Williby v. Aetna Life Ins. Co.

• Decision Date: 31 August 2015
• Docket Number: No. 2:14-cv-04203 CBM (MRWx),2:14-cv-04203 CBM (MRWx)
• Court: U.S. District Court — Central District of California
• Parties: YVETTE WILLIBY, Plaintiffs, v. AETNA LIFE INSURANCE COMPANY and DOES 1-10, inclusive, Defendants.

YVETTE WILLIBY, Plaintiffs, v. AETNA LIFE INSURANCE COMPANY and DOES 1-10, inclusive, Defendants.

No. 2:14-cv-04203 CBM (MRWx)

UNITED STATES DISTRICT COURT CENTRAL DISTRICT OF CALIFORNIA

August 31, 2015

FINDINGS OF FACT AND CONCLUSIONS OF LAW AFTER BENCH TRIAL

Before the Court is a bench trial based on the administrative record pursuant to the parties' stipulation. [Dkt. No. 28.] Having reviewed the administrative record, the parties' trial briefs and arguments of counsel, the Court makes the following findings of fact and conclusions of law pursuant to Fed. R. Civ. P. 52.¹

Plaintiff Yvette Williby ("Williby" or "Plaintiff") brings the present action against Defendant Aetna Life Insurance Company ("Defendant" or "Aetna")under the Employee Retirement Income Security Act of 1974 ("ERISA") after Aetna denied her claim for short term disability ("STD") and long term disability ("LTD") benefits under a plan established by her employer, Boeing (the "Plan").

Primarily at issue is Aetna's termination of STD benefits effective February 28, 2013. Plaintiff's claim for STD benefits beyond February 28, 2013 is supported by relevant medical records and opinions of four treating doctors: (1) neurologist Dr. Edelman; (2) neurologist Dr. Ullman; (3) psychiatrist Dr. Lindberg; and (4) neuropsychologist Dr. Budding. Aetna's termination of STD benefits effective February 28, 2013 is based on findings from three reviewing doctors: (1) neurologist Dr. Cohan; (2) occupational medicine specialist Dr. Swotinsky; and (3) neuropsychologist Dr. Mendelssohn.

I. JURISDICTION

The Court has jurisdiction pursuant to 29 U.S.C. § 1132(e).

II. FINDINGS OF FACT²

1. The Plan is comprised of a Master Welfare Plan and Governing Documents for each benefit program, including the Summary Plan Description ("SPD") for "Disability, Life, and Accident Plans." [A.R. 1-124.]

2. Boeing funds the Short-Term Disability Plan ("STD Plan"), and Aetna administers claims made under the LTD and STD Plans. [A.R. 12-13, 50-51, 114, 123.]

3. Plaintiff began working at Boeing on January 29, 1990. [A.R. at 293, 329, 562.] She was employed as a Supply Chain Specialist with the following job description:

Defines, plans, develops, coordinates, integrates, and manages support requirements . . . Analyzes and resolves support problems to ensure efficient product operation. Coordinates orperforms multi-discipline support tasks that leads to integrated support program (e.g., system support analysis, technical publications, training, supply support, support services, etc.) Interacts with internal and external customers, vendors and subcontractors. . . [p]erforms research and technical assessments and guides product design. [A.R. 715.]

4. Plaintiff was admitted to the hospital on September 8, 2011, with stroke symptoms. Plaintiff underwent a CAT scan and MRI, which showed findings consistent with a stroke. She was discharged two days later, and at that time, her neurological symptoms had resolved fortunately. [A.R. 853.]

5. Plaintiff saw neurologist Dr. David Edelman on November 14, 2012 for chronic headaches. [A.R. 585]

6. Plaintiff stopped working at Boeing on December 12, 2012. [A.R. at 293, 329, 562.]

7. Plaintiff saw neurologist, Dr. Edelman, on December 12, 2012. Dr. Edelman described Plaintiff's problems as "migraine, acute but ill-defined cerebrovascular disease, and vascular dementia uncomplicated." [A.R. 567-68.] Dr. Edelmen noted for Plaintiff to go on disability "pending further testing." [Id. at 568.]

PLAINTIFF'S CLAIM FOR STD BENEFITS.

8. Plaintiff submitted a claim for STD benefits in December 2012 that Aetna approved from December 20, 2012 through January 17, 2013. [Id., 561-66.]

9. A "Screening Physician Report" from December 13, 2012, showed results from computerized cognitive testing by Dr. Edelman, which found that Plaintiff's overall cognitive function score was within normal range, but her executive functions predicted a moderate likelihood of "mild cognitive impairment" (greater than 40%). [A.R. 570-571.]

10. An MRI from December 21, 2012, reported "no acute infarct nor hemorrhage and no mass." [A.R. 573-74.]

11. Neurologist Dr. Edelman stated on February 19, 2013, in an "Attending Provider's Statement," that Plaintiff needed to be absent from work due to disability from December 13, 2012, through June 1, 2013, based on three diagnoses: (1) mild cognitive impairment; (2) acute cerebrascular disease; and (3) migraine. [A.R. 587-588.]

12. Aetna advised Plaintiff on February 28, 2013, that it received additional medical documentation submitted for continued STD benefits. [A.R. 576-580.] Aetna approved Plaintiff's STD claim through February 28, 2013 based on findings from the MRI and cognitive testing which showed probable impairment of Plaintiff's executive functions (the ability to organize, respond quickly and inhibit incorrect responses). [A.R. 334-35.]

13. Aetna retained neurologist, Dr. Vaughn Cohan, to review Plaintiff's STD claim and determine whether Plaintiff's claim was supported beyond February 28, 2013. [A.R. 583-84.] On March 5, 2013, Dr. Cohan concluded based upon review of Plaintiff's medical records and a telephone consultation with Plaintiff's treating neurologist Dr. Edelman, the documentation failed to support functional impairment from February 28, 2013 through June 1, 2013. [Id. at 585-86.] Dr. Cohan acknowledged that the neurological exam by Dr. Edelman found problems with executive functioning, consistent with mild cognitive impairment, but found overall, the exam results were normal and Plaintiff's speech and memory functions were intact. [Id. at 585.] Dr. Cohan also explained that during the telephone consultation, Dr. Edelman stated that while formal neuropsychological testing would be required, Plaintiff had not returned for follow up. [Id.] Dr. Cohan also noted that the MRI from December 2012 showed white matter ischemic changes and an old small temporoparietal infarct but no acute abnormalities. [Id., 584.]

14. Aetna informed Plaintiff by letter that it terminated her STD benefitseffective February 28, 2013, explaining that its peer review process found that her "condition was not of a severity that would prevent her from working beyond February 28, 2013." [A.R. 606.] Aetna also denied Plaintiff's claim for LTD benefits because she was not eligible for LTD benefits having only received STD benefits from December 20, 2012 to February 28, 2013 (10 weeks—as opposed to the requisite 26-weeks). [Id.]

PLAINTIFF UNDERGOES FURTHER EVALUATION.

15. Plaintiff was evaluated by neurologist Dr. Edelman on April 30, 2013, and he found evidence that Plaintiff was suffering from cerebral infractions and cognitive problems. Dr. Edelman stated that he did not believe that Plaintiff was able to return to work at that time. [A.R. 833.] He noted that Plaintiff's headaches were not disabling, but her cognitive problems required further workup. [Id.]

16. Dr. Edelman examined Plaintiff again on May 28, 2013 and reported that Plaintiff was alert and oriented and her memory appeared intact. [A.R. 835-0836.] He further reported that Plaintiff's cranial nerves were normal, and described her problems as migraine, acute but ill-defined cerebrovascular disease, and vascular dementia uncomplicated. [Id.] Dr. Edelman reported similar findings about Plaintiff during three subsequent examinations on July 1, 2013, July 31, 2013, and November 26, 2013. [A.R. 837-38, 893-40, 765-766.]

17. On June 10, 2013, Plaintiff saw another neurologist, Dr. Bernard Ullman, for a consultation. Dr. Ullman reported that Plaintiff's motor function, coordination, and sensory exam appeared "unremarkable." [A.R. 782.]

18. Plaintiff had a follow-up visit with Dr. Ullman on August 12, 2013 during which he referenced findings from a June 5, 2013 neuropsychological evaluation by Dr. Wen, which found that Plaintiff's verbal comprehension index was average, and Plaintiff's IQ, processing speed index andperceptual reasoning index were low average.³ [A.R. 779-780.] Dr. Ullman listed the following under "impression" for Plaintiff: (1) Status post right hemisphere stroke; (2) Extensive small vessel ischemic disease of the brain; (3) Depression, as per neuropsychological testing, and (4) Cognitive problems. [Id., 779.] He opined that Plaintiff was disabled:

The patient scored poorly on many of the psychometric measures. There was some inconsistency, according to Dr. Wen. [] I think, therefore, that it is very important for the patient to have psychiatric evaluation and further treatment. . .[] I do believe that she is disabled at this time and needs the psychiatric treatment, and then re-testing and a new psychological profile before a judgment can be made on her ability to go back to work. [Id., 780.]

19. On August 15, 2013, neurologist Dr. Edelman certified Plaintiff's disability due to (1) mild cognitive impairment; (2) acute cerebrovascular disease; and (3) migraine. [A.R. 747.]

20. Dr. Edelman saw Plaintiff on August 27, 2013, and reported that Plaintiff's cranial nerves were normal and described her problems as migraine, acute but ill-defined cerebrovascular disease, and vascular dementia uncomplicated. [A.R. 762-63.]

21. On August 27, 2013, Dr. Edelmen requested that Plaintiff's medical leave be extended until further treatment. [A.R. 656.]

22. On September 10, 2013, Dr. Edelman opined that Plaintiff was disabled due to cognitive impairment:

Williby presented with severe headaches and her initial diagnosis was migraine type headaches. However, MRI scan of the brain showed evidence of stroke, and subsequent testing showed evidence of an autoimmune type disorder. Her initial diagnosis was based upon her clinical presentation andsubsequent diagnoses were based on her MRI scan and other testing. She has also been seen by Dr. Wen and by Dr. Ullman. They've also been [sic] confirmed her cognitive impairments. Based upon her cognitive impairments alone, she is disabled. [A.R. 785 (emphasis added).]

23. As of October 8, 2013,

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