Wilstead v. United Heritage Life Insurance Company

Filing 37

MEMORANDUM AND ORDER RE: CROSS-MOTIONS FOR SUMMARY JUDGMENT. Defendants motion for summary judgment (Docket No. 27 ) be, and the same hereby is, GRANTED, and that plaintiffs motion for summary judgment (Docket No. 31 ) be, and the same hereby is, DENIED. Signed by Judge William B. Shubb. (alw)

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Case 1:19-cv-00276-WBS Document 37 Filed 09/09/20 Page 1 of 16 1 2 3 4 5 6 7 8 UNITED STATES DISTRICT COURT 9 DISTRICT OF IDAHO 10 ----oo0oo---- 11 12 STEVE WILSTEAD, Plaintiff, 13 v. 14 15 No. 1:19-cv-00276 WBS MEMORANDUM AND ORDER RE: CROSS-MOTIONS FOR SUMMARY JUDGMENT UNITED HERITAGE LIFE INSURANCE COMPANY, 16 Defendant. 17 18 ----oo0oo---- 19 Plaintiff Steve Wilstead (“plaintiff”) brought this 20 21 action against defendant United Heritage Life Insurance Company 22 (“United Heritage” or “defendant”) alleging he was wrongly denied 23 long-term disability benefits under his employer’s group benefits 24 plan in violation of the Employee Retirement Income Security Act 25 (“ERISA”), 29 U.S.C. § 1132(a)(1)(B). 26 Both parties move for summary judgment. 27 I. 28 (Compl. (Docket No. 1).) (Docket Nos. 27, 31.) Facts & Procedural Background Plaintiff was a Certified Registered Nurse Anesthetist 1 Case 1:19-cv-00276-WBS Document 37 Filed 09/09/20 Page 2 of 16 1 employed by Anesthesia Associates of Boise. (Pl.’s Statement of 2 Undisputed Fact (“Pl.’s SUF”) ¶¶ 1, 6 (Docket No. 31-2); Def.’s 3 Statement of Undisputed Fact (“Def.’s SUF”) ¶ 12 (Docket No. 4 28).) 5 accident in August 2016, which required surgery. 6 Def.’s SUF ¶ 13.) 7 working on November 18, 2016. 8 surgery, plaintiff was prescribed opioid pain medications and 9 later developed an addiction to them. Plaintiff suffered a shoulder injury in a motorcycle (Pl.’s SUF ¶ 7; Due to plaintiff’s injuries, he stopped (Pl.’s SUF ¶ 9.) Following (Pl.’s SUF ¶ 26; Def.’s 10 SUF ¶ 14.) 11 term disability benefits under his employer’s group long-term 12 disability benefits plan based on his shoulder injury, substance 13 abuse, and depression. 14 Plaintiff subsequently submitted a claim for long- (Pl.’s SUF ¶ 12; Def.’s SUF ¶ 15.) United Heritage is the claim administrator of 15 Anesthesia Associates of Boise’s long-term disability benefits 16 plan. 17 United Heritage requires claimants to submit a Proof of Loss 18 providing documentation supporting the disability claim. 19 Rec. (“AR”) at 22.) 20 “disability” as: 21 22 23 24 25 26 27 28 (Def.’s SUF ¶ 4.) To claim benefits under the plan, (Admin. In relevant part, the policy defines [The Claimant is] prevented from performing one or more of the Essential Duties of: 1) [The Claimant’s] Occupation during the Elimination Period; 2) [The Claimant’s] Occupation for the 24 months following the Elimination Period, and as a result [The Claimant’s] Current Monthly Earnings are less than 80% of [The Claimant’s] Indexed Pre-disability Earnings; and 3) after that, Any Occupation (Id. at 6.) Disability could result from, among other things, 2 Case 1:19-cv-00276-WBS Document 37 Filed 09/09/20 Page 3 of 16 1 substance abuse. 2 required records, defendant referred plaintiff’s medical records 3 to an outside medical review vendor, MES Solutions. 4 ¶ 19.) 5 two independent physicians, reviewed plaintiff’s cliam, both 6 concluding that he did not have any long-term functional 7 impairment due to his shoulder injury, substance abuse, or 8 depression. 9 Heritage approved the payment of disability benefits to plaintiff 10 (Id.) After plaintiff submitted his claim and There, Dr. Roy Q. Sanders and Dr. Christopher R. Balint, (AR at 314-324.) Based on those reports, United for a limited period, ending on April 3, 2017. 11 (Def.’s SUF (AR at 152-56.) Plaintiff appealed United Heritage’s determination 12 regarding his long-term disability claim based on his substance 13 abuse. 14 appeal the determinations based on his shoulder injury and 15 depression. 16 medical records to Exam Coordinators Network to obtain another 17 independent review of plaintiff’s appeal. 18 There, Dr. Steven I. Dyckman concluded that plaintiff was not 19 able to resume his occupation as a nurse until July 30, 2017 20 because he suffered from “severe depression and anxiety symptoms 21 including hopelessness, suicidal thoughts, and decreased 22 concentration.” 23 revised its initial decision and extended the period of payable 24 disability benefits to July 30, 2017. 25 ¶ 54.) 26 benefits remained unchanged. 27 notified plaintiff he had exhausted his administrative remedies 28 on July 17, 2018 and this suit followed. (AR 231-42; Pl.’s SUF ¶ 17; Def.’s SUF ¶ 42.) (AR at 231-36.) (AR at 226.) He did not United Heritage referred his (Def.’s SUF ¶ 44.) Consequently, United Heritage (AR at 163-66; Def.’s SUF However, its ultimate denial of long-term disability (AR at 163-66.) 3 United Heritage (Pl.’s SUF ¶ 23; Def.’s Case 1:19-cv-00276-WBS Document 37 Filed 09/09/20 Page 4 of 16 1 SUF ¶ 55.) 2 II. 3 Discussion A. Standard of Review 4 In ERISA actions challenging denials of benefits under 5 29 U.S.C. § 1132(a)(1)(B), “[d]e novo is the default standard of 6 review.” 7 (9th Cir. 2006) (en banc) (internal citations omitted); see also 8 Kearney v. Standard Ins. Co., 175 F.3d 1084, 1089 (9th Cir. 1999) 9 (en banc). Abatie v. Alta Heath & Life Ins. Co., 458 F.3d 955, 963 If the plan grants the plan administrator discretion 10 to determine eligibility for benefits and interpret the terms of 11 the plan, a reviewing court applies an abuse of discretion 12 standard. 13 Income, 349 F.3d 1098, 1102 (9th Cir. 2003); see also Abatie, 458 14 F.3d at 963 (citing Kearney, 174 F.3d at 1090). 15 “unambiguously” grant the administrator discretion for abuse of 16 discretion to apply, though there is no “magic word” requirement. 17 Abatie, 458 F.3d at 963 (citing Kearney, 175 F.3d at 1090). 18 Jebian v. Hewlett-Packard Co. Emp. Benefits Org. The plan must Here, Section VIII of Anesthesia Associates of Boise’s 19 plan confers upon United Heritage the “full discretion and 20 authority to determine eligibility for benefits and to construe 21 and interpret all terms and provisions of The Policy.” 22 26.) 23 absent state intervention which spares state policies from ERISA 24 preemption. 25 Term Disability Plan, Plan No. 625, 856 F.3d 686, 689 (9th Cir. 26 2017) (finding California’s prohibition on discretionary clauses 27 fell within ERISA’s saving clause when the plan was funded by 28 insurance policies and was therefore not preempted by ERISA). (AR at Accordingly, the abuse of discretion standard should apply, See, e.g. Orzechowski v. Boeing Co. Non-Union Long- 4 Case 1:19-cv-00276-WBS Document 37 Filed 09/09/20 Page 5 of 16 1 1. Idaho’s Limited Prohibition on Discretionary Clauses 2 “ERISA pre-empts a state law that has an impermissible 3 ‘connection with’ ERISA plans, meaning a state law that ‘governs 4 . . . a central matter of plan administration’ or ‘interferes 5 with nationally uniform plan administration.’” 6 Liberty Mut. Ins. Co., 136 S. Ct. 936, 943 (2016) (quoting 7 Egelhoff v. Egelhoff, 532 U.S. 141, 148 (2001)). 8 plaintiff notes, (Pl.’s MSJ at 3), ERISA’s savings clauses spares 9 “any law of any State which regulates insurance, banking, or Gobeille v. However, as 10 securities” from preemption. 11 867 F.3d 1129, 1135 (9th Cir. 2017) (quoting 29 U.S.C. § 12 1144(b)(2)(A)). 13 health insurance contracts from containing discretionary clauses 14 while transacting insurance in Idaho. 15 16 savings clause allows Idaho Administrative Code 18.04.07 to apply 17 despite ERISA’s preemptive force, as plaintiff contends, the 18 court must consider the base question of whether Idaho 19 Administrative Code 18.04.07 even applies to this policy. 20 Williby v. Aetna Life Insur. Co., Idaho Administrative Code 18.04.07 prohibits See Idaho Admin. Code r. Before reaching the question of whether ERISA’s Idaho Administrative Code defines 21 “Health Insurance Contract” as “any policy, contract, 22 certificate, agreement, or other form or document providing, 23 defining, or explaining coverage for health care services that 24 [are] offered, delivered, issued for delivery, continued, or 25 renewed in this state by a health carrier.” 26 27 subject to regulation under Title 41, Chapter 21” of the Idaho 28 Code, and “Health Care Services” are defined as “[s]ervices for Idaho Admin. Code r. A “Health Carrier” is defined as “[a]n entity 5 Case 1:19-cv-00276-WBS Document 37 Filed 09/09/20 Page 6 of 16 1 the diagnosis, prevention, treatment, cure or relief of a health 2 condition, illness, injury, or disease.” 3 Importantly, the chapter “does not apply to health insurance 4 contract[s] for group coverage offered by or through an employer 5 to its employees.” 6 Id. at (03)-(04). Idaho Admin. Code r. Plaintiff concedes that “the Plan, as administered by 7 United Heritage, is not a health care contract since it does not 8 provide health care services, as defined by the Code.” 9 Reply at 2.) (Pl.’s Nevertheless, plaintiff maintains that United 10 Heritage is still subject to the code because it is an entity 11 regulated by Title 41, Chapter 21 of the Idaho Code as a carrier 12 of disability insurance. 13 41-2101, et seq.).) 14 applies to disability insurance policies broadly, “any group or 15 blanket policy,” such as the one administered by United Heritage, 16 is exempt from regulation. 17 in this chapter shall apply to or affect . . . Any group or 18 blanket policy”). 19 18.04.07 does not apply to the policy here and does not prohibit 20 the application of the policy’s discretionary clause.1 21 22 (Pl.’s Reply at 2. (citing Idaho Code § While Title 41, Chapter 21 of the Idaho Code See Idaho Code § 41-2101(A) (“Nothing Accordingly, Idaho Administrative Code Because the provision in the Idaho Administrative Code does not apply, the court need not consider what role ERISA’s 23 24 25 26 27 28 Even if Idaho Administrative Code 18.04.07’s ban on discretionary clauses were to apply to the United Heritage policy, the provision’s exception for group coverage “offered by or through an employer to its employees” would exempt the policy from the ban. Id. Anesthesia Associates of Boise’s group longterm disability plan, as a group policy offered through plaintiff’s employer to its employees, falls squarely within the stated exception. See Idaho Admin. Code r. 6 1 Case 1:19-cv-00276-WBS Document 37 Filed 09/09/20 Page 7 of 16 1 savings clause would have on the matter. Accordingly, the 2 unambiguous grant of discretion to United Heritage as the plan’s 3 administrator triggers the application of the abuse of discretion 4 standard. 5 at 1090). See Abatie, 458 F.3d at 963 (citing Kearney, 175 F.3d 6 2. Structural Conflict of Interest 7 Under an abuse of discretion standard of review, an 8 administrator’s evaluation “will not be disturbed if reasonable.” 9 Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 111 (1989). 10 Under that standard, the court is limited to a review of the 11 administrative record. 12 abuse of discretion, the court must have a “definite and firm 13 conviction that a mistake has been committed and . . . may not 14 merely substitute [its] view for that of the fact finder.” 15 Salomaa v. Honda Long Term Disability Plan, 642 F.3d 666, 676 16 (9th Cir. 2011). 17 only if the administrator “(1) renders a decision without 18 explanation, (2) construes provisions of the plan in a way that 19 conflicts with the plain language of the plan, or (3) relies on 20 clearly erroneous findings of fact.” 21 Rozelle NFL Players Ret. Plan, 410 F.3d 1173, 1178 (9th Cir. 22 2005). 23 See Jebian, 349 F.3d at 1110. To find an An ERISA administrator abuses its discretion Boyd v. Bert Bell/Pete However, the court’s deference to the administrator’s 24 decision may be tempered by a structural conflict of interest. 25 Abatie, 458 F.3d at 965 (quoting Firestone, 489 U.S. at 115). 26 Where, as here, an insurer acts as both the plan administrator 27 and the funding source for benefits, there is a structural 28 conflict of interest. See id. (citing Tremain v. Bell Indus., 7 Case 1:19-cv-00276-WBS Document 37 Filed 09/09/20 Page 8 of 16 1 Inc., 196 F.3d 970, 976 (9th Cir. 1999)). 2 is operating under a conflict of interest, that conflict must be 3 weighed as a “facto[r] in determining whether there is an abuse 4 of discretion.” 5 of the administrator’s decision will be “tempered by skepticism” 6 to the degree of the severity of the conflict. 7 at 959. 8 must provide “material, probative evidence, beyond the mere fact 9 of the apparent conflict, tending to show that the fiduciary’s 10 self-interest caused a breach of the administrator’s fiduciary 11 obligations to the beneficiary.” 12 also Abatie, 458 F.3d at 968. 13 structural conflict “should prove less important (perhaps to the 14 vanishing point) where the administrator has taken active steps 15 to reduce potential bias and to promote accuracy.” 16 Ins. Co. v. Glenn, 554 U.S. 105, 117 (2008). 17 If the administrator Firestone, 489 U.S. at 115. The court’s review Abatie, 458 F.3d In order to weigh a conflict more heavily, the claimant Tremain, 196 F.3d at 976; see Conversely, a dual role capacity Metro. Life Here, plaintiff did not submit any evidence to show 18 that United Heritage’s structural conflict caused a breach of its 19 fiduciary duty. 20 its efforts to “wall off” claims personnel from the company’s 21 finance department to ensure claims investigations are made 22 separately from, and without consideration of, the financial 23 affairs of United Heritage. 24 33-1).) 25 the arbitrary denial of claims by maintaining a separate appeals 26 unit for the independent consideration of denied claims. 27 Other courts have “give[n] little weight to the [structural] 28 conflict” following similar representations. Instead, United Heritage exhaustively explained (Def.’s Reply at Ex. A (Docket No. United Heritage also represents it has a check against 8 (Id.) See Baker v. Case 1:19-cv-00276-WBS Document 37 Filed 09/09/20 Page 9 of 16 1 Hartford Life & Acc. Ins. Co., No. 4:14-cv-209 BLW, 2015 WL 2 769962, at *5 (D. Idaho Feb. 23, 2015). 3 Heritage’s evaluation “will not be disturbed if reasonable.” 4 Firestone, 489 U.S. at 111. 5 B. Accordingly, United Analysis 6 When considering a claim for benefits, ERISA 7 administrators have a duty to adequately investigate the claim. 8 Booton v. Lockheed Med. Ben. Plan, 110 F.3d 1461, 1463 (9th Cir. 9 1997). If the administrator “believes more information is needed 10 to make a reasoned decision, they must ask for it.” Id. 11 However, “the plan administrator’s decision can be upheld if it 12 is grounded on any reasonable basis.” 13 Acc. Ins. Co., 588 F.3d 623, 629 (9th Cir. 2009) (internal 14 citations omitted). 15 “whose interpretation of the plan documents is most persuasive, 16 but whether the . . . interpretation is unreasonable.” 17 v. Const. Laborers Pension Tr., 93 F.3d 600, 609 (9th Cir. 1996). 18 The court will only find United Heritage’s determination 19 “unreasonable” if “it render[ed] a decision without an 20 explanation, constru[ed] provisions of the plan in a way that 21 conflicts with the plain language of the plan, or fail[ed] to 22 develop facts necessary to its determination.” 23 v. United Behavorial Health, 764 F.3d 1030, 1042 (9th Cir. 2014). Montour v. Hartford Life & The central question before the court is not Canseco Pac. Shore Hosp. 24 1. Initial Determination 25 In its first evaluation of plaintiff’s claim, United 26 Heritage obtained the independent reviews of Dr. Sanders and Dr. 27 Balint through MES Solutions. 28 Board Certified in Psychiatry, with a specialty in addiction, and (AR at 314-324.) 9 Dr. Sanders is Case 1:19-cv-00276-WBS Document 37 Filed 09/09/20 Page 10 of 16 1 Dr. Balint is Board Certified in Orthopedic Surgery. 2 314, 319.) 3 opioid addiction on his ability to work, while Dr. Balint 4 considered whether plaintiff’s shoulder injury would impair his 5 employment. 6 (Id. at Dr. Sanders evaluated the impact of plaintiff’s (See generally id. at 314-24.) Both physicians thoroughly evaluated and summarized 7 “all medical records received,” including “claimant’s most recent 8 self-reported statements of functionality.” 9 They consulted with each other about proposed physical and (Id. at 314, 319.) 10 psychiatric limitations/restrictions following their independent 11 reviews. 12 plaintiff’s treating physicians, Mr. Terry Miller and Dr. Daniel 13 Reed, for further information even after multiple attempts at 14 contact. (Id. at 314, 319.) Neither were able to reach (Id. at 314, 319.) 15 After a detailed review, Dr. Sanders and Dr. Balint 16 eventually concluded that plaintiff was fit to return to work 17 “with supervision.” 18 psychological state, Dr. Sanders found plaintiff was able to 19 “engage with patients,” “take directions,” “give instructions,” 20 and “reliably perform tasks as requested and required by the 21 employer.” 22 physical limitations on the number of hours per day plaintiff 23 could work, due in part to the fact that there was “no 24 documentation of weakness, pain, or impingement that would 25 prevent the claimant from returning to full, unrestricted work on 26 a full time basis.” 27 28 (Id. at 318.) (Id. at 318.) As for plaintiff’s Dr. Balint found that there were no (Id. at 323.) Plaintiff contends the physicians’ evaluations are deficient because neither doctor physically examined him, and 10 Case 1:19-cv-00276-WBS Document 37 Filed 09/09/20 Page 11 of 16 1 furthermore, the doctors relied upon “incomplete” medical 2 records. 3 Anesthesia Associates of Boise’s plan nor ERISA require a peer 4 review physician to examine a claimant during their review. 5 generally AR at 1-31.) 6 evaluating “all medical records received,” although they 7 acknowledged recent records were “few.” 8 terms of the plan, plaintiff was required to provide proof of his 9 disability and provide United Heritage with the records necessary (Pl.’s Resp. at 6 (Docket No. 32).) However, neither (See Similarly, both doctors attested to (Id. at 318.) Under the 10 to properly evaluate his claim. 11 Hartford Life & Accidental Ins. Co., 930 F. Supp. 2d 1216, 1127 12 (D. Idaho 2013) (“[I]f a plan participant fails to bring evidence 13 to the attention of the administrator, the participant cannot 14 complain of the administrator’s failure to consider such 15 evidence.”). 16 (Id. at 22.); see also Cady v. From the administrative record, it is not readily 17 apparent that United Heritage erred in denying plaintiff long- 18 term disability benefits because United Heritage reasonably 19 relied on medical determinations produced by Dr. Sanders and Dr. 20 Balint after careful review of plaintiff’s file. 21 Unite Heritage did not abuse its discretion and the court will 22 not reverse its initial denial of benefits. Consequently, 23 2. The Appeal 24 Similarly, United Heritage’s denial of plaintiff’s 25 claim after his appeal was also reasonable. 26 appealed, United Heritage obtained another independent review 27 from Dr. Dyckman. 28 Certified in General Psychiatry, although he specializes in child (AR at 218-221.) 11 After plaintiff Dr. Dyckman is Board Case 1:19-cv-00276-WBS Document 37 Filed 09/09/20 Page 12 of 16 1 and adolescent psychiatry. 2 argues that the review by United Heritage and Dr. Dyckman of his 3 appeal was deficient for three main reasons: first, Dr. Dyckman 4 did not consider the American Association of Nurse Anesthetists 5 Re-entry Recommendations for recovering nurses in making his 6 recommendations; second, Dr. Dyckman did not consider the 7 recommendations provided by plaintiff’s attending counselor; and 8 third, United Heritage did not consider whether plaintiff’s risk 9 of relapse into substance abuse rose to the level of a disability 10 in and of itself. 11 (Def.’s Reply at 15.) discussed in turn. 12 (See Pl.’s MSJ at 15-21.) Plaintiff Each will be First, plaintiff criticizes Dr. Dyckman’s conclusion 13 that “there is no guideline . . . [that] claimant should be 14 abstinent for at least a year before returning to work [as a 15 nurse anesthetist].” 16 conclusion amounts to a blatant disregard of the American 17 Association of Nurse Anesthetists Re-entry Recommendations (“the 18 Guidelines”). 19 expressly consider the Guidelines during his limited review of 20 the “psychiatric and/or cognitive restrictions and limitations” 21 the other doctors had recommended, (AR at 226-27), United 22 Heritage considered the Guidelines when evaluating plaintiff’s 23 appeal. 24 “may” return to work “in a supervised setting” following 25 treatment for addiction, although recognizing “more time away 26 from the workplace may be needed to reduce risk of relapse.” 27 (Pl.’s MSJ at 8 n. 2 (quoting Opioid Abuse Among Nurse 28 Anesthetist and Anesthesiologists, AANA Journal, April 2012 at (AR at 227.) Plaintiff argues this (Pl.’s MSJ at 15-16.) (AR at 165.) While Dr. Dyckman did not The Guidelines provide, in part, nurses 12 Case 1:19-cv-00276-WBS Document 37 Filed 09/09/20 Page 13 of 16 1 120, 125).) 2 nurses may practice under supervision mirrors the recommendations 3 both Dr. Dyckman and Dr. Sanders gave for plaintiff’s return to 4 work. 5 The Guideline’s recommendation that recovering (See AR at 227, 318.) Second, plaintiff argues that Dr. Dyckman’s conclusions 6 should be disregarded because he did not consider the 7 recommendations provided by plaintiff’s attending therapist, Mr. 8 Terry Miller. 9 offered the opportunity to submit updated clinical records or new (Pl.’s MSJ at 15-16.) On appeal, plaintiff was 10 information to substantiate his disability claim. 11 60.) 12 submitted, inter alia, a May 2018 letter written by Mr. Miller. 13 (AR at 237.) 14 could not return to work until he had completed “at least one 15 year of abstinence” and continued treatment through regular 16 attendance at a 12-step support group because “handling the 17 medications that led to his addition crisis” at work could pose a 18 substantial threat of relapse. 19 to plaintiff’s representations that Dr. Dyckman did not review 20 the letter, (Pl.’s MSJ at 16), Dr. Dyckman thoroughly explained 21 why he disagreed with Mr. Miller’s conclusions in his review of 22 plaintiff’s file. 23 Dyckman found “claimant would be able to return to work as long 24 as there were proper guidelines in place and the claimant 25 continued to receive outpatient therapy.” 26 (AR at 159- Instead of submitting additional medical records, plaintiff In that letter, Mr. Miller stated he felt plaintiff (AR at 237.) (See AR 227.) However, contrary Agreeing with Dr. Sanders, Dr. (Id.) Further, United Heritage was not bound by Mr. Miller’s 27 recommendations. “[P]lan administrators are not obliged to 28 accord special deference to the opinions of treating physicians.” 13 Case 1:19-cv-00276-WBS Document 37 Filed 09/09/20 Page 14 of 16 1 Black & Decker Disability Plan v. Nord, 538 U.S. 822, 825 (2003). 2 Although Mr. Miller and Dr. Dyckman offered different 3 conclusions, the administrative record reveals that, when 4 plaintiff’s benefits ended on July 30, 2017, he was physically 5 and mentally capable of performing his occupational duties. 6 AR at 227, 318.) 7 summarize the pertinent medical records and provide a careful 8 analysis of plaintiff’s physical and psychiatric capabilities. 9 United Heritage denied plaintiff’s claim based on the facts in (See The reviewing physicians’ reports thoroughly 10 the record and adequately explained why in letters to plaintiff. 11 (See AR at 163-166.); see also Pac. Shore Hosp., 764 F.3d at 12 1042. 13 Third, plaintiff argues that United Heritage erred in 14 determining that he was not currently disabled and maintains that 15 his risk of relapse into substance abuse constitutes a disability 16 in and of itself. (See Pl.’s MSJ at 17-21.) 17 Colby v. Union Security Insurance Co. & Management Co. for 18 Merrimack Anesthesia Associates Long Term Disability Plan., 705 19 F.3d 58, 60 (1st Cir. 2013) to support this proposition. 20 Colby, the plaintiff was an anesthesiologist, who, like 21 plaintiff, self-administered opioids on the job and became 22 addicted. 23 Colby is readily distinguishable from plaintiff here; she had 24 unique characteristics which made her risk of relapse 25 particularly severe, including disabling back pain, an extremely 26 turbulent personal life, various mental health disorders 27 including obsessive-compulsive personality traits, and previous 28 instances of relapse. See Colby, 705 F.3d at 60. Id. at 63. 14 Plaintiff relies on In However, the plaintiff in Plaintiff does not appear to Case 1:19-cv-00276-WBS Document 37 Filed 09/09/20 Page 15 of 16 1 have any of those characteristics. 2 Moreover, the Colby court makes clear that their 3 holding is “narrow . . . pivot[ing] on a fusion of the plain 4 language of the plan and [defendant]’s all-or-nothing approach to 5 its benefits determination.” 6 categorically denied that risk of relapse or future disability 7 could be considered a current disability for which benefits are 8 available, despite the particularly high-risk factors for the 9 plaintiff. See id. at 61. Id., at 67. The defendant in Colby Here, in contrast, United Heritage 10 issued no such categorical denial, but rather found that the AANA 11 Guidelines which recommend “[a] minimum of one year in recovery 12 before returning to the clinical anesthesia arena”, (AR 238), 13 “alone [do not] constitute disability.” (See AR at 165.) 14 court therefore agrees with the Fourth Circuit in Stanford v. 15 Continental Casualty Co., 514 F.3d 354 (4th Cir. 2008), abrogated 16 on other grounds in Champion v. Black & Decker (U.S.) Inc., 550 17 F.3d 353 (4th Cir. 2008), that there is widespread, thoughtful, 18 and reasonable disagreement among the courts “as to whether the 19 risk of relapse renders an addict unable to perform the material 20 and substantial duties of his work.” See Stanford, 514 F.3d at 21 359–60 (affirming determination made by insurance company finding 22 that plaintiff’s risk of relapse did not constitute a disability 23 in of itself notwithstanding plaintiff’s opiate addition and 24 instance of relapse after returning to work was not unreasonable 25 under an abuse of discretion standard.) 26 decision of United Heritage to deny plaintiff long-term 27 disability benefits based on the risk of relapse into substance 28 abuse cannot “be termed unreasonable” under an abuse of 15 This Accordingly, the Case 1:19-cv-00276-WBS Document 37 Filed 09/09/20 Page 16 of 16 1 discretion standard of review. 2 Heritage reasonably denied plaintiff’s claim for long-term 3 disability benefits after July 30, 2017. 4 Id. at 360. Consequently, United For the foregoing reasons, the court finds that United 5 Heritage did not abuse its discretion in determining that 6 plaintiff was not disabled under the policy’s definition of 7 “disability” after July 30, 2017. 8 9 IT IS THEREFORE ORDERED that defendant’s motion for summary judgment (Docket No. 27) be, and the same hereby is, 10 GRANTED, and that plaintiff’s motion for summary judgment (Docket 11 No. 31) be, and the same hereby is, DENIED. 12 Court is instructed to enter judgment in favor of defendant 13 United Heritage Life Insurance Company and against plaintiff 14 Steve Wilstead. 15 Dated: September 9, 2020 16 17 18 19 20 21 22 23 24 25 26 27 28 16 The Clerk of the

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