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“Entz V. Standard Insurance Company”

Entz v. Standard Ins. Co., No. EDCV19402JGBSHKX, 2020 WL 5496072 (C.D. Cal. Sept. 11, 2020)

Tisha Entz, was member of the California Teachers Association and participant in the in the California Teachers Association Economic Benefits Trust, which provided Long Term Disability (“LTD”) benefits insured by Standard Insurance Company (“Standard”).

Prior to her disability, Entz worked as an elementary school teacher for 20 years. For years, she worked despite symptoms including fatigue, headache, muscle cramping, palpitations, and cognitive problems. In 2014, Entz was diagnosed with Chronic Lyme Disease and continued working through the 2014/2015 school year while undergoing treatment, which included antibiotic infusions using a peripherally inserted central catheter (PICC line) installed in her arm. She was unable to return to teaching duties for the 2015-2016 school year due to exhaustion, pain, nausea, bladder/bowel incontinence, and general malaise, among other symptoms. Entz applied for LTD benefits from Standard, and disability retirement benefits under the California State Teachers’ Retirement System (“CalSTRS”). Entz’ was awarded CalSTRS disability retirement benefits, but was denied LTD benefits by Standard, even though the requirements for benefits under CalSTRS are much harder to meet than those of Standard’s LTD Policy. Entz appealed the denial of her claim for LTD benefits, but Standard upheld its denial.

We filed suit against Standard on behalf of Entz, seeking LTD benefits and a declaration from the court that her Complaint was timely.

In the Complaint, we asserted various violations of ERISA. Specifically, that Standard breached its fiduciary duties when it denied Entz’ LTD claim, when it failed to apply the correct standard of disability by refusing to consider whether Entz could perform her own occupation with “reasonable continuity,” and when it refused to share peer review reports obtained by Standard, for comment before it issued its final denial. Standard argued that Entz’ Complaint was untimely, and that it had acted properly in all matters, included making the decisions to deny Plaintiff’s LTD benefits and deny her appeal of that decision.
After a bench trial, Judgment was entered in Entz’ favor.

The Court agreed with us that Entz’ Complaint was timely, adopting our interpretation of the Policy’s contractual limitations provision, and also agreeing that Standard’s failure to notify Entz of the applicable limitation period constituted a breach of fiduciary duty precluding reliance upon the limitation period.
In its review of the medical evidence, the Court gave significant weight to evidence from treating physicians who observed Entz in person on multiple occasions. The Court dismissed Standard’s arguments that the many normal test results were proof that Entz was not disabled under the Policy, explaining that “the tests bear only on potential causes of Plaintiff’s symptoms, but do not disprove the existence of the reported symptoms themselves. Nor do the tests bear on Plaintiff’s ability to perform occupational duties. The Plan does not require objective proof, and contemplates disability even where the causes of a sickness are unknown.”

The Court also found persuasive the CalSTRS finding that Entz was disabled, treating the CalSTRS decision as “roughly analogous to an SSA decision, which has been deemed ‘weighty evidence’ of disability,” and noting that “the CalSTRS finding is significant, because the definition of disability in that context is more stringent than that in the Plan. CalSTRS requires a “medically determinable” impairment, whereas the “Total Disability” under the Plan does not by its terms require this level of proof. Cal. Educ. Code § 22126.”

The Court concluded that Entz had adequately established she was “totally disabled” under the Policy, and awarded LTD benefits owed.