Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-azd-4_13-cv-00405/USCOURTS-azd-4_13-cv-00405-0/pdf.json

Nature of Suit Code: 110
Nature of Suit: Insurance
Cause of Action: 28:1441 Petition for Removal- Breach of Contract

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UNITED STATES DISTRICT COURT 

DISTRICT OF ARIZONA 

Laurie Smith, an Arizona resident, 

 Plaintiff, 

vs. 

Mutual of Omaha Insurance Company, a

Nebraska corporation, 

 Defendant. 

 CV 13-0405-TUC-RCC (JR) 

 REPORT AND 

 RECOMMENDATION 

 

 In accordance with the Rules of Practice of the United States District Court for 

the District of Arizona and 28 U.S.C. § 636(b)(1), this matter was referred to the 

Magistrate Judge for report and recommendation. 

 This is an appeal of the denial of short-term disability benefits under the 

Employment Retirement Income Security Act (“ERISA”), 29 U.S.C. § 1001- brought 

by Plaintiff Laurie Smith against Defendant Mutual of Omaha Insurance Company 

(“MOO”). Before the Court are MOO’s Motion for Decision on the Administrative 

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Record (Doc. 17) and Smith’s Response thereto (Doc. 22), and Smith’s Motion for 

Summary Judgment (Doc. 18) and MOO’s response thereto (Doc. 23). The Court 

held a bench trial on the administrative record on February 18, 2014. Having 

reviewed the administrative record, and having considered the pleadings, the 

Magistrate Judge recommends that the District Court, after an independent review of 

the record, grant MOO’s Motion for Decision on the Administrative Record (Doc. 

17) and deny Smith’s Motion for Summary Judgment (Doc. 18). 

I. FINDINGS OF FACT 

 A. Plaintiff’s Employment 

Smith, who was born in 1981, formerly worked as a senior photo designer for 

the Muscular Dystrophy Association (“MDA”). R. 268.1

 She was hired by MDA in 

2004. Id. Her job was sedentary in nature and required that she occasionally carry or 

lift small items weighing less than 10 pounds and that she occasionally walk or stand. 

Id. During the summer of 2011, she began experiencing muscle pain, spasms, 

stiffness, and twitching. R. 268-69. She continued to work until January 12, 2012. 

R. 268. On February 6, 2012, Smith submitted a claim for benefits under MDA’s 

group Short Term Disability Plan, Policy No. G00038H3 (the “Policy”), which was 

 

1 The court uses the abbreviation “R” to refer the administrative record, which is filed as 

Document 16 on the docket. The Court's citations to the record use the last three digits (or 

fewer) of the bates-stamped number at the bottom right corner of each page.

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issued through MOO. Id. The Attending Physician’s Statement accompanying her 

claim indicates a diagnosis of “muscle spasticity/myopathy.” R. 269. 

B. MOO’s Short-Term Disability Policy 

Under the Policy, after satisfying a seven day elimination period, Smith was 

eligible to receive up to 50 percent of her pre-disability income for up to 26 weeks if 

she satisfied the Policy’s requirements. R. 20-21, 41, 47. The Policy defines 

disability as follows: 

Disability and Disabled means that because of an Injury or Sickness, a 

significant change in your mental or physical functional capacity has 

occurred in which you are: 

• prevented from performing at least one of the Material Duties of 

Your Regular Job on a part-time or full-time basis; and 

• unable to generate Current Earnings which exceed 20% of Your 

Weekly Earnings due to that same Injury or Sickness. 

Disability is determined relative to Your ability or inability to work. It 

is not determined by the availability of a suitable position with Your 

employer. 

R. 49. 

 Under the Policy, “Material Duties” are: 

the essential tasks, functions, and operations relating to your Regular 

Job that cannot be reasonably omitted or modified. In no event will we 

consider working an average of more than 40 hours per week in itself 

to be a part of material duties. One of the material duties of your 

regular job is the ability to work for an employer on a full-time basis. 

 

R. 42. “Regular Job” is defined as the occupation a claimant is “routinely 

performing” when the disability begins. R. 43. 

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 “Injury” is defined as: 

An accidental bodily injury which is the direct result of a sudden, 

unexpected and unintended external force or element, such as a blow or 

fall, that requires treatment by a Physician. It must be independent of 

Sickness or any other cause, including, but not limited to, 

complications from medical care. Disability due to such injury must 

begin while You are insured under the Policy. Injury does not include 

cosmetic surgery or procedures, or complications resulting therefrom. 

R. 42. Sickness is defined as: 

a disease, disorder or condition, including pregnancy, for which you are 

under the care of a Physician. Disability must begin while you are 

insured under the Policy. Sickness does not include cosmetic surgery 

or procedures, or complications resulting therefrom. Cosmetic surgery 

does not include reconstructive surgery when such service is incidental 

to or follows surgery resulting from trauma, infection or other diseases 

of the involved part. 

R. 43. 

 C. Smith’s Medical and Claim History 

 On November 22, 2011, Smith saw Sarah Sullivan, D.O., complaining of 

“bilateral muscle spasms and rigidity.” R. 232. Smith reported that she “sometimes 

will have muscle pain” and it was occurring with increasing frequency over the 

previous three to four months. Id. She stated that her symptoms in her muscles were 

“like a constant annoying toothache,” and reported that the pain was present in her 

bracioradialis, shoulders, quadriceps, and occasionally in her calves. Id. The 

doctor’s impression was that Smith’s “neurologic exam is concerning for cervical 

spinal stenosis given global hyperreflexia and increased tone.” R. 234. Dr. Sullivan 

recommended that an MRI of the cervical spine be completed and encouraged Smith 

“not to participate in kickboxing or chiropractic care for now.” Id. 

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 A radiology report dated November 23, 2011, includes an impression of 

“[c]entral disc protrusion at C6/7 which mildly narrows the ventral subarachnoid 

space but does not cause cord deformity or canal compromise,” and noted that the 

examination was otherwise unremarkable. R. 235. An MRI of the brain performed 

that same day was reported as normal. R. 236. On December 7, 2011, Smith was 

seen for EMG and nerve conduction tests. R. 237-45. The tests included bilateral 

lower and upper extremities and revealed normal findings with “[n]o evidence for a 

neuropathy nor a myopathy.” R. 239. 

 Smith was again seen by Dr. Sullivan on January 12, 2012. R. 246-48. Dr. 

Sullivan noted that “[s]ince the patient was last seen by me, she states that she has 

started to feel significantly better but then worse again over the past one week.” Dr. 

Sullivan noted the negative EMG results, but also noted that Smith’s lab work 

showed “an elevated CPK of 1123 and an elevated myoglobin of 301.” The lab tests 

were repeated two weeks later and the CPK had decreased to 626 and the myoglobin 

had improved to 134. Another two weeks later, however, the CPK had increased to 

1030. R. 246. Dr. Sullivan recommended additional lab work, including repeated 

CPK screening. She also sent Smith for a quadriceps muscle biopsy and another 

MRI of the cervical spine due to “continued hyperreflexia.” R. 248. 

 On January 20, 2012, a muscle specimen was collected. Upon examination, 

the diagnosis was “nonspecific changes” and the examiner commented that “[t]here 

is mild neurogenic atrophy which may be an incidental finding, along fiber diameter 

variation, and increased central nuclei.” R. 250-51. 

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 On February 1, 2012, Dr. Sullivan completed a Certification of Health Care 

Provider for Employee’s Serious Health Condition (Family and Medical Leave Act). 

R. 253-56. Dr. Sullivan indicated that Smith would be unable to sit or stand for 

prolonged periods due to “continued muscle spasticity, pain, difficulty with 

walking/balance.” R. 254. She estimated that Smith would be incapacitated from 

February 1, 2012 through April 1, 2012, and would require treatment two or three 

times per month. R. 255. 

 On February 6, 2012, Smith submitted a claim for benefits under the Policy. 

R. 268. The Attending Physician’s Statement accompanying Smith’s claim was 

prepared by Dr. Sullivan and indicates a diagnosis of “muscle spasticity/myopathy.” 

R. 269. Dr. Sullivan indicated that Smith could never lift any amount of weight, 

could never bend, squat, stoop, or kneel, and could sit for 30 minutes, be on her feet 

for 10 minutes, and stand and walk for 5 minutes each. Id. She indicated that Smith 

was expected to be disabled from February 1, 2012 through April 1, 2012. Id. 

 Dr. Sullivan next saw Smith on February 14, 2012. R. 257-59. The doctor 

described Smith with a “history of muscle spasms and discomfort.” At the time, 

Smith reported “continued cramping and pain which . . . are sometimes worse than 

others and can occasionally awaken her at night.” R. 257. Her CPK levels were 

reported as “[f]luctuating but persistently high.” Id. Also noted were the results of 

the muscle biopsy. Id. Dr. Sullivan’s impression noted that “[d]ifferential diagnosis 

remains broad, including an adult onset central nuclear myopathy, mitochondrial 

myopathy, toxic or viral myopathy. Inflammatory myopathy is much less likely in 

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the consideration of current muscle biopsy findings.” R. 259. Dr. Sullivan 

recommended further lab work and indicated that “evaluation by myopathy specialist 

at a tertiary care center may be necessary.” Baclofen was prescribed to treat 

spasticity and Dr. Sullivan decided to “hold off on the use of steroids” until a clear 

diagnosis was made. R. 259. 

 On March 7, 2012, MOO approved Smith’s STD claim and paid her benefits 

retroactive to January 19, 2011 (the date upon which she satisfied the Policy’s seven 

day elimination period). R. 57, 273. 

 At the request of Dr. Sullivan, Smith was seen by Katalin Scherer, M.D., on 

March 26, 2012. R. 200, 210. In her records from that visit, Dr. Scherer summarizes 

the largely normal laboratory and testing results from Dr. Sullivan, but notes that 

Smith’s CPK levels “have been consistently elevated in the 600-1200 range, despite 

rest, and she has had several instances of elevated serum myoglobin level.” R. 208-

09. Smith reported her pain level as 5/10, R. 210, and explained that her problems 

began during “cross-fit” workouts in the fall of 2010. R. 208. At the time of the 

examination, Smith had stopped doing “cross-fit,” and was doing about 10 minutes 

of swimming daily. R. 208. Dr. Scherer performed “a complete review of systems” 

and noted that “[a]ll are unremarkable except . . . hot/cold intolerance, and weight 

gain.” R. 210. A nurses intake notes reflect that Smith was there due to myopathy 

and also indicated that Smith had a history for depression. Id. On physical 

examination, Dr. Scherer found Smith “in no apparent distress.” Id. 

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 Dr. Scherer believed that Smith’s paternal grandfather’s history of muscular 

dystrophy was “probably a red herring,” and noted that it “[s]ounds like she has 

either an autoimmune cramp disorder/myopathy, endocrin[e] myopathy, or more 

likely a metabolic myopathy (not mitochondrial, and not-McArles, based on prior 

muscle biopsy).” R. 211. Dr. Scherer ordered another muscle biopsy, additional 

laboratory tests, and a repeat EMG. Id. She also cautioned Smith not to do any 

strenuous exercise and to stay hydrated, and indicated she would follow-up with 

Smith after testing was completed. Id. 

 Dr. Sullivan next saw Smith on March 29, 2012. R. 200-02. The doctor noted 

that Smith had been seen by Dr. Scherer and stated that “[t]esting is pending on the 

patient and Dr. Scherer has recommended repeat EMG and muscle biopsy which the 

patient would prefer not to undergo.” R. 200. Smith reported that she found that 

hydromorphone, which she was taking up to six times per day, was effective in 

treating her pain and she was able to swim for ten minutes per day. Id. She also told 

Dr. Sullivan that she recently had been fired from her job and was “frustrated that 

disability has not been continued while testing is pending.” Id. Dr. Sullivan noted 

that Smith was following up with Dr. Scherer and also referred her for additional 

testing for cardiac myopathy. Smith also requested that Dr. Sullivan write a letter to 

MOO. R. 202. 

 In a letter to MOO written that same day, Dr. Sullivan reported that Smith was 

under her care and “continues with extensive neuromuscular testing and is being seen 

at the MDA clinic at the University of Arizona for the same.” She also indicated that 

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Smith “may not return to work for an additional 3 months (June 29, 2012) until this 

workup is completed.” She explained that Smith “remains at high risk for muscle 

injury/break-down and subsequent kidney failure.” R. 228. 

 On April 17, 2012, MOO referred Smith’s file for review by Carol Johnson, R.N., 

a nurse case manager. R. 272-76. After reviewing Smith’s medical records, Johnson 

stated that Smith “does have some myopathy and problems with her muscles as noted 

by the elevated CPK, and elevated Serum Aldolase.” R. 275. She noted, however, 

that Smith “reported activities of 02/14/12 where she is walking her dog up to one 

mile a day, and on 03/29/12 . . . reported swimming . . . 10 minutes a day,” and thus 

concluded that Smith “would not be precluded from sitting up to 6 hours in a 8 hour 

day or lifting/carrying up to 10 pounds occasionally.” R. 275. In conclusion, 

Johnson opined that: 

Based on the medical records available for review, the claimant should 

be able to sit for 6 hours in a 8 hour day and lift up to 10 pounds 

occasionally and 5 pound frequently. After conferring with the on site 

physician, recommend sending a clarifying letter to Dr. Scherer to see 

if she would approve the claimant being able to sit for 6 hours in a 9 

hour day with position changes as needed and lifting up to 10 pound 

occasionally and 5 pounds frequently sine the claimants care has been 

turned over to this provider. 

 

Id. 

 On April 25, 2012, the MOO claims manager assigned to Smith’s case sent a 

letter to Dr. Scherer. R. 188-89. The letter indicates that MOO has reviewed Smith’s 

records and provides a summary of the records. Id. Dr. Scherer was asked, based on 

the summary of Smith’s medical records, if she would agree that Smith “is able to sit 

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for 6 hours in a 8 hour day with positional changes as needed and lifting up to 10 

pounds occasionally and 5 pounds frequently.” R. 188. 

 The next day, Smith faxed an Attending Physician Statement (“APS”) 

completed by Dr. Scherer accompanied by an explanatory note from Smith stating 

“Attending Physician’s Statement form Dr. Scherer – who also said she didn’t know 

me/my medical issues well enough to say whether or not I could/can work.” R. 185. 

In the APS, Dr. Scherer indicated that Smith could occasionally lift and carry 1-5 

pounds and could sit, stand, walk, and bend for 20 minutes at a time. R. 186. Dr. 

Scherer indicated that Smith could work with job modifications, but indicated 

“unknown” in response to inquiries into how long Smith had been disabled, when 

Smith would be able to work, and what treatment was planned. R. 187. 

 Shortly thereafter, Dr. Scherer faxed MOO a record from Smith’s April 26, 

2012, office visit. R. 94-95. On the fax cover sheet, Dr. Scherer hand wrote “Scam,” 

followed by a notation that Smith was no longer under her care. R. 178. In the 

records accompanying the note, Dr. Scherer reported that Smith arrived as scheduled 

for a follow-up EMG appointment. R. 94. When taken to the exam room, Smith 

indicated she had a few questions and “promptly presented . . . disability forms to fill 

out.” When discussing lab results and proposed testing, Dr. Scherer noted that Smith 

“seemed very concerned about the look of the scar” from her previous biopsy. Id. 

Then, after discussing the EMG procedures, Smith read through the disability 

paperwork that Dr. Scherer had completed, and stated “that since it seems she won’t 

‘get disability’ based on what [Dr. Scherer] had written, she could not afford the 

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EMG and wanted to cancel it.” Id. Based on their interaction, Dr. Scherer “got the 

sense that Ms. Smith’s priority at this time is being able to obtain disability, and NOT 

obtaining a diagnosis and subsequent treatment for her muscle cramps.” Id. Dr. 

Scherer reported her objective findings as follows: 

Ms. Smith was comfortably dressed. She was well groomed. All her 

toenails were painted pink. Her legs were freshly shaved. She moved 

about with ease, and did not have any difficulty walking, standing up 

from the chair, climbing or moving around on the exam table. She did 

not seem to be in any kind of distress. 

Id. Dr. Scherer then reported her impression: 

This woman has betrayed my trust and my good faith efforts to 

diagnose and treat the source of her muscle cramps. It seem that she is 

only interested in obtaining disability at this time, and “asked” to 

cancel a 1 hour procedure for which she was scheduled after we had 

started the visit, and after I had already spent considerable time and 

effort on her case, as soon as she realized that she did not get what she 

wanted (me signing her disability form with answers she wanted) from 

me, she decided to leave. 

There is no objective evidence at this time, that Ms. Smith has any kind 

of a neuromuscular disorder. Elevated CPK/aldolase in themselves is 

not diagnostic of any specific disorder, and although it can be seen in a 

variety of neuromuscular conditions, it can also be a normal result of 

muscle trauma and exercise. It may also indicate an underlying 

metabolic myopathy, for which I was attempting a good faith 

diagnostic workup, which patient has decided to abort (see above). 

I do not feel that I can continue to care for her, as there is no trust. I 

asked Ms. Smith to seek medical care elsewhere, and she was 

discharged from the MDA clinic at the UA. 

R. 94-95. 

 By letter dated May 1, 2012, MOO denied Smith’s claim beyond March 26, 

2012. R. 174-77. The letter quoted the disability standard from the policy and 

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summarized medical records from Dr. Sullivan, Dr. Carnahan, and Dr. Scherer. The 

letter then summarizes MOO’s decision: 

while you do have pain, it is relieved by medication. Your reported 

activities as of February 14, 2012 were walking your dog up to one 

mile a day, and on March 29, 2012 your reported activity was 

swimming 10 minutes a day. The medical information received does 

not support your inability to perform the Material Duties of your 

Regular Job as a Graphic Designer. Therefore, no benefits are payable 

beyond March 26, 2012 and your claim for further benefits has been 

denied. 

R. 175. The letter advised Smith of her rights to appeal the decision to MOO and to 

file a civil action pursuant to ERISA after exhausting her administrative appeals. R. 

176. 

 On May 21, 2012, Smith was seen by Gordon Watson, M.D., a cardiologist. 

R. 130-133. Dr. Gordon noted that Smith had elevated CPK and myoglobin levels 

and that “so far no other abnormalities have been found.” R. 130. His impression 

included no abnormal findings and her exercise tolerance was good. R. 131. 

 In June and July 2012, Smith was seen twice by her general practitioner’s 

office. R. 118-123. The records reflect her treatment by the Mayo Clinic and by a 

psychologist, but report no new objective findings or a definitive diagnosis. Id. 

 On August 27, 2012, Smith was again seen by Dr. Sullivan. R. 146-48. Dr. 

Sullivan again reported her impression of generalized myopathy, and noted that 

Smith had been seen by Dr. Scherer and at the Mayo Clinic, but that the underlying 

etiology for her myopathy had not been identified. R. 148. Dr. Sullivan noted that 

she would “recheck CPK and BUN/creatinine to assure stability with regard to 

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kidney function,” and recommended follow-up with other doctors. Id. Smith was to 

be seen back in three or four months unless problems arose. Id. 

 On August 28, 2012, Smith was seen by Laurie Bergstrom, M.D., at Catalina 

Pointe Arthritis and Rheumatology, for muscle pain and weakness. R. 124-25. It 

was noted that Smith reported suffering tremors with activity and had gained weight 

since her symptoms began. R. 124. She was assessed for myopathy, myofascial pain 

and anthralgias. R. 125. Dr. Bergstrom indicated that she would review Smith’s 

prior records, consult with Dr. Sullivan, and order further tests as necessary. R. 125. 

 Smith appealed the claim denial on September 3, 2012. R. 159-60. In her 

letter to MOO, Smith claimed Dr. Scherer had made “untrue statements” about her. 

In support of her contention, Smith attached a separate letter detailing her experience 

with Dr. Scherer, refuting Dr. Scherer’s impressions, and noting that contrary to Dr. 

Scherer’s opinion, the Mayo Clinic had diagnosed her with myopathy. R. 161-163. 

She further detailed her treatment at the Mayo Clinic, reporting that she was seeing 

Benn Smith, M.D., who believed that either myopathy or somatization was the source 

of her pain symptoms. R. 159. Smith further explained, however, that she was 

seeing a psychologist who had ruled out somatization. Id. Smith also reported that 

hydromorphone was no longer helping her pain levels so she had been transitioned to 

morphine. R. 159-60. 

 On October 17, 2012, MOO sent Smith’s entire file to a second nurse case 

manager for review. R. 277-81. After summarizing Smith’s medical history, the 

reviewing nurse concluded that: 

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The claimant has consistent preserved function on examinations. 

The claimant demonstrates appropriate cognition on a consistent basis. 

Diagnostic testing has been unrevealing in determination of pathology 

for symptoms with unremarkable findings. 

The reported activity is inconsistent with the stated severity of pain. 

No restrictions or limitations are identified from 1/11/12 forward. 

R. 281. The nurse also suggested that MOO consider obtaining Smith’s psychiatric 

and Mayo Clinic records. Id. 

 By letter dated November 16, 2012, MOO informed Smith that “the medical 

documentation in file does not support restrictions and limitations due to any 

functional or psychiatric impairment that would prevent you from performing the 

material duties of your regular job as a Graphic Designer beyond the date benefits 

were considered.” R. 113. The letter also informed Smith that she had the right to 

file a civil action under ERISA. Id. 

II. Standard of Review 

 Under the default standard, courts must conduct a de novo review of a plan 

administrator’s decision to deny benefits. Burke v. Pitney Bowes Inc. Long-Term 

Disability Plan, 544 F.3d 1016, 1023 (9th Cir. 2008). However, if the plan 

unambiguously gives its “administrator discretion to determine eligibility or construe 

the plan’s terms, a deferential abuse of discretion standard is applicable.” Id. In this 

case, MOO does not contend that the Policy confers such discretion. In a bit of a role 

reversal, however, Smith argues that the Court must review MOO’s decision under 

an abuse of discretion standard. However, given that the de novo standard of review 

does not require the Court to defer to MOO’s discretion, see Muniz v. Amec Constr. 

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Mgmt., Inc., 623 F.3d 1290, 1295-96 (9th Cir. 2010), the Court assumes that Smith 

would prefer the application of the de novo standard to her claim. 

 The application of a de novo standard of review under ERISA requires the 

Court to “simply proceed[] to evaluate whether the plan administrator correctly or 

incorrectly denied benefits.” Abatie v. Alta Health & Life Ins. Co., 458 F.3d 955, 

963 (9th Cir. 2006). “When conducting a de novo review of the record, the court does 

not give deference to the claim administrator’s decision, but rather determines in the 

first instance if the claimant has adequately established that he or she is disabled 

under the terms of the plan.” Muniz, 623 F.3d at 1295-96. The reviewing court must 

conduct an “independent and thorough inspection” of the plan administrator’s 

decision and determine if the benefits were correctly or incorrectly denied. Silver v. 

Executive Car Leasing Long-Term Disability Plan, 466 F.3d 727, 733 (9th Cir. 2006). 

The inspection of the record enables the trial court to “evaluate the persuasiveness of 

conflicting testimony and decide which is more likely true.” Kearny v. Standard Ins. 

Co., 175 F.3d 1084, 1095 (9th Cir. 1999). Under the de novo standard, the plaintiff 

has the burden of proving that she was entitled to benefits under the terms of the plan 

at the time benefits were denied. Muniz, 623 F.3d at 1296. 

III. Conclusions of Law 

 A. Smith Was Not Disabled After March 26, 2012

 The question before the Court is whether Smith has met her burden of 

establishing by a preponderance of the evidence that she is disabled within the 

meaning of the Policy’s disability provision after March 26, 2012, when her benefits 

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were terminated. In the Policy, disability is defined as and a significant change in 

and insured’s mental or physical functional capacity which prevents the insured from 

performing at least one of the material duties of their job on a part-time or full-time 

basis. The definition also requires that the insured be unable to generate earnings 

which exceed 20% of their weekly earnings. 

 Smith contends that she met the Policy’s disability standards and that MOO 

was able to deny her claim only by “carefully selecting evidence that is helpful to the 

denial while ignoring or disregarding” favorable evidence. Plaintiff’s Motion for 

Summary Judgment, p. 7. She then points out that she “consistently had extremely 

abnormal lab results, demonstrating CPK/CK levels which were ten times the high 

end of the normal range and myoglobin levels that were similarly out of the norm.” 

Id. at pp. 7-8. She asserts that Dr. Sullivan and Dr. Scherer correlated the abnormal 

lab results to less than sedentary limitations and Dr. Sullivan even warned that Smith 

could not work due to a “heightened risk of liver failure and muscle injury/breakdown.” Id. at p. 8. Smith also argues that MOO improperly chose to note that she 

was somewhat active and had “relatively stable vital signs without a physiologic 

response to the reported pain,” while ignoring that she was a formerly active person 

who had gained approximately 20 pounds during her course of treatment. Id. 

Finally, Smith contends that MOO’s decision was arbitrary and capricious because it 

failed to obtain an independent medical examination (“IME”) and instead relied on 

file reviews performed by its nurses in denying the claim. Id. at pp. 10. 

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 As Smith asserts, her CPK and myoglobin levels were found to be abnormally 

high after three tests in January 2012. Based on these tests, Dr. Sullivan assessed 

Smith with myopathy and recommended further testing, including additional CPK 

testing. R. 248. Although Smith contends that her CPK levels were “consistently” 

and “extremely” abnormal, there were no tests conducted after January 2012. 

Additionally, she has ignored Dr. Scherer’s statement that “[e]levated CPK/aldolase 

in themselves is not diagnostic of any specific disorder, and although it can be seen in 

a variety of neuromuscular conditions, it can also be a normal result of muscle 

trauma and exercise.” R. 94-95. 

 Faced with Dr. Scherer’s statement, and his suspicions that she was attempting 

to “scam” benefits under the Policy, Smith asserts that the opinion should be ignored 

because it is inconsistent with that of her treating physician, Dr. Sullivan, and 

because Dr. Scherer was not a treating physician. Plaintiff’s Response to 

Defendant’s Motion for Decision on Administrative Record, p. 3. Contrary to 

Smith’s assertions otherwise, Dr. Sullivan’s opinions from February (R. 268-69) and 

May (R. 83-86) 2012 finding that Smith was disabled from working during the 

relevant period do not mandate a finding that Smith was disabled under the Policy. 

The Court is not required under ERISA to accord special deference to the opinions of 

Smith’s treating physician. Black & Decker Disability Plan v. Nord, 538 U.S. 822, 

834 (2003). However, the Court may give appropriate weight to Dr. Sullivan’s 

opinions based on such factors as the length and nature of the doctor-patient 

relationship, the level of the doctor’s expertise, and the compatibility of the doctor’s 

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opinion with the other evidence. Jebian v. Hewlett–Packard Co. Employee Benefits 

Organization Income Protection Plan, 349 F.3d 1098, 1109 n. 8 (9th Cir. 2003). 

 Here, the record reflects that Dr. Sullivan saw Smith at least four times during 

the relevant time period, with her first visit being in November 2011 and her last in 

August 2012. R. 232, 246, 200, 146. Dr. Sullivan is a neurologist, but referred 

Smith to Dr. Scherer for testing and specialized care. R. 210 (note of referral), 200 

(Dr. Sullivan’s note that Smith was being seen by Dr. Scherer and additional testing 

was recommended). Finally, Dr. Sullivan’s opinion is compatible with the January 

2012 CPK and myoglobin tests in that the test results were consistent with myopathy. 

However, even Smith admits that myriad subsequent tests did not establish etiology 

or a more specific diagnosis. Plaintiff’s Motion for Summary Judgment, p. 9. Based 

on these considerations, the Court gives Dr. Sullivan’s opinions some weight, but not 

controlling weight over the opinion of Dr. Scherer. 

 Smith also contends that Dr. Scherer’s opinions should be disregarded because 

the doctor’s statements about her veracity were not valid and were based on 

animosity borne from Smith’s cancelation of testing that she was unable to afford. 

Smith contends that Dr. Scherer’s animosity toward her is illustrated by her reference 

in the medical records to Smith’s painted toe nails and shaved legs. Id. While 

Smith’s interpretation of what transpired between her and Dr. Scherer is not 

unreasonable, MOO’s interpretation is also reasonable. 

 Dr. Scherer’s notes reflect that Smith elected to cancel her scheduled followup EMG after she had presented for her appointment and had been taken into the 

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examination room. According to the doctor’s notes, Smith elected to cancel the tests 

only after Dr. Scherer indicated she could not state that Smith was unable to work. 

R. 94. Given that Smith had already been taken into the examination room and had 

reviewed the procedure with Dr. Scherer’s staff, it was reasonable for Dr. Scherer to 

associate Smith’s recalcitrance with the doctor’s indication that she could not state 

that Smith was unable to work. 

 Smith is also critical of Dr. Scherer’s notation that she had her toe nails 

painted and her legs shaved. As Smith contends, those comments examined in the 

abstract might sound unwarranted and irrelevant to medical treatment. However, 

Smith’s umbrage is less warranted when the comments are reviewed in the context of 

the entire note. In its entirety, the paragraph in which the statements appear reads as 

follows: 

Ms. Smith is comfortably dressed. She was well groomed. All her 

toenails were painted pink. Her legs were freshly shaved. She moved 

about with ease, and did not have any difficulty walking, standing up 

from the chair, climbing or moving around on the exam table. She did 

not seem to be in any kind of distress. 

 

R. 94. The paragraph as a whole paints a picture of someone who is capable of 

activities that are inconsistent with the levels of pain Smith alleges. The note 

describes a person who is able to take care of hygienic needs beyond the basics and is 

able to move without discomfort. But, Smith explains, she had just gone for a 

pedicure as a special treat to help her depression and her husband often had to help 

her shower and dress. R. 163. These assertions do nothing to undermine Dr. 

Scherer’s reports that Smith “moved about with ease” and “did not seem to be in any 

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kind of distress.” In any case, Dr. Scherer’s impression of how and why events 

transpired as they did was at least as reasonable as Smith’s interpretation. 

 Smith asserts that MOO’s decision was improper because it was selective in 

its inclusion of unremarkable test results. She contends that her unremarkable MRI, 

EMG, muscle biopsy, stress echocardiogram, and work-up at Mayo Clinic do nothing 

to undermine her reports of extreme pain and her abnormal CPK findings and Dr. 

Sullivan’s diagnosis of myopathy. Motion for Summary Judgment, pp. 9-10. It is 

important to note first that Dr. Sullivan’s diagnosis was not dispositive of Smith’s 

claim. In the Ninth Circuit, that “a person has a true medical diagnosis . . . does not 

by itself establish disability.” Jordan v. Northrup Grumman Corp. Welfare Benefit 

Plan, 370 F.3d 869, 880 (9th Cir. 2004), overruled on other grounds by Abatie v. Alta 

Health Life Ins. Co., 458 F.3d 955, 969 (9th Cir. 2006). Moreover, an examination of 

MOO’s final decision denying benefits undermines Smith’s contention that MOO 

was selective in the information it considered. The denial letter includes a lengthy 

and thorough inspection of the record. R. 108-113. It includes the lab results 

reflecting elevated CPK and myoglobin. R. 110. It also recognizes Dr. Sullivan’s 

opinion that Smith is unable to work. R. 112. It was the claims administrator’s 

obligation then, as it is the Court’s now, to “evaluate the persuasiveness of 

conflicting testimony and decide which is more likely true.” Kearny, 175 F.3d at 

1095. Thus, it was fair then, as it is now, to consider Dr. Scherer’s opinion, see 

Embrey v. Bowen, 849 F.2d 418, 422 (9th Cir.1988) (“The subjective judgments of 

treating physicians are important, and properly play a role in their medical 

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evaluations.”), and the numerous unremarkable laboratory and diagnostic test 

findings to conclude that Smith had not established that she was disabled during the 

relevant time period. 

B. MOO Was Not Required To Obtain An IME 

 Smith’s final contention is that MOO’s decision was rendered arbitrary and 

capricious by its failure to obtain an IME. In support of this assertion, Smith cites 

Calvert v. Firstar Finance, Inc., 409 F.3d 286 (6th Cir. 2005). In Calvert, the Sixth 

Circuit concluded that an IME should have been considered because the medical 

review was severely inadequate, failed to describe data, and ignored objective 

findings. Id. at 296. As discussed above, none of those shortcomings are present in 

this case. Without such indications, ERISA does not require that the plan 

administrator order an IME before making the benefits determination. See Rutledge 

v. Liberty Life Assurance Co. of Boston, 481 F.3d 655, 661 (8th Cir. 2007); Kushner 

v. Lehigh Cement Co., 572 F.Supp.2d 1182, 1192 (C.D.Cal. 2008). 

 Moreover, Smith does not identify what would have been gained if an IME 

had been ordered. It is undisputed that in January 2012, tests showed elevated CPK 

myoglobin. It is also true that Smith consistently complained of pain. However, 

other than the abnormal CPK and myoglobin findings, there is little objective 

evidence supporting Smith’s claims. This is despite the fact that multiple physicians 

had examined Smith and multiple additional tests had been performed. These facts, 

coupled with Dr. Scherer’s opinions, are at least of equal weight to the information in 

the record that is favorable to a finding of disability. Smith has not identified 

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anything an IME would have established that would have tipped the scale in her 

favor. 

C. Conclusion 

 Under the terms of the Policy, MOO was within its rights to terminate Smith’s 

short-term disability benefits. After conducting a de novo review of her claim, the 

Court concludes that Smith was not disabled under the terms of the Policy after 

March 26, 2012, the date on which her benefits were terminated. 

IV. Recommendation 

 Based on the foregoing, the Magistrate Judge RECOMMENDS that the 

District Court, after its independent review, grant MOO’s Motion for Decision on 

the Administrative Record (Doc. 17) and deny Smith’s Motion for Summary 

Judgment (Doc. 18). 

 This Recommendation is not an order that is immediately appealable to the 

Ninth Circuit Court of Appeals. Any notice of appeal pursuant to Rule 4(a)(1), 

Federal Rules of Appellate Procedure, should not be filed until entry of the District 

Court’s judgment. 

 However, the parties shall have fourteen (14) days from the date of service of 

a copy of this recommendation within which to file specific written objections with 

the District Court. See 28 U.S.C. § 636(b)(1) and Rules 72(b), 6(a) and 6(e) of the 

Federal Rules of Civil Procedure. Thereafter, the parties have fourteen (14) days 

within which to file a response to the objections. Replies shall not be filed without 

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first obtaining leave to do so from the District Court. If any objections are filed, this 

action should be designated case number: CV 13-0405-TUC-RCC. Failure to timely 

file objections to any factual or legal determination of the Magistrate Judge may be 

considered a waiver of a party’s right to de novo consideration of the issues. See 

United States v. Reyna-Tapia, 328 F.3d 1114, 1121 (9th Cir.2003)(en banc). 

 Dated this 10th day of March, 2014. 

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