In this case, Yvette Williby (“Williby”) was a supply chain specialist for The Boeing Company (“Boeing”). Her job duties required problem-solving abilities, interactions with customers and vendors, research, and assessment of technical issues and problems. Williby experienced a stroke or similar episode in September of 2011. She later began to experience chronic headaches and additional issues that led her to having trouble at work. In December of 2012, Dr. David Edelman did some cognitive testing which indicated that her executive functions “predicted a moderate likelihood or ‘mild cognitive impairment.’” Dr. Edelman further opined that Williby experienced “migraine, acute but ill-defined cerebrovascular disease, and vascular dementia uncomplicated.” On December 12, 2012, Williby stopped working for Boeing.
Boeing offered its employees a self-funded short-term disability plan, which was administered by Aetna Life Insurance Company (“Aetna”). Under the plan, Boeing pays from sixty to eighty percent of an employee’s salary if they cannot perform their job duties or similar work at Boeing because of a disability. After twenty-six weeks of short-term disability benefits, an employee must then apply for long-term disability benefits. Aetna granted Williby short-term disability benefits from December 20, 2012, to February 28, 2013, as a result of Dr. Edelman’s testing. However, Aetna denied short-term disability benefits for February to June. Aetna retained Dr. Vaughn Cohan, neurologist, to review Williby’s file. However, he noted that she could still work because there were no “acute” abnormalities on her MRI, because her overall function was normal, and because she had not followed up with neuropsychological testing after her initial tests.
From April to November, Dr. Edelman again affirmed that Williby was not able to work. From June to December, Williby saw additional doctors, including a neurologist, neuropsychologist, psychologist, and psychiatrist. Each of those also stated that she had a cognitive impairment that would cause her to be disabled and limit her from working. After Aetna’s denial, Williby appealed the decision. She submitted more doctors’ reports to support her claim. Aetna then hired both a neuropsychologist and occupational medicine specialist to look at Williby’s file. They both stated that there was not enough objective evidence to prove her disability. In February 2014, Aetna stood by its decision to deny Williby benefits.
Williby then filed suit under ERISA. The court held that Williby was disabled during the February 28 through June 20 period and that Aetna’s denial of her benefits was improper. More specifically, the court believed that Aetna’s denial of Williby’s benefits did not meet the level of abuse of discretion because (1) all of the doctors who treated her opined that she was disabled or demonstrated cognitive impairment, and (2) that Aetna overly relied on a “lack of objective clinical support” regarding her short-term disability benefits, even though it never had her examined or tested. Then, Aetna appealed in the instant case.
This court held that the lower court should have evaluated Williby’s claim under an abuse of discretion standard. Therefore, the main issue at hand is whether a remand is required so that the district court can reevaluate the case under that standard. Williby claims that the lower court already utilized the abuse of discretion standard and that the instant court should affirm that ruling. On the other hand, Aetna argues that because the lower court did not properly use the abuse of discretion standard, that the issue should be remanded for the district court to review again.
Underlying this issue is whether the lower court followed the “treating physician rule.” This rule formerly allowed a court to give “especially great weight to the opinion of a claimant’s treating physician.” More specifically, the rule would require Aetna to “either accept the opinion of a claimant’s treating physician, or, if the administrator rejects that opinion, come forward with specific reasons for that decision, based on substantial evidence in the record.” However, the Supreme Court struck down the “treating physician rule” in 2003, providing that “courts have no warrant to require administrators automatically to accord special weight to the opinions of a claimant’s physician; nor may courts impose on plan administrators a discrete burden of explanation when they credit reliable evidence that conflicts with a treating physician’s evaluation.”
The two reasons cited previously by the lower court for the denial of Williby’s benefits appear to be very similar to the “treating physician rule.” However, because it did not feel that the lower court properly applied the abuse of discretion standard, the instant court decided not to determine whether such rule was actually followed. Further, the district court stated that it was “viewing Aetna’s decision with no degree of skepticism since Aetna did not have a conflict of interest.” However, the instant court noted the fact that the district court supported its abuse of discretion decision based solely on Salomaa v. Honda Long Term Disability Plan, 42 F.3d 666 (9th Cir. 2011). In that case, there was a conflict of interest.
Because the lower court appeared to fully rely on the Salomaa case alone, the instant court felt that it would be unable to determine whether the lower court appropriately used the correct standard of evaluation. In fact, the Salomaa case states that “every doctor who personally examined [the employee] concluded that he was disabled,” which was one of several factors that led to a decision that a claimant was disabled. Other factors included an award of Social Security benefits that did not align with the medical records. Those factors were not the same or even similar circumstances in the instant case, and the lower court did not take them into account.
Since the lower court only highlighted a recitation of the abuse of discretion standard along with a single citation that was not appropriate, the instant court believed that the standard was improperly applied. As such, the court ruled that the case should be remanded to the lower court in order for there to be a review under the proper standard.
Here is a PDF copy of the Court’s decision:Williby_v_Aetna-9thCir-2017