Adkins v. Life Ins. Co. of N. Am.

522 F.Supp.3d 830

Carrie ADKINS, Plaintiff,

v.LIFE INSURANCE COMPANY OF NORTH AMERICA, Defendant.

NO. 4:20-CV-5104-TOR

United States District Court, E.D. Washington.

Signed March 1, 2021

Melton L. Crawford, Law Office of Mel Crawford, Seattle, WA, for Plaintiff.

Stephania Evelyn Camp Denton, D. Michael Reilly, Lane Powell PC, Seattle, WA, for Defendant.

ORDER DENYING PLAINTIFF'S MOTION FOR JUDGMENT AND GRANTING DEFENDANT'S MOTION FOR JUDGMENT

THOMAS O. RICE, United States District Judge

BEFORE THE COURT are the parties’ cross-motions for judgment on the administrative record (ECF Nos. 17, 19). This matter was submitted for consideration without oral argument. The Court has reviewed the record and files herein, and is fully informed. For the reasons discussed below, Plaintiff's Motion for Judgment (ECF No. 17) is DENIED and Defendant's Motion for Judgment (ECF No. 19) is GRANTED.

BACKGROUND

This is an action to recover long-term disability benefits allegedly owing to Plaintiff under Section 502(a) of the Employee Retirement Income Security Act ("ERISA"), 29 U.S.C. § 1132(a). In the instant cross-motions, the parties ask the Court to review the administrative record de novo and resolve any factual disputes concerning Plaintiff's entitlement to benefits pursuant to Federal Rule of Civil Procedure 52(a). The parties are seeking judgment with regard to Plaintiff's claim arising under § 1132(a)(1)(B) ; Plaintiff's remaining claim under § 1132(a)(3) is not presently before the Court.

For the reasons discussed below, the Court finds that Plaintiff is not "disabled" within the meaning of Defendant's policy and is therefore not entitled to payment of benefits.

STANDARD OF REVIEW

The default standard of review in ERISA cases is de novo , "unless the benefit plan gives the administrator or fiduciary discretionary authority to determine eligibility for benefits or to construe the terms of the plan." Firestone Tire & Rubber Co. v. Bruch , 489 U.S. 101, 115, 109 S.Ct. 948, 103 L.Ed.2d 80 (1989). Where the plan administrator or fiduciary retains discretionary authority to interpret the plan and determine benefits, then an abuse of discretion standard applies. Id. Here, LINA is the plan fiduciary and has discretionary authority to interpret the terms of the plan, determine eligibility, and make findings of fact. AR 1988. Under Supreme Court and Ninth Circuit precedent, this would ordinarily trigger an abuse of discretion standard. See Firestone , 489 U.S. 101, 109 S.Ct. 948, 103 L.Ed.2d 80 ; Abatie v. Alta Health & Life Ins. Co. , 458 F.3d 955 (9th Cir. 2006).

However, Washington state insurance regulations prohibit disability insurance plans from containing discretionary clauses. See WAC 284-96-012. Although ERISA broadly preempts state law and regulation, courts have concluded WAC 284-96-012 invalidates discretionary clauses in disability insurance plans. See, e.g., Mirick v. Prudential Ins. Co. of Am. , 100 F. Supp. 3d 1094 (W.D. Wash. 2015). The parties agree, de novo review is the standard here. De novo review affords no deference to the plan administrator's determination. McDaniel v. Chevron Corp. , 203 F.3d 1099, 1108 (9th Cir. 2000). The plaintiff has the burden of proving disability. Muniz v. Amec Const. Mgmt., Inc. , 623 F.3d 1290, 1294 (9th Cir. 2010).

The parties agree the challenged benefits decision under § 1132(a)(1)(B) should be resolved pursuant to Federal Rule of Civil Procedure 52(a). ECF No. 13 at 7. Where a court reviews an ERISA action under Rule 52(a), the court conducts "a bench trial on the record" using the material considered by the plan administrator. Kearney v. Standard Ins. Co. , 175 F.3d 1084, 1095 (9th Cir. 1999). Evidence outside the administrative record may only be considered when "circumstances clearly establish that it is necessary to conduct an adequate de novo review of the benefit decision." Ingram v. Martin Marietta Long Term Disability Income Plan for Salaried Emp. of Transferred GE Operations , 244 F.3d 1109, 1115 (9th Cir. 2001) (quotation and citation omitted). In an ERISA action, the relevant inquiry under Rule 52(a) is not whether there are genuine issues of material fact, but whether the plaintiff "is disabled within the terms of the policy." Kearney , 175 F.3d at 1095.

The court must necessarily weigh conflicting evidence and resolve disputed factual issues. Id. Rule 52(a) further requires the court to "find the facts specially and state its conclusions of law separately." Fed. R. Civ. P. 52(a)(1).

SUMMARY OF ADMINISTRATIVE RECORD

A. Plaintiff's Symptoms

At all times relevant to these proceedings, Plaintiff Carrie Adkins ("Plaintiff") was insured under a disability insurance plan issued by Defendant Life Insurance Company of North America ("Defendant"). This plan provides for long-term disability ("LTD") benefits to an insured who becomes "disabled." The plan defines "Disability/Disabled" as follows:

The Employee is considered Disabled if, solely because of Injury or Sickness, he or she is:

1. unable to perform the material duties of his or her Regular Occupation; and

2. unable to earn 80% or more of his or her Indexed Earnings from working in his or her Regular Occupation.

AR 44. The plan defines "Regular Occupation" as:

The occupation the Employee routinely performs at the time the Disability begins. In evaluating the Disability, the Insurance Company will consider the duties of the occupation as it is normally performed in the general labor market in the national economy. It is not work tasks that are performed for a specific employer or at a specific location.

AR 116.

Plaintiff alleges she began experiencing neck, back, and shoulder pain, as well as traumatic brain injury symptoms, following a car accident in January 2016. ECF No. 17 at 4; AR 644. Imaging of Plaintiff's cervical spine taken on January 19, 2016 showed "mild degenerative disc disease," "mild spondylolisthesis," and suspected "mild facet arthritis." AR 3438. The administrative record does not contain any other medical records from 2016; however, later medical evaluations reference Plaintiff's symptoms during that timeframe.

A psychological report conducted in 2018 summarized a Speech Therapy Initial Plan of Care from February 24, 2016 as follows:

[Plaintiff] presented with mild to moderage [sic] cognitive and communication deficits secondary to concussion. Cognitive communication assessment revealed reduced complex attention, speed of processing, working memory, verbal fluency and cognitive endurance. All affect her daily functioning. She is unable to track details and information and to express herself effectively. She would like to return to work. She reports moderate impairment in her life. She has vision and balance changes that adversely affect her cognitive-linguistic performance. OT and PT orders are being requested.

AR 633. Another psychological report conducted in September 2019 indicated Plaintiff attempted to return to work part-time following the accident, but "was forced to leave" due to "severe headaches, confusion, poor concentration, visual impairments, and other sequelae of the presumable head injury." AR 629. At the time of the 2016 accident, Plaintiff worked full-time as an office manager for a medical practice in Portland, Oregon. Id.

In May 2107, Plaintiff moved from Portland, Oregon to Walla Walla, Washington because she "found it easier to manage in the smaller town." AR 644. Plaintiff began working for Providence Medical Center part-time as a receptionist in October 2017. AR 629, 644. Plaintiff alleged continued symptoms relating to her brain injury, such as "severe migraines, nausea, vomiting, dizziness, balance problems, light sensitivity" and was "easily over-stimulated." AR 644. Plaintiff also reported chronic fatigue and chronic pain. Id.

It is unclear what, if any, medical care Plaintiff received between January 19, 2016 and February 4, 2018. Medical records for that timeframe are not presently before the Court.

On February 5, 2018, Plaintiff was referred by a disability adjudicator to licensed psychologist N.K. Marks, Ph.D., for a "psychodiagnostics memory assessment." AR 633. Dr. Marks reviewed two medical records, including the February 2016 Speech Therapy Initial Plan of Care and a June 2017 evaluation from Insight Osteopathic Medicine, in addition to conducting an in-person exam of Plaintiff. Id. Dr. Marks diagnosed Plaintiff with the following conditions: "Mild neurocognitive disorder due to traumatic brain injury ; Major depressive disorder, Single episode, Moderate; and Unspecified anxiety disorder, moderate." AR 639.

Regarding Plaintiff's ability to work, Dr. Marks opined Plaintiff could "manage simple directions that she sees and hears, but not complex directives" and that Plaintiff's concentration became "tangential at times." AR 639-40. Dr. Marks also found Plaintiff's "[m]ental fatigue may be worsened with intense social interactions" and Plaintiff's brain injury made "it hard to process things," which could lead to Plaintiff becoming "stressed with increased work demands." AR 640. Dr. Marks recommended counseling to assist with Plaintiff's depression and anxiety. Id. It does not appear Plaintiff saw Dr. Marks again.

At some point, Plaintiff began seeing Justin Olswanger, D.O., for her chronic pain and anxiety. The first record available to the Court is dated March 15, 2018. AR 357. On that date, Dr. Olswanger adjusted Plaintiff's pain medications and assessed Plaintiff as "alert, cooperative, dressed appropriately" and not in acute distress. AR 357-58. Dr. Olswanger also noted Plaintiff's reported improvement with anxiety after a reduction in driving and increased walking. AR 357. Plaintiff continued to see Dr. Olswanger on a regular basis throughout 2018. AR 347-56. Plaintiff regularly reported stable anxiety but continued to have daily headaches with varying degrees of severity, and chronic neck and back pain. AR 355, 353, 351, 349, 347. Dr. Olswanger never observed Plaintiff to be in...