Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-cand-5_04-cv-02943/USCOURTS-cand-5_04-cv-02943-0/pdf.json

Nature of Suit Code: 791
Nature of Suit: Employee Retirement Income Security Act (ERISA)
Cause of Action: 29:1002 E.R.I.S.A.: Employee Retirement

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 This disposition is not designated for publication and may not be cited.

Case No. C 04-02943 JF

ORDER (1) GRANTING PLAINTIFF’S MOTION FOR SUMMARY JUDGMENT, (2) DENYING DEFENDANTS’

MOTION FOR SUMMARY JUDGMENT, AND (3) REMANDING CASE FOR DETERMINATION OF BENEFITS

(JFEX2)

** E-filed on 7/29/05 **

NOT FOR CITATION

IN THE UNITED STATES DISTRICT COURT

FOR THE NORTHERN DISTRICT OF CALIFORNIA

SAN JOSE DIVISION

GRETCHEN HEINRICH,

 Plaintiff,

 v.

THE PRUDENTIAL INSURANCE COMPANY

OF AMERICA and KNIGHT-RIDDER, INC.

LONG TERM DISABILITY PLAN,

 Defendants.

Case Number C 04-02943 JF

ORDER1 (1) GRANTING

PLAINTIFF’S MOTION FOR

SUMMARY JUDGMENT (2)

DENYING DEFENDANTS’ MOTION

FOR SUMMARY JUDGMENT, AND

(3) REMANDING CASE FOR

DETERMINATION OF BENEFITS

[Docket Nos. 17, 23]

Plaintiff Gretchen Heinrich (“Heinrich”) and Defendants The Prudential Insurance

Company of America and Knight-Ridder, Inc. Long Term Disability Plan (collectively

“Defendants”) dispute whether Heinrich properly was denied long-term disability benefits. The

parties have filed cross-motions for summary judgment. The Court has read the moving and

responding papers and has considered the oral arguments of counsel presented on July 15, 2005. 

For the reasons set forth below, Heinrich’s motion for summary judgment will be granted,

Defendants’ motion for summary judgment will be denied, and the case will be remanded to

Defendants for determination of benefits in accordance with the findings and conclusions set
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Case No. C 04-02943 JF

ORDER (1) GRANTING PLAINTIFF’S MOTION FOR SUMMARY JUDGMENT, (2) DENYING DEFENDANTS’

MOTION FOR SUMMARY JUDGMENT, AND (3) REMANDING CASE FOR DETERMINATION OF BENEFITS

(JFEX2)

forth herein.

I. BACKGROUND

Heinrich, a former employee of Knight-Ridder, Inc. (“Knight-Ridder”), was a participant

in the Knight-Ridder, Inc. Long Term Disability Plan (“Plan”). The Plan offers long-term

disability benefits to employees through an insurance policy issued by The Prudential Insurance

Company of America (“Prudential”). Prudential also functions as the claims administrator. This

action, brought pursuant to the Employee Retirement Income Security Act of 1974 (“ERISA”),

29 U.S.C. §§ 1001 et seq., arises out of Heinrich’s allegation that Prudential improperly denied

her claim for long-term disability benefits.

Heinrich was employed by Knight-Ridder as an office systems manager responsible for

general maintenance of the computer network system. See Silver Decl., Ex. 4. Heinrich’s last

day of work was August 7, 2002. She stopped working due to stress, depression, and the effects

of fibromyalgia. The American College of Rheumatology describes fibromyalgia as “a common

condition that is associated with widespread aching, stiffness and fatigue, and originates in

muscles and soft tissue.” Silver Decl., Ex. 23. According to the Arthritis Foundation, other

symptoms include sleep disorders, irritable bowel syndrome, chronic headaches, and cognitive or

memory impairment. See Silver Decl., Ex. 20. Heinrich had been diagnosed with fibromyalgia

in 2000.

On February 23, 2003, Heinrich filed a claim for long-term disability benefits under the

Plan. See Silver Decl., Ex. 2. The Plan provides that “[y]ou are disabled when Prudential

determines that . . . you are unable to perform the material and substantial duties of your

regular occupation due to your sickness or injury.” Silver Decl., Ex. A2 at 12. “Material and

substantial duties” are defined as duties that “are normally required for the performance of your

regular occupation” and “cannot be reasonably omitted or modified.” Id. “Regular occupation”

is defined as “the occupation you are routinely performing when your disability begins” and is

based on how the occupation “is normally performed instead of how the work tasks are

performed for a specific employer or at a specific location.” Id. The Plan requires that the
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Case No. C 04-02943 JF

ORDER (1) GRANTING PLAINTIFF’S MOTION FOR SUMMARY JUDGMENT, (2) DENYING DEFENDANTS’

MOTION FOR SUMMARY JUDGMENT, AND (3) REMANDING CASE FOR DETERMINATION OF BENEFITS

(JFEX2)

claimant be “continuously disabled” for an “elimination period” of 180 days before she is eligible

to receive benefits. Id. at 13. 

As part of her claim, Heinrich submitted, among other things, a medical report from her

primary care physician, Dr. Rakesh Chaudhary, M.D. (“Chaudhary”), dated February 28, 2003. 

In this report, Chaudhary made a primary diagnosis of fibromyalgia and a secondary diagnosis of

depression. See Silver Decl., Ex. 8. Chaudhary noted that Heinrich was experiencing “lots of

pain from fibromyalgia with severe sleep disturbance” and characterized Heinrich’s functional

abilities as “sedentary.” Id. In a follow-up report dated March 10, 2003, Chaudhary added that

Heinrich “cannot concentrate on work tasks due to severe sleep disturbance [and] depression.” 

Silver Decl., Ex. 9. On May 1, 2003, Prudential Claim Manager Susan Williams (“Williams”)

prepared a “SOAP Note” summarizing Heinrich’s medical history as reported by her treating

physicians and analyzing her claim for benefits. See Silver Decl., Ex. 11. The “SOAP Note”

described Heinrich’s condition from August 9, 2002, to January 16, 2003, including her disturbed

sleep patterns, and listed the prescription medications she was taking. See id. On May 6, 2003,

Williams prepared another “SOAP Note,” in which she concluded that the medical information

in Heinrich’s file “does not support continuous disability through [the elimination period] of

8/8/02 through 2/4/03 for depression or [fibromyalgia] flare.” Id. Prudential denied Heinrich’s

claim on May 13, 2003. See Silver Decl., Ex. 12. The denial letter stated that “the current

medical documentation in file [sic] does not support that the severity of your conditions rendered

you unable to perform the material and substantial duties of your regular occupation throughout

the elimination period” and that Heinrich “should have been able to perform the duties of [her]

regular occupation with reasonable self-accommodations or modifications during the elimination

period.” Id. It addressed both Heinrich’s fibromyalgia and her psychiatric conditions,

concluding that there was insufficient evidence to support Heinrich’s claim for disability as a

result of either condition.

Heinrich appealed the denial of her claim on November 3, 2003. See Hanna Decl., Ex. A

at PRU0339-63. As part of her appeal, Heinrich submitted several additional reports regarding
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Case No. C 04-02943 JF

ORDER (1) GRANTING PLAINTIFF’S MOTION FOR SUMMARY JUDGMENT, (2) DENYING DEFENDANTS’

MOTION FOR SUMMARY JUDGMENT, AND (3) REMANDING CASE FOR DETERMINATION OF BENEFITS

(JFEX2)

her conditions. Jeff Beeman (“Beeman”), a self-titled “vocational expert,” interviewed Heinrich

on September 10, 2003. See Silver Decl., Ex. 6. Based on that interview, Heinrich’s medical

record, and various occupational references, Beeman concluded that

Ms. Heinrich’s physical, mental and cognitive problems, including fatigue,

weakness, insomnia, depression, severe pain, inability to do physical labor, and

difficulty with concentration, presents [sic] an individual unable to perform the

material and substantial duties of her regular occupation. Ms. Heinrich is simply

not able to sustain on a full time basis work activities at any exertional level with

any reasonable continuity. Based on the totality of medical records reviewed, Ms.

Heinrich is not employable in her own occupation or in any occupation, at any

skill or exertional level at this time. 

Id. at 10. Beeman characterized Heinrich’s job as “high stress and physically demanding,”

requiring “high level sophisticated skills and physical demands along with high aptitudes.” Id. at

9. In response, Prudential Claim Manager Thomas Virgilio (“Virgilio”) prepared a “SOAP

Note” dated December 3, 2003, in which he concluded that Beeman’s characterization of

Heinrich’s job was accurate but distinguished what Heinrich actually did from how the

occupation normally is performed, noting that the latter is the relevant inquiry under the Plan. 

See Silver Decl., Ex. 26. By Virgilio’s analysis, Heinrich’s occupation necessitated only “light

work” in the areas of lifting, carrying, pushing, and pulling, and her actual physical activities in

“mov[ing] equipment, crawl[ing] under desks, etc. . . . would not be considered material and

substantial.” Id.

Heinrich also was examined by Dr. Oscar Abeliuk, M.D. (“Abeliuk”), a neurologist, who

conducted a neurological consultation on September 11, 2003. See Silver Decl., Ex. 13. Abeliuk

diagnosed Heinrich with (1) chronic fibromyalgia syndrome according to the criteria established

by the American College of Rheumatology, (2) “chronic pain syndrome, sleep disturbance and

chronic spinal pain,” and (3) a “history of significant depression and anxiety as well as other

psychological difficulties.” Id. at 9. Abeliuk concluded that Heinrich had “significant residual

functional capacity problems . . . as documented not only on a subjective basis but also on her

clinical evaluation,” noting that, “although at one point in the past she was able to work despite

her fibromyalgia, she has noted significant worsening,” which is “true in many patients with
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Case No. C 04-02943 JF

ORDER (1) GRANTING PLAINTIFF’S MOTION FOR SUMMARY JUDGMENT, (2) DENYING DEFENDANTS’

MOTION FOR SUMMARY JUDGMENT, AND (3) REMANDING CASE FOR DETERMINATION OF BENEFITS

(JFEX2)

fibromyalgia, despite treatment.” Id. at 10. He also stated that “[a]ll of these significant residual

functional capacity difficulties . . . secondary to her fibromyalgia are clear-cut impairments for

her to return to [her] job.” Id.

On September 17, 2003, Dr. L. Neena Madireddi, M.D. (“Madireddi”), a specialist in

physical medicine and rehabilitation, examined Heinrich and noted “multiple fibromyalgia tender

spots” and “active trigger points” throughout the body. Silver Decl., Ex. 15 at 5-6. Madireddi

also tested Heinrich’s range of motion and evaluated her tenderness, sensitivity, and reflexes at

various points on the body. Based on the physical examination and a review of Heinrich’s

medical record, Madireddi described her “impression” of fibromyalgia, lumbar strain, carpal

tunnel syndrome, migraine headaches, and “history of attention deficit activity disorder.” Id. at

7. Madireddi concluded that “Ms. Heinrich can not [sic] return to her prior line of work as an

office system manager,” that “she cannot concentrate on the tasks at hand [and] will be

constantly bothered by such severe pain that she cannot work in a typical work day,” and that

“she is incapable of even a low stress job.” Id. 

On October 14, 2003, Dr. Alfred Scopp, Ph.D (“Scopp”), a licensed psychologist, 

prepared a neuropsychological report on Heinrich based on four examinations of her verbal and

cognitive abilities. See Silver Decl., Ex. 17. Scopp conducted a number of neuropsychological

tests to evaluate Heinrich’s verbal skills, recall ability, speech and language functioning, and

motor functioning, as well as to test whether Heinrich was malingering. The tests revealed

impairment in memory and recall ability. Scopp stated that “there is clear evidence of major

verbal impairment on the Verbal Memory Scale of the Memory Assessment Scale. . . . [H]er

Verbal Memory is . . . at the 6th percentile.” Id. at 8. Thus, Scopp concluded that “it would be

impossible for her to assimilate and remember new technical information required of her job . . . . 

She would also have difficulty understanding her own notes of things to do, remember,

understand and respond to e-mail requests from other employees, of which she receives many per

day.” Id. at 9.

Finally, in a letter dated October 20, 2003, Chaudhary reiterated that the “manifestations
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Case No. C 04-02943 JF

ORDER (1) GRANTING PLAINTIFF’S MOTION FOR SUMMARY JUDGMENT, (2) DENYING DEFENDANTS’

MOTION FOR SUMMARY JUDGMENT, AND (3) REMANDING CASE FOR DETERMINATION OF BENEFITS

(JFEX2)

[of Heinrich’s fibromyalgia] . . . make it impossible for her to function in her usual job. She is

unable to concentrate on complex tasks . . . [and] her severe sleep disturbance precludes her

ability to stay on a work schedule of any type.” Silver Decl., Ex. 18.

In processing Heinrich’s appeal, Prudential arranged for Dr. Douglas Martin, M.D.

(“Martin”), who is board certified in occupational and environmental medicine, and Dr. Carroll

Brodsky, M.D. (“Brodsky”), who is board certified in psychiatry, to evaluate Heinrich’s claim. 

See Silver Decl., Exs. 28, 29, 39. Based upon a review of Heinrich’s record, Martin concluded

that “the medical documentation presented does not support an ongoing claim for long-term

disability as a result of fibromyalgia.” Silver Decl., Ex. 28 at 8. He explained that 

[t]here is very little if any objective information contained within the medical

report presented that shows any effect with respect to function from the standpoint

of range of motion, strength, or cardiovascular problems. Rather, what I see

throughout the medical records presented are claims of subjective difficulties such

as pain, anxiety, difficulty coping, difficulty with stress at the job, and difficulty

sleeping. 

Id. Martin also objected to the conclusions drawn by Heinrich’s physicians on the grounds that

(1) Abeliuk’s report revealed “no recorded abnormality with respect to weakness of the

musculature” and “seems to mix the terms ‘tender’ and ‘trigger’ when he talks about girdle

musculature as well as other muscles identified,” id. at 5, (2) Madireddi’s report did not list

specific degree values associated with range of motion but rather described the range of motion

in relation to “what is ‘expected of normal,’” id. at 6, (3) Madireddi used an “invalid test” to

evaluate muscular strength, id., (4) Madireddi’s report did not “address the typical 18 tender

points that the American College of Rheumatology considers in this diagnosis,” id., (5) Scopp

failed to administer a particular neuropsychological test and instead used a “relatively poor test,”

id., and (6) the reports of Heinrich’s psychologists or psychiatrists were “somewhat difficult to

interpret,” due in part to “handwriting quality,” id. Martin expressed his belief that Heinrich

“would have much more of a significant psychological or psychiatric problem than she would

with the fibromyalgia.” Id. at 9. He also acknowledged an “increased association” between

fibromyalgia and “psychiatric difficulties such as depression and anxiety” without concluding
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Case No. C 04-02943 JF

ORDER (1) GRANTING PLAINTIFF’S MOTION FOR SUMMARY JUDGMENT, (2) DENYING DEFENDANTS’

MOTION FOR SUMMARY JUDGMENT, AND (3) REMANDING CASE FOR DETERMINATION OF BENEFITS

(JFEX2)

that there is a causal relationship between the two. Id. Finally, he questioned whether Heinrich’s

treatment had been adequate or appropriate and suggested that having Heinrich “resume normal

activities including that of work” would constitute treatment that is “just as important as any

medication or rehabilitation program” for fibromyalgia. Id.

Brodsky agreed with Martin’s conclusion that “fibromyalgia does not explain all of

[Heinrich’s] symptoms, the pattern of her symptoms, the duration of her symptoms, or the

distribution of her physical symptoms.” Silver Decl., Ex. 29 at 3. Brodsky stated that “there is

no evidence that [Heinrich] has a physical disorder that is producing the level of disability that

she describes.” Id. Further, Brodsky concluded that, “[f]rom a psychiatric standpoint alone,

except for her belief that she is unable to function and would be unable to function, there is no

evidence that she would be unable to do the job that she did formerly.” Id. Brodsky suggested

that Heinrich may have an aversion to returning to her job because of a stressful relationship with

her former supervisor and stated that there also may be “some disorganizing or obtunding

effects” from Heinrich’s medication. Id. at 4.

In response, Madireddi and Scopp prepared reports contesting the accuracy of Martin’s

and Brodsky’s conclusions and reaffirming their respective opinions on Heinrich’s condition. 

See Silver Decl., Exs. 30, 33. Abeliuk issued a similar report with respect to Martin’s

conclusions. See Silver Decl., Ex. 31. On February 5, 2004, Dr. Charles Casella, M.D.

(“Casella”), a specialist in psychiatry and neurology, performed a psychiatric evaluation of

Heinrich and concluded that she is “disabled for competitive employment by a combination of

her psychiatric and physical disorders” and that “[h]er fibromyalgia disorder has exacerbated her

preexistent depression.” Silver Decl., Ex. 32. Casella noted, however, that Heinrich’s

“depression in and of itself would likely not be work-disabling.” Id. He also refuted Brodsky’s

conclusions, remarking that “there is, in fact, a wealth of data which indicates that [Heinrich]

does have multiple physical disorders” and that “her emotional and psychiatric disorders . . .

interact with her physical disorders in a vicious cycle.” Id.

On March 14, 2004, Heinrich was awarded disability benefits from the Social Security
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Case No. C 04-02943 JF

ORDER (1) GRANTING PLAINTIFF’S MOTION FOR SUMMARY JUDGMENT, (2) DENYING DEFENDANTS’

MOTION FOR SUMMARY JUDGMENT, AND (3) REMANDING CASE FOR DETERMINATION OF BENEFITS

(JFEX2)

Administration (“SSA”). See Silver Decl., Ex. 34. The award letter states that the SSA “found

that [Heinrich] became disabled under [their] rules on August 8, 2002,” id., the day after her last

day of work. However, there is no evidence in the record as to the SSA’s guidelines for

determining disability or the documents that the SSA relied upon in reaching its conclusions.

In a “SOAP Note” dated April 27, 2004, Prudential Claim Manager Jill Fallon, M.D.

(“Fallon”) concluded, based on a review of the medical record, that Heinrich’s condition was not

disabling. Fallon agreed with Martin’s conclusion that “there is little if any objective evidence”

to support a finding that Heinrich was incapable of performing “a light or medium duty job.” 

Silver Decl., Ex. 35. Fallon further stated that Heinrich “appears to have personality traits

resulting in strong orientation toward physical illnesses and somatic explanations of her

difficulties with pain, weakness and fatigue beyond medical expectations for her current physical

status” but that “these [difficulties] are not disabling.” Id. Fallon suggested that external

stressors, such as difficulty with a new supervisor, may have prompted Heinrich’s physical

complaints, and she noted that Heinrich had worked for years in spite of many of her symptoms. 

See id. 

On May 24, 2004, Prudential denied Heinrich’s appeal. See Silver Decl., Ex. 39. The

denial letter concluded, based on the findings in the reports of Martin, Brodsky, and Fallon, that

the

[m]edical documentation reviewed does not support that there has been a change

in Ms. Heinrich’s long-standing condition(s) with which she has worked in the

past. Professional opinions regarding Ms. Heinrich’s disability status that

[Heinrich has] submitted on appeal are based on her self-reported symptoms and

not on objective findings, such as decreased range of motion and/or strength or

significant findings of cognitive dysfunction.

Id. The denial letter also summarized the findings of the various medical reports submitted by

Heinrich and referred Heinrich to her copies of Martin’s and Brodsky’s reports for “more

detailed information.” Id. Prudential primarily relied on Martin’s report to conclude that

Heinrich was not disabled from a physical standpoint and on Brodsky’s report to conclude that

Heinrich was not disabled from a psychiatric standpoint.
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Case No. C 04-02943 JF

ORDER (1) GRANTING PLAINTIFF’S MOTION FOR SUMMARY JUDGMENT, (2) DENYING DEFENDANTS’

MOTION FOR SUMMARY JUDGMENT, AND (3) REMANDING CASE FOR DETERMINATION OF BENEFITS

(JFEX2)

II. LEGAL STANDARDS

A. Standard for Summary Judgment

A motion for summary judgment should be granted if there is no genuine issue of

material fact and the moving party is entitled to judgment as a matter of law. Fed. R. Civ. P.

56(c); Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 247-48 (1986). Material facts are those

that might affect the outcome of the case under the governing law. Anderson, 477 U.S. at 248.

There is a genuine dispute about a material fact if there is sufficient evidence for a reasonable

jury to return a verdict for the nonmoving party. Id. The moving party bears the initial burden of

informing the Court of the basis for the motion and identifying portions of the pleadings,

depositions, answers to interrogatories, admissions, or affidavits that demonstrate the absence of

a triable issue of material fact. Celotex Corp. v. Catrett, 477 U.S. 317, 323 (1986). Where the

party moving for summary judgment would bear the burden of proof at trial, it has the initial

burden of establishing the absence of a genuine issue of fact on each issue material to its case. 

C.A.R. Transp. Brokerage Co., Inc. v. Darden Restaurants, Inc., 213 F.3d 474, 480 (9th Cir.

2000). Where the party moving for summary judgment would not bear the ultimate burden of

persuasion at trial, it must either produce evidence negating an essential element of the

nonmoving party’s claim or defense or show that the nonmoving party does not have enough

evidence of an essential element to carry its ultimate burden of persuasion at trial. Nissan Fire &

Marine Ins. Co. v. Fritz Cos., 210 F.3d 1099, 1102 (9th Cir. 2000).

If the moving party meets its initial burden, the burden shifts to the nonmoving party to

present specific facts showing that there is a genuine issue of material fact for trial. Fed. R. Civ.

P. 56(e); Celotex Corp., 477 U.S. at 324. The nonmoving party may not rely on the mere

allegations or denials in its pleading in order to preclude summary judgment. Fed. R. Civ. P.

56(e); Anderson, 477 U.S. at 248. The evidence and all reasonable inferences therefrom must be

viewed in the light most favorable to the nonmoving party. T.W. Elec. Serv., Inc. v. Pac. Elec.

Contractors Ass’n, 809 F.2d 626, 630-31 (9th Cir. 1987). Summary judgment thus is not

appropriate if the nonmoving party presents evidence from which a reasonable jury could resolve
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Case No. C 04-02943 JF

ORDER (1) GRANTING PLAINTIFF’S MOTION FOR SUMMARY JUDGMENT, (2) DENYING DEFENDANTS’

MOTION FOR SUMMARY JUDGMENT, AND (3) REMANDING CASE FOR DETERMINATION OF BENEFITS

(JFEX2)

the material issue in its favor. Anderson, 477 U.S. at 248-49; Barlow v. Ground, 943 F.2d 1132,

1134-36 (9th Cir. 1991). 

B. Standard of Review for Denial of Benefits

A denial of benefits challenged under 29 U.S.C. § 1132(a)(1)(B) is reviewed under a de

novo standard unless the benefit plan gives the administrator 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 (1989). The default is that the administrator has no discretion, and the

administrator has to show that the plan gives it discretionary authority in order to get any judicial

deference to its decision. Kearney v. Standard Ins. Co., 175 F.3d 1084, 1089 (9th Cir. 1999). 

The presumption of de novo review can be overcome only when a plan’s reservation of

discretion is unambiguous. McDaniel v. Chevron Corp., 203 F.3d 1099, 1107 (9th Cir. 2000). 

Where the benefit plan does give the administrator such discretion, a deferential standard of

review is appropriate. Firestone Tire & Rubber Co., 489 U.S. at 111. The deferential standard

of review is referred to interchangeably as “abuse of discretion” or “arbitrary and capricious,”

both of which have the same meaning in this context. Hensley v. Northwest Permanente P.C.

Ret. Plan & Trust, 258 F.3d 986, 994 n.4 (9th Cir. 2001).

III. DISCUSSION

To determine the appropriate standard of review, the Court must determine whether the

Plan grants Prudential discretionary authority to determine eligibility for benefits or to construe

the terms of the plan. See Firestone Tire & Rubber Co., 489 U.S. at 109. The policy at issue

contains the following language: “You are disabled when Prudential determines that . . . you are

unable to perform the material and substantial duties of your regular occupation.” Silver

Decl., Ex. A2 at 12. Prudential argues that the phrase “You are disabled when Prudential

determines that” constitutes a grant of discretionary authority sufficient to trigger the abuse-ofdiscretion standard. It relies on two Ninth Circuit cases to argue that the power to “determine” or

“make a determination” regarding eligibility for benefits constitutes a grant of discretionary

authority. See Bogue v. Ampex Corp., 976 F.2d 1319, 1324 (9th Cir. 1992); Eley v. Boeing Co.,
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 The Plan also states that the claimant may be required to send proof of continuing

disability “satisfactory to Prudential.” Silver Decl., Ex. A2. Because Prudential does not argue

that such language constitutes a conferral of discretionary authority, the Court does not address

this language.

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Case No. C 04-02943 JF

ORDER (1) GRANTING PLAINTIFF’S MOTION FOR SUMMARY JUDGMENT, (2) DENYING DEFENDANTS’

MOTION FOR SUMMARY JUDGMENT, AND (3) REMANDING CASE FOR DETERMINATION OF BENEFITS

(JFEX2)

945 F.2d 276, 278 (9th Cir. 1991). However, both of these cases pre-date Kearney v. Standard

Insurance Co., in which the Ninth Circuit clarified that the grant of discretion must be

unambiguous in order to trigger the abuse-of-discretion standard. See Kearney, 175 F.3d at

1089. 

Since Kearney, the Ninth Circuit has held that an “allocation of decision-making

authority . . . is not, without more, a grant of discretionary authority in making those decisions.” 

Ingram v. Martin Marietta Long Term Disability Income Plan for Salaried Employees of

Transferred GE Operations, 244 F.3d 1109, 1112-13 (9th Cir. 2001). The Ingram court

emphasized that it is not difficult for insurance companies to use unambiguous language in order

to retain discretionary authority if they wish to do so and that the absence of such explicit

language consequently should trigger de novo review. See id. at 1114. Thus, in Ingram, the

language “the management and control of the operation and administration of claims procedures

under the Plan, including the review and payment or denial of claims . . . shall be vested in the

carrier” was found not to grant unambiguous discretionary authority but merely to “make[] clear

that [the carrier], rather than the employer or some other party, makes all administrative decisions

to grant or deny claims.” Id. at 1112. In the instant case, this Court similarly concludes that the

Plan language does not constitute an unambiguous conferral of discretionary authority on

Prudential,2 and it notes that other district courts, ruling on plan language identical to the

language in the instant case, have reached the same conclusion. See Flores v. The Prudential Ins.

Co., No. C-03-5589 MMC, 2004 U.S. Dist. LEXIS 19492, at *16 (N.D. Cal. Sept. 16, 2004);

Urso v. Prudential Ins. Co. of Am., No. 03-024-JD, 2004 U.S. Dist. LEXIS 23930, at *10

(D.N.H. Nov. 23, 2004). Accordingly, the Court will review the denial of Heinrich’s claim de

novo.

Reviewing the administrative record de novo, the Court must determine whether Heinrich
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Case No. C 04-02943 JF

ORDER (1) GRANTING PLAINTIFF’S MOTION FOR SUMMARY JUDGMENT, (2) DENYING DEFENDANTS’

MOTION FOR SUMMARY JUDGMENT, AND (3) REMANDING CASE FOR DETERMINATION OF BENEFITS

(JFEX2)

was disabled under the terms of the Plan during the elimination period, thus entitling her to

benefits. It is undisputed that Heinrich has fibromyalgia. The parties dispute only whether

Heinrich’s fibromyalgia and psychiatric conditions rendered her disabled under the terms of the

Plan. The record contains medical reports from Heinrich’s numerous physicians, all of whom,

following a physical or psychiatric examination, have diagnosed her with fibromyalgia and/or

concluded that her condition rendered her unfit to work. Among other things, Heinrich’s

physicians specifically have concluded that the chronic pain and severe sleep disturbance

associated with fibromyalgia have prevented Heinrich from being able to function in a normal

work environment or to keep a normal work schedule. In concluding otherwise, Prudential

primarily has relied on the report of its own reviewing physician, Martin, whose main contention

is that there is no objective evidence in Heinrich’s file to substantiate the alleged severity of her

condition—only Heinrich’s subjective reports of her symptoms. Although Martin’s opinion is

not unreasonable in and of itself, the Court does not find it persuasive in light of the record as a

whole.

First, although Prudential bases its denial of benefits principally on a lack of objective

evidence of the severity of Heinrich’s fibromyalgia claim, the terms of the Plan do not

specifically require “objective” medical evidence as proof of disability. Second, even if the Plan

contained such a requirement, the nature of fibromyalgia—a condition that manifests as what the

Arthritis Foundation describes as “generalized muscular pain,” Silver Decl., Ex. 20—is such that

neither its presence nor its severity can be verified by purely objective laboratory tests. The

American College of Rheumatology states that “[d]iagnosis is based on the patient’s description

of chronic widespread pain and the finding of tender points at specific locations by a physician”

and that “[t]here are no blood or x-ray tests that are abnormal in fibromyalgia.” Silver Decl., Ex.

23. Yet, despite the subjectivity inherent in diagnosing fibromyalgia, which requires patients to

report their own sensations of pain and tenderness, courts have held that claimants were entitled

to disability benefits due to impaired functioning resulting from fibromyalgia. See, e.g., Lang v.

Long-Term Disability Plan of Sponsor Applied Remote Tech., Inc., 125 F.3d 794, 799-800 (9th
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Case No. C 04-02943 JF

ORDER (1) GRANTING PLAINTIFF’S MOTION FOR SUMMARY JUDGMENT, (2) DENYING DEFENDANTS’

MOTION FOR SUMMARY JUDGMENT, AND (3) REMANDING CASE FOR DETERMINATION OF BENEFITS

(JFEX2)

Cir. 1997); Hawkins v. First Union Corp. Long-Term Disability Plan, 326 F.2d 914, 919 (7th

Cir. 2003); Ellis v. Egghead Software Short-Term & Long-Term Disability Plans, 64 F. Supp. 2d

986, 993-94 (E.D. Wa. 1999). 

Heinrich’s examining physicians noted the presence of these tender points, as well as

Heinrich’s complaints of other fibromyalgia-related symptoms, and thus appear to have had a

medically sound basis for their diagnoses and conclusions. In opposition to these findings,

Prudential’s physicians primarily asserted that the severity of Heinrich’s condition was

substantiated only by self-reported symptoms rather than by objective evidence. However, the

fact that Heinrich’s physicians could not use a completely objective test to evaluate the severity

of her fibromyalgia does not undermine their considered medical opinions, based on their inperson examinations, that her condition rendered her incapable of performing her occupation. 

Moreover, Martin’s objections to the adequacy of some of the other diagnostic techniques used

by Heinrich’s physicians are insufficient to negate the conclusions drawn by Heinrich’s multiple

examining physicians, who reaffirmed their medical opinions in response to the reports of Martin

and Brodsky. Of particular significance is the fact that Prudential’s physicians never examined

Heinrich or even spoke to Heinrich’s physicians. Martin, Brodsky, and Fallon appear to have

concluded that Heinrich was not disabled based only upon a review of the reports by Heinrich’s

physicians. Although “plan administrators are not obliged to accord special deference to the

opinions of treating physicians,” Black & Decker Disability Plan v. Nord, 538 U.S. 822, 825

(2003), the failure of Prudential’s physicians to perform their own examinations of Heinrich

entitles their opinions to less weight, because fibromyalgia produces symptoms that must be

reported by the patient to the physician and that can be evaluated more fully through an actual

examination than by a mere review of a patient’s medical record.

In addition to asserting that there is a lack of objective evidence of disability, Prudential

argues that Heinrich’s ability to work for several years after being diagnosed with fibromyalgia

demonstrates that her condition was not disabling enough to merit disability benefits. However,

there is sufficient evidence in the record—specifically, the reports of Chaudhary and
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Case No. C 04-02943 JF

ORDER (1) GRANTING PLAINTIFF’S MOTION FOR SUMMARY JUDGMENT, (2) DENYING DEFENDANTS’

MOTION FOR SUMMARY JUDGMENT, AND (3) REMANDING CASE FOR DETERMINATION OF BENEFITS

(JFEX2)

Abeliuk—indicating that Heinrich’s condition worsened around the time she ceased working. 

Moreover, a “disabled person should not be punished for heroic efforts to work by being held to

have forfeited his entitlement to disability benefits should he stop working.” Hawkins, 326 F.3d

at 918. 

Finally, in the process of arguing about whether Heinrich was able “to perform the

material and substantial duties of [her] regular occupation,” Silver Decl., Ex. A2 at 12, the

parties dispute the appropriate characterization of Heinrich’s occupation. Based on Beeman’s

report, Heinrich argues that her position at Knight-Ridder was a hybrid position that

encompassed the responsibilities of a number of occupations as described in various occupation

resource handbooks. See Silver Decl., Ex. 6 at 7. Beeman concluded that Heinrich’s position

was best classified as “medium exertional,” occasionally rising to “heavy exertional.” Id.

Prudential’s claim manager, Virgilio, acknowledged the accuracy of Beeman’s analysis of the

character of the tasks actually performed by Heinrich but asserted that Heinrich’s occupation, as

normally performed in the market rather than for Knight-Ridder specifically, should be classified

as being in the “light work” range. Silver Decl., Ex. 26. This dispute need not be resolved by the

Court for present purposes, as the reports from Heinrich’s physicians appear to conclude that she

was incapable of performing any duties of her occupation during the elimination period and thus

was disabled under the terms of the Plan, regardless of the specific exertion level required by a

given task. See Silver Decl., Exs. 13-19.

For the foregoing reasons, the Court concludes, based on a de novo review of the

evidence in the administrative record, that Heinrich was disabled under the terms of the Plan for

the duration of the elimination period and was entitled to disability benefits. The case will be

remanded to Prudential for a determination of the scope of benefits owed to Heinrich in light of

this conclusion. As the Court’s review is limited to decisions actually made by

Prudential—specifically, its conclusion that Heinrich was not disabled during the elimination

period—the Court will not address the parties’ arguments regarding potential limitations on the
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 For example, the Plan provides that “[t]he limited pay period for self-reported symptoms

and mental illness combined is 24 months during your lifetime,” Silver Decl., Ex. A2 at 21, and

it gives Prudential the right to request proof of continuing disability, id. at 25.

15

Case No. C 04-02943 JF

ORDER (1) GRANTING PLAINTIFF’S MOTION FOR SUMMARY JUDGMENT, (2) DENYING DEFENDANTS’

MOTION FOR SUMMARY JUDGMENT, AND (3) REMANDING CASE FOR DETERMINATION OF BENEFITS

(JFEX2)

length of time Heinrich can receive benefits.3 Such matters properly should be determined by

Prudential in the first instance, and Heinrich retains the right to challenge Prudential’s decision

administratively and, after exhausting her administrative remedies, through the courts. 

Defendants shall determine the scope of benefits owed to Heinrich within ninety days of the date

of this Order, which is the same amount of time provided for a plan administrator to notify a

claimant of a benefits determination. See 29 C.F.R. § 2560.503-1(f)(1).

At the hearing on the instant motions, Heinrich’s counsel requested that, should Heinrich

prevail on summary judgment, the time to file a motion for attorney’s fees be extended to thirty

days. A motion for attorney’s fees normally must be filed within fourteen days of entry of

judgment, though the time may be extended either by stipulation pursuant to Civil Local Rule 6-2

or by motion pursuant to Civil Local Rule 6-3. Civil L.R. 54-6(a). The Court will act on the

request by Heinrich’s counsel upon receipt of one of the aforementioned documents.

IV. ORDER

Good cause therefore appearing, IT IS HEREBY ORDERED that Heinrich’s motion for

summary judgment is GRANTED, Defendants’ motion for summary judgment is DENIED, and

the instant case is remanded for determination of benefits consistent with the findings and

conclusions set forth herein.

DATED: July 29, 2005

/s/ electronic signature authorized

JEREMY FOGEL

United States District Judge
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Case No. C 04-02943 JF

ORDER (1) GRANTING PLAINTIFF’S MOTION FOR SUMMARY JUDGMENT, (2) DENYING DEFENDANTS’

MOTION FOR SUMMARY JUDGMENT, AND (3) REMANDING CASE FOR DETERMINATION OF BENEFITS

(JFEX2)

This Order has been served upon the following persons:

Rebecca Labat Crosby crosbyr@wemed.com

Beth A. Fruechtenicht Fruechtenichtb@wemed.com 

Melvyn D. Silver MDSRST@cs.com 

Ruth Silver Taube 

Law Offices of Silver & Taube

300 South First St., Suite 205

San Jose, CA 95113