 95 percent. Doctors performed another angioplasty on Silver, his second. Medical reports from this hospitalization indicate that the procedure was successful and that the results from the angioplasty were excellent. Upon his release from the hospital, Silver consulted his long-time cardiologist, Dr. Melvin Tonkon, who advised him to stop working. Silver followed Dr. Tonkon's advice, stopped working, and filed a claim for benefits under the UNUM Policy. He described his disability as "heart disease and angioplasty," and he listed his date of disability as December 14, 2000—the date on which his second angioplasty procedure had been performed.

In the 90 days that followed his second angioplasty procedure—i.e., during the critical "elimination period" that followed his purported "date of disability"—Silver continued to experience complications related to his cardiac condition. He visited a pulmonary specialist, Dr. Fox, whose records contain mixed news on Silver's condition—while Dr. Fox noted that there was only "mild obstruction" of some of Silver's blood vessels, he also reported that Silver complained of shortness of breath, that Silver was experiencing decreased blood flow on the left side of his body (which another doctor attributed to a partially occluded artery), and that Silver had symptoms consistent with chronic bronchitis and emphysema. Silver also/visited a sleep specialist, who diagnosed Silver as having "obstructive sleep apnea," a condition related to high blood pressure and other cardiovascular disease that causes its sufferers to stop breathing repeatedly during their sleep, sometime hundreds of times during the night and often for a minute or longer. Again during the elimination period Silver returned to the emergency room after waking up with "sharp, stabbing" chest pain. The medical records from this visit contain mixed results. Some tests indicated an "abnormal resting electrocardiogram" and "changes of uncertain significance" in Silver's heart condition, including one diagnosis that suspected partial blockage of his "left subclavian" artery. With other tests, doctors noted that there had been improvement in the area where angioplasty had been performed, and they ultimately released Silver from the, hospital without change in his medical condition. Throughout the elimination period, Silver worked with Dr. Tonkon on a program of cardiac rehabilitation; due to concerns about being able to drive safely to and from the proper medical facilities, he pursued this rehabilitation program at home.

Following the end of the 90-day elimination period, Silver's cardiac woes continued. He returned to Western Medical Center on May 28, 2001, complaining of chest pain. Once again, doctors found his heart in poor condition, with his right coronary artery and his left anterior descending artery nearly completely blocked. Again, doctors performed an angioplasty procedure. This third angioplasty procedure was completed with "no complications," and Silver was again released. Thereafter, Silver successfully pursued a claim for disability benefits from the Social Security Administration (SSA). Though the SSA ultimately determined that Silver was entitled to benefits as a result of a psychological exam diagnosing him with affective mood disorder, the SSA also determined that Silver "became disabled under our rules on December 14,...