Case 2:20-cv-03732-JWH-JEM Document 74 Filed 09/02/22 Page 1 of 24 Page ID #:1709

1 2 3 4 5 6 7 8 UNITED STATES DISTRICT COURT 9 FOR THE CENTRAL DISTRICT OF CALIFORNIA 10 11 BERNARDO SANCHEZ, Case No. 2:20-cv-03732-JWH-JEM

12 Plaintiff,

FINDINGS OF FACT AND

13 v. CONCLUSIONS OF LAW PURSUANT TO RULE 52(a) OF 14 HARTFORD LIFE & ACCIDENT THE FEDERAL RULES OF CIVIL INSURANCE CO.; and PROCEDURE 15 DOES 1 through 10, inclusive,

16 Defendants.

17 18 19 20 21 22 23 24 25 26 27 28 Case 2:20-cv-03732-JWH-JEM Document 74 Filed 09/02/22 Page 2 of 24 Page ID #:1710

1 I. INTRODUCTION 2 This case concerns an ERISA claim that Plaintiff Bernardo Sanchez 3 asserts against Defendant Hartford Life & Accident Insurance Co., through 4 which Sanchez seeks short-term and long-term disability benefits. Sanchez was 5 an employee of non-party Illinois Tool Works Inc. (“ITW”). ITW’s disability 6 benefits plans were administered by non-party Aetna Life Insurance Company 7 (“Aetna”). Defendant Hartford acquired Aetna’s group benefits business in 8 late 2017. In connection with that transaction, Aetna appointed Hartford as its 9 attorney-in-fact to administer claims under certain Aetna group plans, including 10 the plan at issue in this litigation. Accordingly, references herein to “Hartford” 11 refer to Hartford acting on behalf of Aetna as its attorney-in-fact. 12 This matter was tried in this Court on July 27, 2021. The issues 13 presented for adjudication were as follows: 14 1. Did Aetna abuse its discretion when it denied Sanchez’s claim for 15 short term disability benefits? 16 2. Is Sanchez is entitled to long term disability benefits? 17 For the reasons set forth below, the Court answers “no” to both questions. 18 II. FINDINGS OF FACT1 19 A. The Self-Funded STD Plan 20 1. ITW operates two separate and distinct employee welfare benefits 21 plans governed by ERISA: a self-funded short-term disability plan (the “STD 22 Plan”) and an insured long-term disability plan (the “LTD Plan”). 23 2. Because the STD Plan is self-funded, ITW pays benefits under the 24 terms, conditions, and limitations of the Plan. In contrast, ITW’s LTD Plan is 25 fully insured through a policy issued by Aetna. 26 1 To the extent that any of the Findings of Fact herein are considered 27 Conclusions of Law, they are adopted as such. Likewise, to the extent that any of the Conclusions of Law in Part III are considered Findings of Fact, they are 28 adopted as such. -2- Case 2:20-cv-03732-JWH-JEM Document 74 Filed 09/02/22 Page 3 of 24 Page ID #:1711

1 3. Aetna is the claim administrator under both the STD Plan and the 2 LTD Plan. 3 4. The STD Plan grants to Aetna discretionary authority to interpret 4 plan terms and to determine eligibility for, and entitlement to, benefits. 5 5. The STD Plan states: “You will be considered disabled while 6 covered under the ITW STD Plan on the first day that you are disabled as a 7 direct result of a significant change in your physical or mental condition caused 8 by a non-occupational illness or injury.” 9 6. The STD Plan provides coverage for only non-occupational illness 10 or injury. 11 7. The STD Plan defines “occupational” illness or injury broadly as 12 that which “[a]rises out of (or in the course of) any activity in connection with 13 employment . . . .” 14 8. A significant difference between the Plans is that while the STD 15 Plan covers only non-occupational illness or injury, the LTD Plan covers both 16 occupational and non-occupational illness or injury. 17 9. The STD Plan provides benefits for a maximum benefit duration of 18 26 weeks after a seven-day waiting period. 19 10. Other income, such as social security benefits, are deducted from 20 the gross monthly benefit. 21 11. To submit a claim under the STD Plan, the participant must give 22 “proof of the nature and extent” of the disability. The Test of Disability is as 23 follows: 24 From the date that you first become disabled, you meet the test of 25 disability on any day that: 26 You cannot perform the material duties of your own 27 occupation solely because of an illness, injury, or disabling 28 pregnancy-related condition. -3- Case 2:20-cv-03732-JWH-JEM Document 74 Filed 09/02/22 Page 4 of 24 Page ID #:1712

1 You are not performing the material duties of your own occupation 2 if you are only performing some of the material duties of your own 3 occupation. 4 12. The LTD Plan has very different features from the STD Plan. 5 Those differences include the following: a 180-day waiting period; coverage for 6 occupational illness or injury; a different definition of disability; a disability test 7 change after 24 months to disability from “any reasonable occupation”; a 24- 8 month benefit limitation for psychiatric condition; and varying offsets and 9 limitations. 10 13. Because the terms of the STD Plan and the LTD Plan are 11 materially different, the fact that a claim is payable or not payable under one plan 12 does not necessarily mean the claim is payable or not payable under the other. 13 B. The Claimant 14 14. Plaintiff Bernardo Sanchez lives in Ventura County, California. He 15 served as a Corporal in the United States Marine Corps during Operation 16 Desert Storm in 1990. He is a decorated Marine, and he was honorably 17 discharged in 1994. After Sanchez completed his enlistment, he earned his B.S. 18 in Public Relations with a minor in Business. 19 15. Sanchez worked essentially the same job for 23 years, but, as a 20 result of multiple corporate buyouts, Sanchez’s employment with ITW began in 21 2011. ITW specializes in the manufacture of automotive service products. 22 Sanchez served as regional sales manager, and he was responsible for selling 23 ITW products and for maintaining existing distributor relationships and 24 securing new ones. Sanchez’s job activities were sedentary, requiring mostly 25 sitting and occasionally standing or walking. His job also required frequent 26 travel. 27 16. While working at ITW, Sanchez believed that he was exposed to a 28 hostile work environment. He received hostile work emails from his supervisor -4- Case 2:20-cv-03732-JWH-JEM Document 74 Filed 09/02/22 Page 5 of 24 Page ID #:1713

1 regarding his job performance, and he concluded that his supervisor was trying 2 to force him to quit. 3 C. The STD Claim for Symptoms of PTSD and Anxiety Arising Out of a 4 Hostile Work Environment 5 17. Sanchez made a claim for disability under the STD Plan for 6 symptoms of post-traumatic stress syndrome and anxiety exacerbated by a 7 hostile work environment. 8 18. On February 1, 2019, through the Department of Veterans Affairs 9 (the “VA”), Sanchez saw Erica Espinoza, N.P., who reported diagnoses of 10 PTSD and anxiety. Nurse Practitioner Espinoza wrote the following in 11 Sanchez’s medical record: 12 [W]orsening PTSD and hostile work environment r/t supervisor 13 interactions x 1 yr that is causing pt to have a “short fuse”. Has 14 worked for company x 21 years. Reports having panic attacks on 15 plane when reading an email from supervisor. Emails are hostile and 16 “personal attacks” with negative feedback. Gets startled and 17 anxious every time he hears a ping on his phone notifying him that 18 he has a new email. States that supervisor is discriminating and 19 singling him out—making him loose [sic.] his confidence. Pt feels 20 weak. He feels that his supervisor is trying to make him quit. Pt 21 states “he can’t do the job anymore” . . . Pt states that he is 22 “terrified of HR” He “doesn’t trust company or HR” . . . . 23 19. Sanchez submitted a claim to Aetna under the STD Plan with a 24 medical note from Nurse Practitioner Espinoza that Sanchez was out of work for 25 six days, from February 1 to 7, 2019. Sanchez made that claim within the STD 26 Plan’s seven-day waiting period. 27 20. The next week, Nurse Practitioner Espinoza transmitted to Aetna a 28 letter extending Sanchez’s disability—for PTSD—until April 1, 2019. In her -5- Case 2:20-cv-03732-JWH-JEM Document 74 Filed 09/02/22 Page 6 of 24 Page ID #:1714

1 letter, Nurse Practitioner Espinoza provided no additional clinical support for 2 the extension. 3 21. The medications that Sanchez was taking were unrelated to his 4 PTSD. 5 D. Denial of the STD Claim Due to the Lack of Treating Records, 6 Mental Status Evaluation, or Observable Symptoms on Examination 7 22. Aetna referred the claim to its behavioral health unit for 8 assessment. The clinical case manager, Maria Villalba, determined that the 9 claim information failed to evidence observable symptoms and global 10 impairment. Ms. Villalba advised that, at a minimum, mental health records of 11 observable examination findings and a mental status evaluation (“MSE”) were 12 required to assess the severity of Sanchez’s condition, the extent of his 13 functional impairment, and whether his symptoms were global in nature or 14 specific to the work environment—i.e., occupational in nature. 15 23. In February and March 2019, Aetna asked Sanchez, Nurse 16 Practitioner Espinoza, and the VA to complete behavioral health clinician 17 statements and to provide records of a February 13, 2019, mental health 18 appointment previously noted by Nurse Practitioner Espinoza, as well as any 19 other supporting medical records or progress notes. 20 24. Aetna, however, received no MSE or treating records pertaining to 21 Sanchez’s alleged disability. 22 25. On March 19, 2019, Aetna denied the claim because Sanchez did 23 not meet the policy definition of “disability.” Aetna noted that it received 24 insufficient medical evidence of observable findings and behaviors that would 25 prevent Sanchez from working. Aetna identified the medical documentation 26 that would be needed to support Sanchez’s claim, such as a detailed narrative 27 report outlining physical or mental restrictions and limitations, physician 28 progress notes including course of treatment, frequency of visits, specific -6- Case 2:20-cv-03732-JWH-JEM Document 74 Filed 09/02/22 Page 7 of 24 Page ID #:1715

1 medications prescribed for the condition, and copies of diagnostic tests and 2 clinical findings. 3 E. Request for Reconsideration and Affirmance of Denial Based Upon 4 Insufficient Medical Evidence 5 26. Sanchez sought the reconsideration of his claim, noting that a 6 “hostile work environment has made my life nearly impossibly [sic].” 7 27. Dr. Yaniv Simon, a VA attending psychiatrist, provided a letter 8 stating that Sanchez had trouble interacting with coworkers and supervisors. 9 Dr. Simon noted that Sanchez was diagnosed with PTSD, that Sanchez had 10 received care at the VA for the past three years, and that Sanchez received 11 unspecified “medications and counseling.” Dr. Simon also stated that Sanchez 12 experienced difficulties following a schedule and sleeping, trouble at work, a 13 depressed mood, and significant anxiety. Dr. Simon included no medical 14 records, progress notes, or mental health examination results with her letter. 15 28. Aetna agreed to reconsider its decision. It asked Dr. Simon to 16 complete a behavioral health clinician statement and to provide medical records 17 of care, but Sanchez provided no additional information. 18 29. On June 24, 2019, Aetna notified Sanchez that, based upon its 19 further review, Sanchez did not meet the definition of “disability” under the 20 policy. Aetna again offered to review supporting information, such as observable 21 exam findings and an MSE to assess function. Aetna asked for clarification 22 regarding whether the condition was global, because Nurse Practitioner 23 Espinoza’s records suggested that Sanchez’s condition was work related, as 24 Sanchez had worked for the same company for more than 21 years before he 25 claimed disability due to his pre-existing PTSD. 26 F. STD Administrative Appeal 27 30. On or about September 6, 2019, Sanchez appealed Aetna’s denial 28 of his claim. Sanchez informed Aetna that his doctor did not expect him to -7- Case 2:20-cv-03732-JWH-JEM Document 74 Filed 09/02/22 Page 8 of 24 Page ID #:1716

1 return to work and that he was “terminated . . . due to that fact.” Sanchez 2 stated that psychologist Dr. Barbara Weismann diagnosed Sanchez with PTSD, 3 but that information was not readily available through the VA system. 4 31. Together with Sanchez’s appeal, Aetna received a VA PTSD 5 disability benefits questionnaire completed by psychiatrist Dr. Eulogio Eclerinal. 6 Dr. Eclerinal evaluated Sanchez for PTSD on August 4, 2019. Dr. Eclerinal 7 noted that Sanchez had been diagnosed with PTSD, and she certified total 8 occupational and social impairment to the VA based upon Sanchez’s self- 9 reported symptoms. Dr. Eclerinal noted that Sanchez sought counseling once 10 per month and that Sanchez had a prescription for Prazosin. Dr. Eclerinal noted 11 Sanchez’s self-reported temper, rage, and panic attacks related to work. 12 32. Aetna also received a March 22, 2019, behavioral health clinician 13 statement by Nurse Practitioner Espinoza and a VA disability certification. 14 Nurse Practitioner Espinoza opined that Sanchez was unable to perform 15 functional activities due to his PTSD and anxiety caused by his conflict with his 16 supervisor. Nurse Practitioner Espinoza believed that Sanchez’s PTSD was 17 “caused and/or aggravated” by his work. 18 33. Nurse Practitioner Espinoza also noted no psychotic symptoms. 19 She found that Sanchez’s speech, hygiene, and dress were all normal. 20 34. Nurse Practitioner Espinoza found that Sanchez could volunteer 21 full-time or part-time with no modifications and could participate in 22 rehabilitation counseling. 23 35. In a disability certification form, Nurse Practitioner Espinoza 24 clarified that Sanchez’s PTSD was caused and/or aggravated by his specific 25 employment. 26 36. Aetna obtained the ITW job description for Sanchez’s position. 27 28 -8- Case 2:20-cv-03732-JWH-JEM Document 74 Filed 09/02/22 Page 9 of 24 Page ID #:1717

1 37. Aetna retained an independent, board-certified psychologist, 2 Dr. Avila Steele, Ph.D., to review the records and to assess Sanchez’s condition 3 and level of impairment. 4 38. In Dr. Steele’s October 6, 2019, report, she concluded that there 5 was a lack of evidence to support functional impairment. While acknowledging 6 that Sanchez was diagnosed with generalized anxiety, PTSD, and depression, 7 Dr. Steele reported that “[t]he available information lacks compelling evidence 8 and exam data that describes functional impairments of sufficient intensity and 9 severity as to preclude the claimant from engaging in previous activities, or 10 returning to functional capacity of 40 hours weekly and 8 hour days.” 11 39. Dr. Steele found no reports of mental status abnormalities, 12 cognitive deficits, the inability to complete activities of daily living, or the 13 inability to drive and travel. She noted that Sanchez’s symptoms were described 14 as specific to the environment and not global in nature. 15 40. Dr. Steele twice attempted peer-to-peer consultations with both 16 Dr. Simon and Nurse Practitioner Espinoza, but neither answered nor returned 17 Dr. Steele’s calls. 18 41. Aetna transmitted Dr. Steele’s report to Nurse Practitioner 19 Espinoza and Dr. Simon for comment and with specific questions to clarify the 20 condition, the nature and extent of treatment, the medications, and the referral 21 to a higher level of psychiatric care. Neither Nurse Practitioner Espinoza nor 22 Dr. Simon responded. 23 42. Aetna notified Sanchez of the lack of response from Dr. Simon and 24 Nurse Practitioner Espinoza, and it afforded him 21 days to provide additional 25 information. Aetna received no response. 26 43. On November 12, 2019, Aetna affirmed its decision on appeal on 27 the basis that Sanchez did not meet the STD Plan’s definition of “disability.” 28 Aetna noted a lack of clinical findings to support Sanchez’s alleged inability to -9- Case 2:20-cv-03732-JWH-JEM Document 74 Filed 09/02/22 Page 10 of 24 Page ID #:1718

1 work and remarked that Sanchez’s condition appeared specific to his work 2 environment rather than global in nature. 3 44. In view of Sanchez’s exhaustion of his administrative remedies, 4 Aetna closed Sanchez’s claim. 5 45. Sanchez retained counsel who, on March 18, 2020, submitted 6 additional records to be included in the administrative record and considered by 7 Aetna with regard to an LTD claim. 8 46. On April 14, 2020, Aetna’s appeal specialist advised Sanchez’s 9 counsel that the STD claim was closed but that Aetna would forward the 10 correspondence (and enclosures) to the LTD unit to respond to the request. 11 G. Post-STD Lawsuit for Benefits and Attorneys’ Fees 12 47. On April 21, 2020, Sanchez’s counsel filed this lawsuit on behalf of 13 Sanchez for benefits and attorneys’ fees. In his Complaint, Sanchez sought both 14 STD benefits and LTD benefits, even though Aetna never made a decision 15 under the LTD Plan. 16 48. On May 12, 2020, Aetna transmitted to Sanchez an LTD 17 application, including updated medical record authorizations for Sanchez to 18 complete and return. Rather than complete the application and authorizations, 19 Sanchez’s counsel responded to Aetna’s counsel that Sanchez would not file an 20 LTD claim because it would be futile. 21 49. On May 27, 2020, Aetna made a final request for Sanchez to 22 complete the forms and to return them by June 12, 2020, in order for Sanchez to 23 claim LTD benefits. 24 50. On June 11, 2020, Aetna followed up with a letter advising Sanchez 25 that it had closed the LTD claim because it did not receive further information, 26 but Aetna offered to reopen the claim if Sanchez submitted an LTD application. 27 Sanchez did not submit an LTD application. 28 -10- Case 2:20-cv-03732-JWH-JEM Document 74 Filed 09/02/22 Page 11 of 24 Page ID #:1719

1 III. CONCLUSIONS OF LAW 2 A. Standard of Review 3 The standard of review for the STD Claim is abuse of discretion. See 4 Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989); Williby v. Aetna 5 Life Ins. Co., 867 F.3d 1129, 1136 (9th Cir. 2017). Aetna’s decision to deny 6 benefits to Sanchez under the STD Plan cannot be disturbed unless that decision 7 was arbitrary and capricious. See Firestone, 489 U.S. at 109. The Court cannot 8 “substitute its judgment for that of the administrator unless the latter’s decision 9 was clearly erroneous in light of the available record.” Voight v. Metropolitan 10 Life Ins. Co., 28 F. Supp. 2d 569, 579 (C.D. Cal. 1998). For the reasons stated 11 below, however, the Court’s decision would be the same under a de novo 12 standard of review. 13 Sanchez bears the burden to prove his entitlement to benefits. See Muniz 14 v. Amec Const. Mgmt. Inc., 623 F.3d 1290, 1294 (9th Cir. 2010). Sanchez must 15 prove that the evidence available to Aetna during its review of the STD claim 16 establishes disability within the meaning of the STD Plan’s definition of 17 disability, from a non-occupational illness or injury. Sanchez must prove that 18 Aetna’s decision to deny benefits was clearly erroneous in light of the available 19 record. 20 B. The Medical Evidence Fails to Establish that Sanchez Meets the 21 Definition of “Disability” Under the Terms of the STD Plan 22 To be eligible for benefits, Sanchez must prove a condition of sufficient 23 severity that it requires restrictions and limitations preventing him from 24 performing his occupation. See Muniz, 623 F.3d 1290; Sabatino v. Liberty Life 25 Assurance Co. of Boston, 286 F. Supp. 2d 1222, 1232 (N.D. Cal. 2003). A mere 26 diagnosis does not establish disability. See Jordan v. Northrop Grumman Corp. 27 Welfare Benefit Plan, 370 F.3d 869, 880 (9th Cir. 2004), overruled on other 28 grounds as recognized by Salomaa v. Honda Long Term Disability Plan, 642 F.3d -11- Case 2:20-cv-03732-JWH-JEM Document 74 Filed 09/02/22 Page 12 of 24 Page ID #:1720

1 666, 673-74 (9th Cir. 2011); see also Voight v. Metropolitan Life Ins. Co., 28 2 F. Supp. 2d 569, 578 (C.D. Cal. 1998); Seleine v. Fluor Corp., 598 F. Supp. 2d 3 1090 (C.D. Cal. 2009), aff’d 409 F. App’x 99 (9th Cir. 2010). 4 Simply claiming symptoms does not prove “disability,” which requires 5 functional impairment. Subjective self-reporting of symptoms is not a solid basis 6 for a disability claim. See Langlois v. Metropolitan Life Ins. Co., 2012 WL 1910020 7 (N.D. Cal. May 24, 2012); Martucci v. Hartford Life & Acc. Ins. Co., 863 8 F. Supp. 2d 269, 278 (S.D.N.Y. 2012). A subjective claim requires support from 9 testing, data, and treatment to establish functional impairment. See Western v. 10 Unum Life Ins. Co. of America, 2018 WL 6071090, at *12 (C.D. Cal. July 3, 2018), 11 aff’d 798 F. App’x 154 (9th Cir. 2020). 12 Courts should not, however, require “objective proof” of conditions that 13 are inherently subjective. See Montour v. Hartford Life & Acc. Ins. Co., 588 F.3d 14 623, 635 (9th Cir. 2009); see also Hagerty v. Am. Airlines Long Term Disability 15 Plan, 2010 WL 3463620, at *2 (N.D. Cal. Sept. 3, 2010) (“requiring objective 16 medical evidence of fatigue, when The Plan documents do not expressly require 17 such proof, is a factor suggesting The Plan abused its discretion”); Cook v. 18 Liberty Life Assur. Co. of Boston, 320 F.3d 11, 21 (1st Cir.2003) (requiring 19 objective documentation of Chronic Fatigue Syndrome is unreasonable). 20 The fact that a treating physician certifies or supports disability need not 21 be given special weight. See Black & Decker Disability Plan v. Nord, 538 U.S. 22 822, 834 (2003). Even under de novo review, factors to assess the credibility of a 23 treating physician include the extent of the patient’s treating history, the 24 doctor’s specialization (or lack thereof), and the amount and strength of the 25 detail that the doctor provides for his or her conclusion. See Shaw v. Life Ins. Co. 26 of N. Am., 144 F. Supp. 3d 1114, 1129 (C.D. Cal. 2015). “A physician’s opinion 27 is more credible when supported by medical and vocational evidence of 28 contemporaneous functional limitations.” Graham v. First Reliance Standard -12- Case 2:20-cv-03732-JWH-JEM Document 74 Filed 09/02/22 Page 13 of 24 Page ID #:1721

1 Life Ins. Co., 2007 WL 2192399, at *2 (S.D.N.Y. July 31, 2007). By contrast, a 2 treating physician’s diagnosis can be discounted when it lacks supportive 3 evidence, it is contradicted by other statements and assessments of medical 4 condition, and it is based upon subjective descriptions of pain or limitations. See 5 Calcagno v. Unum Life Ins. Co. of America, 2019 WL 2488716, at *15 (D. Or. 6 Feb. 19, 2019) (citing Batson v. Comm’r of Soc. Sec. Admin., 359 F.3d 1190, 1195 7 (9th Cir. 2004)). 8 Here, it is undisputed that Sanchez was diagnosed with anxiety and PTSD 9 sustained from his experiences in Operation Desert Storm. Mere diagnoses, 10 however, are insufficient to conclude that Sanchez is totally disabled from 11 performing essential duties as a sales manager in 2019. Sanchez worked for 12 more than two decades after he sustained PTSD. He worked for three years at 13 ITW after his PTSD diagnosis in 2016. 14 Diagnoses or conclusory statements from providers are insufficient to 15 establish “disability” under the definition of the STD Plan. Sanchez must 16 prove that he was totally and functionally disabled—unable to perform the 17 material duties of his occupation. See, e.g., Seleine v. Fluor Corp. Long-Term 18 Disability Plan, 598 F. Supp. 2d 1090, 1100 (C.D. Cal. 2009), aff’d 409 F. App’x 19 99 (9th Cir. 2010). Here, however, Aetna officials reasonably determined that 20 Sanchez presented insufficient medical evidence to establish functional 21 impairment. On multiple occasions, Aetna requested medical records—beyond 22 mere diagnoses and certification—to support a finding of functional impairment. 23 In addition, Aetna specified the type of records that could demonstrate the 24 extent and severity of a disability; e.g., treating records, progress notes, 25 observable symptoms on examination, or an MSE. Those records could have 26 provided information of medications, consistent treatment, restrictions, and 27 limitations. Despite those specific requests, neither Sanchez nor any of his 28 caregivers provided such medical evidence to support a finding of disability. -13- Case 2:20-cv-03732-JWH-JEM Document 74 Filed 09/02/22 Page 14 of 24 Page ID #:1722

1 The Court notes that during the trial, Sanchez’s counsel blamed the VA for its 2 failure to respond to Aetna sufficiently and that the administrative record shows 3 that placing such blame on the VA is not unreasonable. Nevertheless, the VA is 4 not on trial here. 5 The records and statements from Nurse Practitioner Espinoza, 6 Dr. Simon, and Dr. Eclerinal do not weigh heavily. There is no evidence to 7 demonstrate that those health care providers treated Sanchez on a consistent 8 basis. Their opinions are based upon Sanchez’s self-reported symptoms. They 9 do not submit treating records of observable symptoms on examination, 10 standard mental health evaluation, or contemporaneous therapy records. The 11 Court is sympathetic to the argument from Sanchez’s counsel at trial that PTSD 12 is not an objective condition for which one can do objective testing. Aetna is, 13 however, entitled to expect evidence such as contemporaneous therapy records. 14 Other reasons also exist that cause the Court to discount the records and 15 statements from Nurse Practitioner Espinoza, Dr. Simon, and Dr. Eclerinal: 16  Nurse Practitioner Espinoza did not consistently treat Sanchez. Her 17 office visit note demonstrates Sanchez’s functionality. She provided no 18 specific restrictions or limitations of work duties but found that Sanchez 19 could participate in volunteer activities with no restrictions, and she 20 recommended him for rehabilitation counseling. 21  Dr. Simon’s opinion is unsubstantiated. Dr. Simon submitted a 22 conclusory letter certifying disability with no detail of any MSE, 23 examination findings or results, or contemporaneous medical records. 24 Dr. Simon reported that Sanchez underwent counseling for the prior 25 three years, but he provided no details regarding the frequency of 26 treatment, therapy records, or records of medications prescribed. 27 28 -14- Case 2:20-cv-03732-JWH-JEM Document 74 Filed 09/02/22 Page 15 of 24 Page ID #:1723

1  Additionally, neither Nurse Practitioner Espinoza nor Dr. Simon 2 responded to Dr. Steele and Aetna’s multiple attempts to obtain their 3 opinions regarding Dr. Steele’s report. 4  Finally, Dr. Eclerinal noted that Sanchez received counseling at the VA, 5 but only one session per month, which is hardly as intensive or consistent 6 as would be expected if Sanchez was experiencing debilitating symptoms. 7 While Dr. Eclerinal noted that Sanchez was prescribed with Prazosin, 8 there are no treating records demonstrating whether Sanchez took the 9 medication, how he responded to it, or whether he was successfully 10 treated. The details supporting Dr. Eclerinal’s certification are self- 11 reported subjective symptoms, not examination results, testing, or 12 observed symptoms. 13 Sanchez referred to his diagnosis from Dr. Weismann for PTSD, but that 14 diagnosis is undisputed, and, in any event, Sanchez was working at the time of 15 Dr. Weismann’s diagnosis. Indeed, Sanchez had worked with his condition for 16 years. Regardless, Dr. Weismann’s records were not provided to Aetna during 17 its review of the STD claim. 18 At the same time, there are no contemporaneous treating records, 19 standard mental health evaluations, or other evidence of the extent and severity 20 of Sanchez’s symptoms to establish that Sanchez could not perform the material 21 duties of his occupation as a regional sales manager. No treating mental health 22 physician identified physical or mental restrictions or limitations that would 23 prevent Sanchez from performing the essential duties of his occupation as a sales 24 manager. What remains is a mere diagnosis of PTSD from the early 1990s with 25 self-reported symptoms exacerbated due to a hostile work environment and 26 certifications from providers who did not treat Sanchez consistently. The 27 evidence provided is insufficient to meet the STD Plan’s functional test of 28 disability—that Sanchez cannot perform the material duties of his occupation. -15- Case 2:20-cv-03732-JWH-JEM Document 74 Filed 09/02/22 Page 16 of 24 Page ID #:1724

1 Accordingly, the Court concludes that Sanchez fails to satisfy his burden 2 to prove that he meets the definition of disability under the STD Plan. Based 3 upon the lack of sufficient medical evidence, Sanchez is not entitled to benefits 4 under the STD Plan. Under the abuse of discretion standard of review, Aetna’s 5 decision to deny STD benefits—on the basis that Sanchez failed to meet the 6 definition of disability—was not arbitrary and capricious. Under the de novo 7 standard of review, Aetna’s decision to deny STD benefits—on the basis that 8 Sanchez failed to meet the definition of disability—was correct. 9 C. The STD Plan Does Not Cover—but Excludes—Coverage for 10 Sanchez’s Occupational Illness 11 Even if the medical evidence supported disability, which it fails to do, 12 Sanchez’s claim is not covered because it is occupational in nature and is not a 13 global impairment. Sanchez fails to establish that he cannot perform the 14 material duties of his occupation solely because of a non-occupational illness or 15 injury. 16 The STD Plan covers only “non-occupational” illnesses or injuries. It 17 covers disability “as a direct result of a significant change in your physical or 18 mental condition caused by a non-occupational illness or injury.” It specifically 19 excludes “occupational” illness or injury, which it defines as an injury or illness 20 that: 21  arises out of (or in the course of) any activity in connection with 22 employment or self-employment whether or not on a full-time basis; or 23  results in any way from an illness or injury which does. 24 Thus, the STD Plan’s definition of an occupational illness or injury is broad, as 25 it encompasses maladies arising out of, or in the course of, employment and 26 because it uses the terms “any activity in connection with employment 27 [emphasis added].” The definition goes further, to include “results in any way” 28 from illnesses or injuries that arise out of or in the course of employment. -16- Case 2:20-cv-03732-JWH-JEM Document 74 Filed 09/02/22 Page 17 of 24 Page ID #:1725

1 Here, it is undisputed that Sanchez completed his military service in 1994 2 and that he began working for ITW in 2011. Sanchez alleges that he was first 3 diagnosed with PTSD in July of 2016, when he was seen at the VA. He also 4 asserts that his PTSD was triggered by a hostile work environment. Those 5 undisputed facts demonstrate that his illness arose in connection with his 6 employment. 7 Moreover, even if Sanchez’s PTSD was a latent condition that pre- 8 existed his employment, it still would not be covered under the STD Plan. The 9 rule for occupational injuries is that if a worker’s disability—although arising 10 from a pre-existing non-industrial condition—was brought on by any strain or 11 excitement incident to employment, then industrial liability still exists, since 12 acceleration or aggravation of a pre-existing disease is an injury in the occupation 13 causing such acceleration. See Guerra v. Workers’ Compensation Appeals Board, 14 246 Cal. App. 4th 1301 (2016) (death from preexisting tuberculosis condition 15 that was aggravated by exertion from work constituted occupational injury). As 16 counsel for Hartford noted at the trial, one reason behind the STD definition is 17 that the insurance company does not want an insured to make an STD claim if 18 and when the insured can make a claim for workers’ compensation. If the 19 worker’s compensation claim is declined, then the insured can make an STD 20 claim. 21 At the least, Sanchez’s hostile work environment aggravated his 22 latent/pre-existing PTSD to the point where he could no longer work. The 23 administrative record reflects that when Sanchez applied for benefits under the 24 STD Plan, it was related to “a hostile work environment . . . .” Nurse 25 Practitioner Espinoza reported that Sanchez’s “supervisor [was] singling him 26 out—making him loose [sic] his confidence. Pt feels weak. He feels that his 27 supervisor is trying to make him quit.” As a result, Sanchez felt that he could 28 not “do the job anymore,” and, thus, he filed for disability. Sanchez repeatedly -17- Case 2:20-cv-03732-JWH-JEM Document 74 Filed 09/02/22 Page 18 of 24 Page ID #:1726

1 made clear throughout the STD claim that his specific work environment 2 triggered or exacerbated his PTSD, leading to his disability. Indeed, both 3 Sanchez and his providers consistently attributed the exacerbation of Sanchez’s 4 symptoms to his hostile work environment. 5 Aetna asked for records to demonstrate that Sanchez’s condition resulted 6 from a global impairment, because, according to the documentation received, 7 Sanchez’s symptoms were work-specific, but no such documentation was ever 8 provided. Sanchez’s claimed disability is not “as a direct result of a significant 9 change in [his] physical or mental condition caused by a non-occupational illness 10 or injury.” Instead, Sanchez claims disability for an occupational illness or 11 injury that is not covered under the terms of the STD Plan. Because the terms 12 of the STD Plan do not cover—and, indeed, exclude—claims for occupational 13 illnesses and injuries, Sanchez is not entitled to benefits under the STD Plan. 14 Accordingly, Sanchez’s claim for benefits under the STD Plan is DENIED. 15 D. The Post-STD Documents That Sanchez Seeks to Admit Are 16 Inadmissible, and They Do Not Prove Disability 17 Sanchez seeks to admit four documents: (1) Dr. Weismann’s record; 18 (2) a questionnaire completed by Dr. Michael Gould, Psy. D., who treated 19 Sanchez at the VA; (3) a Social Security Administration award letter; (4) and a 20 personal statement (collectively, the “Extrinsic Documents”) to support his 21 STD claim. Those Extrinsic Documents were either unavailable, nonexistent, 22 or not provided to Aetna during its administrative review of the STD claim. 23 Thus, Aetna could not have considered the Post-STD records in its review of 24 the STD claim. Those documents are extrinsic to the administrative record that 25 closed on November 12, 2019. 26 Even under de novo review, subject to limited exceptions, evidence 27 extrinsic to the administrative record is inadmissible. See Quesinberry v. Life Ins. 28 Co. of North America, 987 F.2d 1017, 1026-27 (4th Cir. 1993). “A district court -18- Case 2:20-cv-03732-JWH-JEM Document 74 Filed 09/02/22 Page 19 of 24 Page ID #:1727

1 should not take additional evidence merely because someone at a later time 2 comes up with new evidence.” Id. at 1025. Extrinsic evidence should be 3 considered only under exceptional limited circumstances showing that the 4 evidence is clearly necessary to conduct an adequate review of the 5 administrator’s decision. See id.; Opeta v. Northwest Airlines Pension Plan, 484 6 F.3d 1211, 1217 (9th Cir. 2007) (citing Mongeluzo v. Baxter Travenol Long Term 7 Disability Benefit Plan, 46 F.3d 938, 943-44 (9th Cir. 1995)). Even when 8 exceptional circumstances exist, a court has discretion to admit or exclude 9 extrinsic evidence. See Clifton v. Connecticut General Life Ins. Co., 2020 WL 10 6498964, at *3 (D. Ariz. Oct. 21, 2020). 11 Here, exceptional circumstances supporting the admission of the 12 Extrinsic Documents do not exist. The Extrinsic Documents are not clearly 13 necessary to adjudicate Sanchez’s STD claim. The STD claim underwent a full 14 and fair administrative review, and the administrative record is fully developed. 15 Aetna repeatedly specified the medical information required to support the 16 claim, and it gave Sanchez and his providers multiple opportunities to submit 17 additional records and information. There is no complex, disputed medical or 18 other issue, or ambiguity in the records, requiring extrinsic evidence. The 19 Extrinsic Documents are therefore inadmissible. The Court OVERRULES 20 Sanchez’s objection to the STD Administrative Record submitted by Hartford 21 and DENIES Sanchez’s request to augment the administrative record. 22 Even if admissible, however, the Extrinsic Documents do not prove 23 disability from a non-occupational illness or injury. Dr. Weismann’s VA 24 disability benefits questionnaire is dated July 13, 2016—while Sanchez was 25 working—and, therefore, it does not reflect Sanchez’s condition and level of 26 functionality from 2019 onward. Dr. Gould’s October 10, 2019, disability 27 benefits questionnaire duplicates Dr. Eclerinal’s earlier conclusion of social and 28 occupational impairment that Aetna already considered, and, like Dr. Eclerinal, -19- Case 2:20-cv-03732-JWH-JEM Document 74 Filed 09/02/22 Page 20 of 24 Page ID #:1728

1 Dr. Gould failed to provide treating records or examination results. Dr. Gould’s 2 certification of disability was issued pursuant to VA standards. It was not based 3 upon the STD Plan’s definition of disability, and it is, therefore, not dispositive. 4 Moreover, both Dr. Weismann and Dr. Gould based their conclusions on 5 Sanchez’s self-reported symptoms and noted that Sanchez appeared well- 6 oriented. Sanchez’s thinking was “rational and linear.” Both indicate that 7 Sanchez’s PTSD was exacerbated by a hostile work environment. 8 The Social Security disability benefits award letter provides no medical 9 evidence, because it does not include the examination report upon which the 10 award is based or the time period considered. The award, which is not based 11 upon the STD Plan’s definition of disability, is not dispositive. Finally, Sanchez 12 submitted his personal statement of his background, his work, and the duties 13 that he cannot perform, such as travel and interacting with people. The 14 statement, however, is simply a statement of claim; it is not evidence of medical 15 restrictions and limitations. 16 E. Aetna’s Denial of Benefits Under the STD Plan Was Not an Abuse of 17 Discretion; It Was Reasonable and Correct 18 Aetna’s decision to deny Sanchez benefits under the STD Plan was not 19 arbitrary and capricious. Aetna did not abuse its discretion in denying Sanchez 20 benefits under the STD Plan. Under a de novo standard of review, Aetna’s 21 decision to deny Sanchez benefits under the STD Plan was correct. 22 F. Sanchez Fails to State a Justiciable Claim Under the LTD Plan 23 1. Sanchez’s Claim is Unripe 24 “Absent a decision by the plan administrator, district courts have no 25 jurisdiction to make an assessment of a beneficiary’s eligibility for benefits.” 26 Peterson v. Continental Cas. Co., 282 F.3d 112, 118 (2d Cir. 2002). Adjudication 27 is premature when a “benefits question” has “not yet ripened into a case or 28 controversy.” Id. at 118 (citing Jones v. Unum Life Ins. Co. of America, 223 F.3d -20- Case 2:20-cv-03732-JWH-JEM Document 74 Filed 09/02/22 Page 21 of 24 Page ID #:1729

1 130, 140-41 (2nd Cir. 2000)). Under ERISA, claims administrators are to make 2 factual determinations in the first instance. See Saffle v. Sierra Pac. Power Co. 3 Bargaining Unit Long-Term Disability Income Plan, 85 F.3d 455 (9th Cir. 1996). 4 The Court is not to act as the “substitute plan administrator” for the factual 5 determination of whether Sanchez is entitled to LTD benefits under plan terms. 6 Taft v. Equitable Life Assurance Soc’y, 9 F.3d 1469, 1472 (9th Cir. 1993), 7 abrogated on other grounds by Saffron v. Wells Fargo Long-Term Disability Plan, 8 522 F.3d 863, 872 n.2 (9th Cir. 2008). 9 Here, Sanchez’s claim fails under the ripeness doctrine. The 10 administrator has not rendered an adverse LTD benefit determination. Sanchez 11 never reported a claim to Hartford as required by LTD Plan procedure. 12 According to the LTD Plan, no claim determination was possible. By statute, 13 administration of plan benefits in accordance with claim review procedure is a 14 duty of Hartford , as the designated LTD Benefits Administrator. See 29 U.S.C. 15 § 1104(a)(1)(D); Metropolitan Life Ins. Co. v. Parker, 436 F.3d 1109, 1111 (9th Cir. 16 2006); Silk v. Metropolitan Life Ins. Co., 477 F. Supp. 2d 1088, 1091-92 (C.D. 17 Cal. 2007). Claim review is not a duty of the Court, and it is thus improper for 18 Sanchez to seek a legal adjudication of his entitlement to LTD benefits on a 19 claim that he did not file. 20 2. Sanchez Failed to Exhaust His Administrative Remedies Under 21 the Plan 22 An ERISA claimant “must avail himself or herself of a plan’s own internal 23 review procedures before bringing suit in federal court.” Diaz v. United Agr. 24 Employee Welfare Benefit Plan and Trust, 50 F.3d 1478, 1483 (9th Cir. 1995); see 25 also Amato v. Bernard, 618 F.2d 559, 568 (9th Cir. 1980). “[F]ederal courts have 26 the authority to enforce the exhaustion requirement in suits under ERISA, and 27 . . . as a matter of sound policy they should usually do so.” Amato, 618 F.2d at 28 568. The exhaustion requirement “enables the employer, or its plan, to obtain -21- Case 2:20-cv-03732-JWH-JEM Document 74 Filed 09/02/22 Page 22 of 24 Page ID #:1730

1 full information about a claim for benefits, to compile an adequate record, and to 2 make a reasoned decision . . . . The process is of substantial benefit to reviewing 3 courts because it gives them a factual predicate upon which to proceed.” Brown 4 v. J.B. Hunt Transport Services, 586 F.3d 1079, 1085 (8th Cir. 2009) (citing Black 5 v. Danka Corp., 335 F.3d 790 (8th Cir. 2003)). 6 The Ninth Circuit explains several policy considerations for enforcing the 7 exhaustion requirement as a general rule, including: “reduction of frivolous 8 litigation, the promotion of consistent treatment of claims, the provision of a 9 non-adversarial method of claims settlement, . . . and a proper reliance on 10 administrative expertise.” Diaz, 50 F.3d at 1483. ERISA plaintiffs fail to 11 exhaust administrative remedies when they do not submit an LTD claim, even 12 when the same insurer administered the STD claim. See, e.g., Walsh v. Life Ins. 13 Co. of North America, 2007 WL 2343657 (D. Mass. Aug. 15, 2007); Leggett v. 14 Provident Life and Accident Ins. Co., 2004 WL 291223 (M.D. Fla. 2004); see also 15 Taylor v. Prudential Ins. Co. of Am., 954 F. Supp. 2d 476, 485 (S.D. Miss. 2013) 16 (holding that “given the absence of the administrative record, this Court is not 17 in a position to award her LTD benefits if she were to prevail on her claim for 18 STD benefits”); Norberry v. Life Ins. Co. of N. Am., 2008 WL 5170404 19 (M.D. Tenn. Dec. 10, 2008) (dismissing the plaintiff’s LTD claim because she 20 did not file an LTD benefit claim and there was no administrative record to 21 review). 22 Sanchez failed to exhaust his administrative remedies under the terms of 23 the LTD Plan. He never submitted an LTD claim to the claim administrator, 24 and, therefore, he failed to avail himself of the LTD Plan’s administrative 25 process and procedures. With no reported LTD claim and proof of loss, 26 Hartford could not have rendered a benefit decision. Consequently, there is no 27 administrative record or administrative determination under ERISA for this 28 -22- Case 2:20-cv-03732-JWH-JEM Document 74 Filed 09/02/22 Page 23 of 24 Page ID #:1731

1 Court to review. Accordingly, the Court finds that it lacks jurisdiction to decide 2 the LTD claim. 3 3. The Futility Exception Does Not Apply 4 The Ninth Circuit recognizes a narrow exception to the exhaustion 5 requirement: when pursuing a claim administratively would be futile. See Diaz, 6 50 F.3d at 1483. Futility, however, must be certain and “bare assertions of 7 futility are insufficient to bring a claim within the futility exception.” Id. at 8 1485; Zhou v. Guardian Life Ins. Co. of Am., 295 F.3d 677, 679 (7th Cir. 2002). 9 The burden is on the plaintiff seeking an excuse for failure to comply with a 10 plan’s administrative procedure. See Zhou, 295 F.3d at 679. The futility 11 exception does not apply when a claim denial is founded on the employee’s 12 failure to comply with a plan’s administrative requirements. See Diaz, 50 F.3d 13 at 1485-86. The denial of an STD claim does not render pursuit of an LTD 14 claim futile. See Gambino v. Arnouk, 232 F. App’x 140 (3rd Cir. 2007); Messick 15 v. McKesson Corp., 640 F. App’x 796 (10th Cir. 2016). 16 In Grenell v. UPS Health and Welfare Package, 390 F. Supp. 2d 932 17 (C.D. Cal. 2005), another court in this district rejected a plaintiff’s futility 18 argument and found that the plaintiff offered “no such excuse for his complete 19 failure to appeal the denial of his claim.” Id. at 935. Here, Sanchez offers no 20 reasonable excuse for his complete failure to follow the prescribed 21 administrative procedure of the ITW LTD Plan. Sanchez cannot, through 22 hypothetical assertions, meet his burden to establish with certainty that Hartford 23 would deny his LTD simply because his STD claim was denied. 24 The STD Plan and the LTD Plan are separate and distinct plans with 25 different terms, conditions, and limitations. A claim that is not payable under 26 the STD Plan may nevertheless be payable under the LTD Plan. Sanchez does 27 not meet his burden to prove that an LTD claim was futile. Pursuing an LTD 28 claim was not futile. The futility exception does not apply and does not excuse -23- Case 2:2))-cv-03732-JWH-JEM Document 74 Filed 09/02/22 Page 24 of 24 Page ID #:1732

1) Sanchez’s failure to exhaust administrative remedies under the LTD Plan. 2\ Accordingly, Sanchez’s claim for benefits under the LTD Plan is DENIED 3|| without prejudice. 4 IV. CONCLUSION 5 For the foregoing reasons, the Court will enter Judgment in favor of 6}| Hartford and against Sanchez. 7 IT ISSO ORDERED.

MLV LO

ol Dated: September 2, 2022

10 UNITED STATES DISTRICT JUDGE 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 -24-