Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-cand-4_06-cv-07025/USCOURTS-cand-4_06-cv-07025-4/pdf.json

Nature of Suit Code: 791
Nature of Suit: Employee Retirement Income Security Act (ERISA)
Cause of Action: 29:1001 E.R.I.S.A.: Employee Retirement

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United States District Court

For the Northern District of California

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IN THE UNITED STATES DISTRICT COURT

FOR THE NORTHERN DISTRICT OF CALIFORNIA

ILENE P. KING,

Plaintiff,

v.

CIGNA CORPORATION; CONNECTICUT

GENERAL LIFE INSURANCE COMPANY; and

ALLTEL TELEPHONE SERVICES LONG TERM

DISABILITY PLAN,

Defendants.

 /

No. C 06-7025 CW

ORDER GRANTING IN

PART PLAINTIFF'S

MOTION FOR JUDGMENT,

GRANTING IN PART

DEFENDANTS CGLIC'S

AND ALLTEL PLAN'S

CROSS-MOTION FOR

JUDGMENT AND

GRANTING DEFENDANT

CIGNA'S CROSS-MOTION

FOR JUDGMENT

Plaintiff Ilene P. King filed this lawsuit against Cigna

Corporation, Connecticut General Life Insurance Company (CGLIC) and

Alltel Telephone Services Long Term Disability Plan (the Plan or

Alltel Plan), after CGLIC terminated her long-term disability

benefits. Plaintiff now moves, pursuant to Federal Rule of Civil

Procedure 52, for judgment. Defendants oppose the motion, and

cross-move for judgment in their favor. The matter was heard on

July 26, 2007. Having considered all of the papers filed by the

parties, the evidence cited therein and oral argument, the Court

grants the motions in part and denies them in part. 

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1

Prior to her work as a senior programmer analyst, Plaintiff

worked as a programmer analyst, a computer operator and a key punch

operator. CGLIC 1008. 

2

References to "CGLIC __" are to the bates-stamped

administrative record Defendants provide. Plaintiff provides her

own copy of the administrative record, which is marked as "IK __." 

2

BACKGROUND

Plaintiff worked at C.P. National Corporation, which was later

acquired by Alltel Telephone Services, as a senior programmer

analyst from 1982 to 1986.1

 CGLIC 1008.2 The position was largely

sedentary, requiring sitting approximately seventy percent of the

time, bending approximately fifteen percent of the time, walking

approximately ten percent of the time and standing approximately

five percent of the time. CGLIC 1023. According to Plaintiff,

while working as a senior programmer analyst, she was working

fourteen to sixteen hour days and began having muscle spasms. 

Report of Dr. Robert Hines, p. 2. 

In December, 1985, Plaintiff's back went out completely; she

had bent over and was then unable to straighten her back. Id.;

CGLIC 934. She spent a week on bed rest and then returned to work. 

CGLIC 934. Despite physical therapy, Plaintiff's pain increased. 

Id. She was diagnosed with herniated discs at L4-5 and L5-S1 with

radiculitis and radiculopathy into the lower right leg. 

Dr. William E. Mathews determined that Plaintiff should undergo a

L4-5, L5-S1 diskectomy. CGLIC 960.

Plaintiff's last day of work was July 10, 1986. CGLIC 1023. 

The next day she had a diskectomy, her first of three back

surgeries. Hines Report, pp. 2-3. She attempted to return to work

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in December, 1986, but, after working one day, she could not

return. Id. 

In January, 1987, CGLIC began paying disability benefits to

Plaintiff under a policy that it had issued. The policy did not

designate a plan administrator. Cigna, an indirect parent

corporation of CGLIC, did not issue the policy, nor did it have any

role in the processing of Plaintiff's claims for long-term

disability benefits. The policy provides a gross monthly benefit

of sixty-six and two-third percent of an employee's monthly salary. 

CGLIC 14. Under the policy, if the disability prevents the

employee from performing the duties of his or her occupation, the

monthly benefit will be paid for twenty-four months. After twentyfour months passes, however, an employee is entitled to a monthly

benefit only if the employee is so disabled that he or she is

completely prevented from engaging in any occupation or employment

for which he or she is qualified, or may reasonably become

qualified, based on his or her training, education or experience. 

CGLIC 20. 

According to a letter Dr. Mathews wrote in July, 1987, even

after the first surgery, Plaintiff had continued complaints of low

back pain; the pain intensified with prolonged sitting or bending. 

CGLIC 933. Dr. Mathews concluded that Plaintiff was suffering from

recurrent lumbar disc displacement and that a second surgery would

be necessary. Id. The second lumbar surgery occurred in August,

1987. Hines Report, p. 3. Dr. Mathews estimated that the

disability time following this type of surgery would be

approximately six to nine months. CGLIC 933. 

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Plaintiff's pain continued after the second surgery. Any

activity, especially sitting, walking or standing, increased her

pain. CGLIC 920. Plaintiff was given Colchicine IV injections and

epidural injunctions with morphine and Demerol, but the pain

continued. Hines Report, p. 3. In September, 1988, Plaintiff

underwent a third surgery. Id. It did not alleviate her back pain

and she was sent home from the surgery with her first prescription

for a walker. Id. 

In April, 1989, Dr. William Haddock evaluated Plaintiff for

structural abnormality, noting that she had "severe low back pain

radiating into left leg." CGLIC 879. The images of Plaintiff's

lumbar spine, however, showed post-operative changes but no other

significant findings. Id. 

A few months later, Dr. Charles Barnes performed a lumbar

diskogram, with the hopes of reducing Plaintiff's pain: it was not

successful. CGLIC 876. In September, 1989, Dr. Barnes sent a

letter to CGLIC, informing it that Plaintiff remained disabled and

that she may have to undergo yet another surgery. CGLIC 873. 

An evaluation form Dr. Barnes filled out in 1993 stated that

Plaintiff's subjective symptoms were low back pain, neck pain,

headaches and spasms in her back with severe leg pain; the

objective findings were minor degeneration and disc protrusion at

C5-6 level and C4-5 minor protrusion. CGLIC 843. Dr. Barnes

concluded that Plaintiff's prognosis had not changed and that she

was limited in her ability to stand, climb, walk, stoop, lift and

sit. CGLIC 843-44. He further concluded that Plaintiff was

totally disabled from her occupation and any other occupation and

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was not a suitable candidate for further rehabilitative services. 

CGLIC 844. He marked the box "Indefinite" as to when he thought

Plaintiff would be able to resume any work. Id.

In 1994, Dr. Barnes retired. He referred Plaintiff to Dr. Tim

Howard, who, according to Plaintiff, found her problems so

overwhelming and complex that he felt he had nothing surgically to

offer. Hines Report, p.4. Plaintiff also saw a sports

orthopedist, Dr. Torsten Jacobsen, who concluded that Plaintiff was

"psychologically and physically significantly handicapped as a

result of her spinal history." Id.; CGLIC 818-20. But, after Dr.

Barnes's retirement, Plaintiff did not see another orthopedist on a

regular basis. See id.

In 1995, Dr. Carl Ahroon, an internist, completed Plaintiff's

evaluation form. This evaluation was largely identical to the one

Dr. Barnes filled out in 1993. Dr. Ahroon retired in 2000 and

Dr. Vivek Jain took over Dr. Ahroon's practice and Plaintiff's

primary care. Like Dr. Ahroon, Dr. Jain specialized in internal

medicine.

In March, 2001, Dr. Jain referred Plaintiff to a pain

specialist, Dr. Kasra Amirdelfan, who evaluated Plaintiff. Dr.

Amirdelfan noted that Plaintiff "ambulated with a walker and walks

quite slowly" and that she "has frequent episodes of grimacing,

moaning and response gestures more customary for acute pain than

chronic pain." CGLIC 660. He also noted that Plaintiff stated

that she had been using a walker for approximately twenty years. 

CGLIC 661. His assessment was that Plaintiff suffered from postlaminectomy syndrome, depression and severe decompensation. Id.

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He recommended that Plaintiff increase her dosage of morphine and

Celebrex, an anti-depressant, and that she seek psychological

support. CGLIC 661-62. 

Dr. Amirdelfan again saw Plaintiff in July, 2001. Plaintiff

reported that the pain was approximately the same and that she had

not sought any psychological evaluation or support, as he had

recommended. He again recommended that Plaintiff increase her dose

of morphine. CGLIC 657.

In August, 2002, Plaintiff filled out a disability

questionnaire and activities of daily living form. She stated that

she cannot remain in any position for any period of time without

increased pain spasms shooting through her spine: "sitting is

worse, followed by walking." CGLIC 762. She listed her condition

that prevented her from working as "degenerative disc disease in

lumbar and cervical areas." Id. She stated that she used a walker

and wheelchair if she had to "walk distances," and that she could

drive, but not on freeways and approximately only five miles. She

was, however, able to do a bit of cooking, cleaning and shopping. 

Id. But she was unable to exercise or to go for walks because the

longer she is on her feet the more intense the spasms and pain

becomes. CGLIC 763.

A couple of months later, Dr. Jain responded to CGLIC's

request for information. He listed Plaintiff's primary diagnosis

as cervical lumbar disc disease and her secondary diagnosis as

chronic obstructive pulmonary disease and asthma. CGLIC 697. 

Included among Plaintiff's subjective complaints were muscle

spasms, leg weakness, inability to sit, to stand or to walk for

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prolonged periods, depression, back pain, numbness/tingling and

buttock and thigh pain. Id. Dr. Jain's current clinical findings

were limited range of motion, paraspinal muscle spasm, splinting

behavior, motor weakness and antalgic gait. CGLIC 698. Under

current level of funationality, he wrote, "Unable to do any type of

work due to her symptoms." Id. 

In the beginning of 2003, CGLIC began to question whether

Plaintiff was totally disabled and, thus, entitled to long-term

benefits. At a staffing session in February, 2003, CGLIC's medical

director and a nurse case manager determined that the medical

information in the file did not support a total disability finding. 

CGLIC 265. They further determined that, "to accurately assess

current functionality," Plaintiff should have a Functional Capacity

Evaluation (FCE) and recommended surveillance to observe

Plaintiff's daily activities.

On April 8, 2003, Plaintiff had a FCE. The evaluation noted

that Plaintiff was "only able to do sitting once, but with great

difficulty due to pain in her low back. She sat only for five

minutes due to her back pain." CGLIC 631. For the majority of the

evaluation, Plaintiff stood with her walker and often had her back

leaning against a wall. Id. At the evaluation, Plaintiff reported

that she could generally only sit for ten minutes, stand for twenty

minutes, walk for five minutes, drive for ten miles and lift ten

pounds. CGLIC 633. On a scale of one to ten, her pain ranged from

four at best to ten at its worst. Sitting, turning in bed,

reaching, lifting, bending, stooping and walking up an incline

aggravated Plaintiff's back and neck; ice, heat, lying supine and

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leaning against a wall provided relief. Id. 

The physical therapist conducting the evaluation concluded:

The results of this evaluation indicated that Ilene King was

minimally able to participate in the Functional Capacity

Evaluation. Ms. King demonstrated self-limiting behavior. 

She was only able to complete the subjective and limited

musculosketal screening parts of the evaluation due to her

very limited tolerance. She also demonstrated pain behaviors

and was very emotionally labile, as shown by frequent

grimacing, moaning and tearfulness. Her speech was slow and

deliberate, with frequent pauses accompanied by facial

grimacing. During small body movements and transfers from one

position to another, Ms. King demonstrated facial expressions

with crying that suggest an acute shooting or stabbing pain.

CGLIC 630. Nonetheless, the therapist found that Plaintiff could

occasionally sit and walk and could frequently stand. CGLIC 635.

That same day and the next day, CGLIC had surveillance of

Plaintiff conducted. She was videotaped on April 8, 2003, as she

arrived at her evaluation, using the assistance of a walker for

orthopedic support. CGLIC 596. She was also videotaped as she

left her evaluation. Her husband had picked her up and then they

went out to eat. CGLIC 597. 

On April 9, 2003, Plaintiff was seen leaving her home and

driving to various locations, including Kinko's, the credit union,

a medical building, a liquor store and a grocery store. CGLIC 598-

601. She would get her walker out of the car, use it to walk where

she was going, and then put it back in the car. At least once she

was seen struggling, trying to get the walker back into the car.

CGLIC 599. When she was at the grocery store, however, she did not

use her walker; rather she used a shopping cart for support. GCLIC

600. 

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Later that month, CGLIC's medical director watched the

surveillance video. He concluded that there were inconsistencies

in what she was able to do at the FCE, her reported activities of

daily living and what was captured on the video. CGLIC 264. But

he did note that, when Plaintiff dropped her keys on the ground,

she picked them up with her right foot instead of bending over

which would have put pressure on the S1 nerve and caused pain. Id.

The medical director recommended doing additional surveillance.

Surveillance was conducted on May 22 and 23, 2003. CGLIC 580-

589. Crawford Investigation Services provided the following

summary:

An investigation was conducted for a period of two consecutive

days and approximately 17 minutes and 26 seconds of videotape

were obtained of the Subject. During the investigation, the

Subject traveled to Long's Drugstore, an unidentified medical

facility, and Burlington Coat Factory. The Investigator was

successful in obtaining videotape of the Subject as she walked

at a slow place while utilizing an orthopedic walker; as she

walked at a quick pace; as she raised her right hand over

head; as she walked with an apparent limp; as she apparently

tried on shoes while lifting her right foot partially into the

air and bending at the waist; and as she reached within a

vehicle trunk while bending at the waist.

CGLIC 582. On May 22, 2003, the investigator observed Plaintiff

going to a doctor's appointment and Long's Drugstore. Although

Plaintiff used her walker for her doctor's appointment, she did not

use it at Long's Drugstore; instead, she pushed around a shopping

cart. On May 23, 2003, Plaintiff was seen entering the Burlington

Coat Factory. She did not use her walker. Although she walked

with a limp, the investigator stated that she entered the store at

a quick pace. Approximately ninety minutes later, the investigator

videotaped Plaintiff leaving the store carrying large white plastic

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bags, which she then loaded into her car trunk.

These surveillance videos were also reviewed by one of CGLIC's

medical directors, who concluded that the observations in the

videos failed to support the restrictions and limitations provided

by Dr. Jain. The medical director instructed that more

surveillance should be conducted. CGLIC 572.

Two more days of surveillance were conducted on August 20 and

21, 2003. CGLIC 550-559. On August 20, 2003, Plaintiff's parent

picked her up from her home, taking her to lunch and assisting her

with grocery shopping. CGLIC 552-54. Although the investigator

was not able to videotape it, he observed Plaintiff on two separate

occasions sitting at a table in the restaurant. It is not clear

how long she sat at the table. CGLIC 552-53. She was away from

home approximately two and a half hours that day. The next day,

Plaintiff was away from her home from approximately 1:00 p.m. to

4:00 p.m. CGLIC 555-559. She went to the liquor store, the gas

station and three different grocery stores. She used her walker

when she went into the liquor store, but at the grocery stores she

used "the shopping cart to steady herself." CGLIC 556.

In September, 2003, Plaintiff had an MRI. CGLIC 346. The

impression from the MRI was "multi-level degenerative disk disease

most notable for mild left-sided C5-6 foraminal stenosis." Id. 

In December, 2003, one of CGLIC's medical directors reviewed

the August surveillance. He noted that Plaintiff presented

"variable pictures" ranging from "walker dependance" when with her

family to "independent ambulation without an assistive device while

carrying small bags." CGLIC 548. He concluded that Plaintiff's

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FCE "was clearly not representative of the claimant's known

capacity from various surveillance observations." CGLIC 548. 

Although he acknowledged that Plaintiff "limits spinal flexion" and

is slow with "vehicular ingress and egress," he determined that

"she appears functional for sedentary activity given limited

walking and ability to change positions from sitting as needed." 

CGLIC 548. 

Nonetheless, CGLIC continued to pay disability benefits to

Plaintiff as before and Plaintiff and Dr. Jain continued to provide

CGLIC with the required paperwork. For example, on January 19,

2005, Dr. Jain submitted an attending physician statement, again

concluding that Plaintiff was totally disabled from any occupation

and that "she will not be able to resume work anytime." CGLIC 525. 

In 2005, Plaintiff also submitted an updated disability

questionnaire and activities of daily living form. CGLIC 519-20. 

As in previous questionnaires and forms, she stated that the reason

she cannot work is because while sitting, standing or walking for

any period of time her spinal pain and spasms intensify and that

medication only takes the edge off; it does not relieve her pain. 

She also stated that "writing or other repetitive hand/arm

movements cause pain/spasms/numbness in arms into fingers & into

neck area with severe headaches." CGLIC 519. According to

Plaintiff, she uses a walker regularly and is able to walk a few

blocks as long as she stops frequently. If she has to go any

distance, she needs a wheelchair. She can cook, clean, shop,

garden, read and watch television, but she does not do all these

things daily. Sometimes she will go weeks without cooking; other

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times she can cook but only for small periods at time. CGLIC 519. 

Plaintiff listed Dr. Jain and Dr. Clark Tsai, an eye doctor, as

doctors she sees regularly. Plaintiff explained that, after Dr.

Barnes retired, she was unable to find another orthopedic

specialist willing to treat her and that Dr. Jain monitors her

spinal problems and prescribes medication. 

Shortly after Plaintiff filed out this disability

questionnaire, CGLIC requested that Dr. Jain complete a Physical

Ability Assessment. CGLIC 456. Dr. Jain reported that, throughout

an eight-hour work day, with positional changes and meal breaks,

Plaintiff can sit occasionally, less than 2.5 hours, can stand

occasionally, less than 2.5 hours, and can walk occasionally, less

than 2.5 hours. CGLIC 457. 

In August, 2005, CGLIC concluded that, although Plaintiff's

physician stated that she is unable to perform any occupation for a

forty-hours-a-week period, Plaintiff was more active on

surveillance and her disability questionnaire than the medical

limitations provided by her doctor. This qualified as a "Red Flag

Indicator." CGLIC 259. More surveillance and a peer review report

were recommended.

Two more days of surveillance were conducted on October 17 and

18, 2005. CGLIC 446-452. On the first day of surveillance, the

investigator observed Plaintiff leaving her home at 2:40 p.m. and

driving to a nearby mall, a liquor store and a law office before

returning home less than two hours later. She used her walker,

which she retrieved from the trunk of her car, occasionally bending

at the knee as she folded it back up and put it back in the truck. 

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Although the investigator determined that Plaintiff was home on

October 18, 2005, no activity was observed. CGLIC concluded that

these two days of surveillance suggested "a functional level of at

least sedentary capacity." CGLIC 224. 

CGLIC requested that Dr. Dan Gerstenblitt, who specializes in

occupational medicine, conduct a peer review. On January 31, 2006,

Dr. Gerstenblitt prepared his report, which acknowledged that he

had not examined Plaintiff. CGLIC 401. Based on his review of the

medical records and surveillance videos, he concluded:

The claimant is felt to be able to work full time sedentary

work . . . . The claim is being driven by the self reports and

self-imposed limitation of activity by the claimant. There

was no documentation of objective evidence for radiculopathy

in this case. The claimant's pain complaints are out of

proportion to the relatively innocuous appearing MRI and other

diagnostic studies. . . . The surveillance clearly shows the

claimant driving, going grocery shopping and able to go to

other stores. She was able to walk without a walker if she

chose so. Additionally, the claimant apparently was walking

with a walker for 25 years, so presumably she can work with

the use of a walker in a sedentary job. The surveillance

activity clearly supports that the claimant can perform in at

least a sedentary job capacity. . . . In summary, the claimant

used a walker prior to the lumbar surgeries and going out of

work, and, frankly, there was no reason she could not return

to work at some point in time after the lumbar surgeries. The

available information indicated that the claimant was capable

of working in at least a sedentary job with the only thing

stopping the claimant from doing so being her self-limiting

activities and subjective complaints.

CGLIC 403. 

CGLIC received Dr. Gerstenblitt's report on February 2, 2006. 

IK 50. Five days later an entry was created in CGLIC's internal

claim file: "f/u with VRC for formal TSA--forward denial letter and

inform cx of determination." IK 16. The next day, seemingly after

CGLIC decided to terminate Plaintiff's long-term disability

benefits, CGLIC requested a transferable skills analysis (TSA) to

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3Cigna Group Insurance is a registered service mark and refers

to various operating subsidiaries of Cigna Corporation. Cigna

Corporation's subsidiaries provide products and services; Cigna

Corporation does not. CGLIC is one of these subsidiaries. IK 1. 

14

determine Plaintiff's transferable work skills and residual

functional capacities and to determine whether relevant occupations

existed at or above the wage requirements. CGLIC 415. According

to the TSA, which was completed later that day, there were four

suitable occupations for Plaintiff: check writer; appointment

clerk; charge-account clerk; and dispatcher, maintenance service. 

Id. 

On February 10, 2006, Cigna Group Insurance3, representing

CGLIC, the underwriting company, sent Plaintiff a letter advising

her that CGLIC had determined that she was able to engage in a

sedentary occupation for which she was qualified or which she may

reasonably become qualified by education, training or experience;

therefore, as of February 8, 2007, her long-term disability

benefits were terminated. CGLIC 177-81. To "prevent financial

hardship," however, CGLIC would continue to pay her through

March 6, 2006. CGLIC 180. The letter informed Plaintiff that she

could appeal the denial of her claim and that her appeal "should be

in writing" and should "state the reasons why you feel your claims

should not have been denied." Id. Her appeal was to be addressed

to CGLIC's representative, Cigna Disability Management Solutions. 

Id.

On March 7, 2006, Plaintiff's counsel wrote to Cigna Group

Insurance, Cigna Disability Management Solutions and the Plan,

informing them that Plaintiff wished to appeal the termination of

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her benefits and requesting the documents and information necessary

for her to do so. IK 46-7. Her counsel asked that Plaintiff be

informed "of any particular additional medical information or

records which you consider necessary to perfect Ms. King's claim

for benefits." IK 47. 

Later that month, Cigna Group Insurance, again representing

the underwriter CGLIC, purported to provide Plaintiff "with a copy

of the information requested" in the March 7, 2007 letter. IR 1. 

According to Plaintiff, however, all the information she requested

was not provided. She did not receive copies of the Summary Plan

Description or claim manuals. In addition, there was no response

to her request to explain what was needed to perfect her claim.

On August 8, 2006, Plaintiff's counsel sent a letter

requesting the omitted information. CGLIC 376-9. Three days

later, Cigna Group Insurance, on behalf of CGLIC, responded, "As

noted in our letter of February 10, 2006, we will consider any

additional relevant information which supports your Disability. 

However, it is your responsibility to provide this information to

us by September 1, 2006 or our decision may be based on the

available information." CGLIC 174. It provided no further

information. 

Plaintiff's counsel arranged for Plaintiff to be examined by

Dr. Robert Hines, who is certified by the American Board of

Psychiatry and Neurology and the American Board of Pain Medicine. 

Hines Report, p. 12. Plaintiff met with Dr. Hines for three and a

half hours. In addition, he reviewed her medical records, the

surveillance videos, Dr. Gerstenblitt's report, the FCE, an

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administrative law judge's decision granting Plaintiff Social

Security Disability, and other correspondence and evaluations. 

Hines Report, pp. 1-2. His conclusion was as follows:

This 53-year-old woman presents with a severe chronic pain

disorder secondary to multi-level painful degenerative disc

disease and failed lumbar surgery. In reviewing the patient's

medical records, presentation today, video surveillance, and

past evaluations by neurosurgeons and orthopedists, it is

clear that she is disabled.

One of the striking features of the patient's longitudinal

course is the absence of neurosurgical or orthopedic follow

up. That is, the last note authored by Dr. Barnes, the

surgeon performing the lumbar fusion, suggests the patient's

fusion is not solid at L5-S1 nor at L3-4. This was

substantiated by the CT examination at that time which is the

best way to evaluate such. . . .

Indeed, this patient's overwhelming pain and disability have

appeared to be consistent throughout the patient's records as

well as sub rosa taping. In my experience with many thousands

of failed back surgery patients, the dismissing as overly

complex of a patient's symptoms is an all too common feature. 

The postural flexion bias which the patient clearly prefers 

. . . and the repeated observation of investigators that the

patient prefers either her walker or a push cart in stores is

also consistent with the patient's severe lumbar pathology and

failed lumbar fusion. . . .

It is my strong opinion, based on the finding and review of

records, including the sub rosa observations, that Ms. King is

unable to perform the duties of any full-time occupation. 

While I philosophically feel that all patients, even those

with severe pain disorders such as Ms. King, would benefit

from a positive focus in their life, it is unreasonable to

expect that she would be competitive in the open labor market,

and any job would have to be done in an extraordinarily

modified, part-time way . . . .

At this juncture, I do not feel that the patient's medications

greatly affect her ability to perform in the work place . . . .

It is conceivable that if she were aggressively treated with

medications, she might be somewhat more functional, but it is

not medically probably that she would be functional enough to

be employed. . . .

In reviewing this patient's condition, course, and medical

records, as well as presentation today, I find her symptoms to

be both reasonably reliable and credible. . . . I am frankly

at a loss to completely understand Dr. Gerstenblitt's opinion. 

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It would appear that, without a good faith examination and

without adequate training or knowledge of pain medicine and

orthopedics, he has rendered a highly subjective and injurious

report regarding Ms. King.

One of the most striking features of his report and that which

he makes a great deal of -- and, subsequently, the insurance

company makes a great deal of -- is his statement that "What

is significant about this note [from Dr. Amirdelfan] is that

the claimant has been using a walker since the age of 27!" He

goes on in his conclusion of his report to state, "In summary,

the claimant used a walker prior to the lumbar surgeries and

going out of work, and frankly, there was no reason she could

not return to work at some point in time after the lumbar

surgeries." As noted in the body of my report, this is simply

an error. The patient began using a walker after her threelevel lumbar fusion and continues to use such to this date. 

This use is consistent with her lumbar pathology and failed

lumbar fusion and post-laminectomy syndrome. . . . On the

whole, I find Dr. Gerstenblitt's evaluation to be extremely

inadequate. . . .

I find the videotape surveillance showing the patient using a

walker and ambulating with an antalgic gait when not using a

walker to be quite consistent with the finding and medical

history. Indeed, the fact that she does put the walker into

the trunk herself is not inconsistent. The patient uses

others to put the walker in the trunk when they are available

and such activity, while not ideal and aggravating to her

pain, can be done but with likely sequelae of flares of pain. 

Whether the patient, out of necessity, can occasionally do

activities that might be routine in the work place seems to

have little to do with whether she can sustain such

activities. Flares of pain are quite detrimental to one's

focus and ability to perform cognitive tasks. 

Hines Report, pp. 8-12.

On September 15, 2006, Plaintiff's counsel sent Dr. Hine's

report and medical records from Dr. Jain to Cigna Group Insurance,

serving as CGLIC's representative. Attached with the report and

records was a letter from Plaintiff's counsel stating that "the

information CIGNA has should now be sufficient to uphold Mrs.

King's appeal of CIGNA's decision. If CIGNA disagrees, however, I

respectfully request once again that you inform me promptly of any

additional information or documentation that you believe is

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necessary for Mrs. King to perfect her claim for continued

insurance benefits." CGLIC 372.

On December 12, 2006, Cigna Group Insurance, representing

CGLIC, sent a letter to Plaintiff's counsel, informing him that it

had completed its review; it would uphold its prior decision to

deny benefits. CGLIC 168. The letter explained,

Ms. King's complete file, including any additional information

you submitted, was reviewed in its entirety without deference

to our prior reviews. Additional medical information we

received consisted of medical documentation previously

reviewed prior to our February 10, 2006 decision to deny

benefits as well as Pain Management evaluation dated

August 11, 2006. However, medical documentation has not been

submitted to refute the peer review performed by Dr.

Gerstenblitt. Therefore, the Transferable Skills Analysis

remains valid. 

CGLIC 168.

Plaintiff brought this action against Cigna Corporation, CGLIC

and the Plan, seeking benefits due under ERISA. Plaintiff has

alleged a second cause of action for breach of fiduciary duty and a

third cause of action for statutory penalties, based on the

purported failure to provide plan documents as required by ERISA. 

CGLIC explains that, because it issued the policy and is

responsible for the payment of long-term benefits under the policy,

it is providing a defense to the Plan with respect to Plaintiff's

claims for long-term disability benefits and breach of fiduciary

duty based on the handling of Plaintiff's claim. As discussed

below, Cigna contends that it is an improper party in this action. 

It requested that Plaintiff voluntarily dismiss the claims against

it. Plaintiff refused. 

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LEGAL STANDARD

ERISA provides Plaintiff with a federal cause of action to

recover the benefits she claims are due under her policy. 29

U.S.C. § 1132(a)(1)(B). The standard of review of a plan

administrator's denial of ERISA benefits depends upon the terms of

the benefit plan. Absent contrary language in the plan, the denial

is reviewed under a de novo standard. Firestone Tire & Rubber Co.

v. Bruch, 489 U.S. 101, 115 (1989). When reviewing de novo, a

"court simply proceeds to evaluate whether the plan administrator

correctly or incorrectly denied benefits." Abatie v. Alta Health &

Life Ins. Co., 458 F.3d 955, 963 (2006). However, if "the benefit

plan expressly gives the plan administrator or fiduciary discretionary authority to determine eligibility for benefits or to

construe the plan’s terms," an abuse of discretion standard is

applied. Firestone Tire, 489 U.S. at 115. Here, the parties agree

that the Plan does not confer discretion and that this matter is

subject to de novo review.

DISCUSSION

I. First cause of action for recovery of benefits

Defendants argue that CGLIC's decision to terminate

Plaintiff's benefits must be upheld because Plaintiff's claim of

total disability from any occupation is not supported by the

record. Defendants do not challenge Plaintiff's medical diagnoses;

rather, they contend that, notwithstanding her diagnoses, she is

capable of doing sedentary work. As the Ninth Circuit instructs,

"That a person has a true medical diagnosis does not by itself

establish disability." Jordan v. Northrop Grumman Corp. Welfare

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Benefit Plan, 370 F.3d 869, 880 (9th Cir. 2004) (noting that

"sometimes people are able to work despite their conditions; and

sometimes people work to distract themselves from their

conditions"). Defendants point out that it has been over a decade

since Plaintiff was treated by an orthopedist.

That an orthopedist has not treated Plaintiff in many years

weakens her claim. And her argument that Dr. Gerstenblitt's

opinion should be disregarded because he is not a orthopedist, a

neurologist or a pain management specialist fails. Nonetheless,

the Court finds that Plaintiff has offered evidence to establish

that she has a disabling medical condition. This evidence includes

her own reports about the effect of her condition on her ability to

function, the agreement of Dr. Hine that the symptoms that

Plaintiff describes are consistent with those caused by her medical

conditions, and her physicians' reports. 

The only evidence that undermines Plaintiff's claim for

benefits is Dr. Gerstenblitt's report. Dr. Gerstenblitt, however,

concluded that Plaintiff was capable of working a sedentary job

based only on her medical records and the surveillance videos. Had

he examined Plaintiff, the Court might have found his opinion more

persuasive. See Jebian v. Hewlett-Packard Co. Employee Benefits

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

2003) (“On de novo review, a district court may . . . take

cognizance of the fact (if it is a fact in the particular case)

that a given treating physician has a greater opportunity to know

and observe the patient than a physician retained by the plan

administrator.”) (internal quotation marks omitted). 

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Reviewing Plaintiff's medical records and watching the

surveillance videos, the Court did not reach the same conclusions

as Dr. Gerstenblitt. That Plaintiff is able to bend to put her

walker in her car, to run errands or to stay at a restaurant for an

hour does not establish that she is able to work an eight-hour-aday job, especially one that requires her to spend most of her day

sitting. Defendants provide no evidence showing otherwise. As Dr.

Hine concluded, "Whether the patient, out of necessity, can

occasionally do activities that might be routine in the work place

seems to have little to do with whether she can sustain such

activities. Flares of pain are quite detrimental to one's focus

and ability to perform cognitive tasks." Hine Report, p. 12. 

Therefore, after reviewing all of the evidence in the

administrative record, the Court concludes that Plaintiff has

established that she is entitled to an award of benefits. Further,

these benefits are to continue until such time as her entitlement

to such benefits shall change or terminate pursuant to the terms of

the long term disability plan. 

Although Plaintiff is entitled to benefits, she is not

entitled to those benefits from Defendant Cigna, which is not the

plan, the plan sponsor, a plan fiduciary, or the plan

administrator. Nor did Defendant Cigna issue the policy,

administer Plaintiff's claim under the policy or participate in the

denial of Plaintiff's benefits. See Everhart v. Allmerica

Financial Life Ins. Co., 275 F.3d 751, 753-54 (9th Cir. 2001)

(holding that the plaintiff could sue the plan and plan

administrator for ERISA plan benefits, but not the plan insurer). 

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Plaintiff's reliance on Seagate US LLC v. Cigna Corp., 2006

U.S. Dist. LEXIS 26776 (N.D. Cal. 2006) is misplaced. In Seagate,

the court denied Cigna's motion to dismiss because the plaintiff

had alleged that Cigna appeared on the face of the policies. This

case, however, is past the pleading stage and Plaintiff provides no

evidence to establish that Defendant Cigna is legally responsible

for paying the benefits which Plaintiff seeks in this action. 

Nonetheless, the Court's ruling is based on counsel's

representation at the hearing that CGLIC is responsible for the

judgment awarded to Plaintiff as well as any attorneys' fees and

costs awarded.

II. Second cause of action for breach of fiduciary duty

Defendants argue that Plaintiff's claim for breach of

fiduciary duty fails because it is premised solely on the purported

mishandling of her benefits claim. The Ninth Circuit instructs

that a "'fiduciary's mishandling of an individual benefit claim

does not violate any of the fiduciary duties defined in ERISA.'” 

Ford v. MCI Communications Corp. Health and Welfare Plan, 399 F.3d

1076, 1082 (9th Cir. 2005) (quoting Amalgamated Clothing & Textile

Workers Union, AFL-CIO v. Murdock, 861 F.2d 1406, 1414 (9th Cir.

1988)). In addition, Defendant Cigna argues that Plaintiff's claim

against it fails because it is not a fiduciary under ERISA with

respect to the Plan and, therefore, it owes Plaintiff no fiduciary

duties.

Plaintiff responds by pointing to this Court's recent decision

in Caplan v. CNA Short Term Disability Plan, 479 F. Supp. 2d 1108

(N.D. Cal. 2007). Her reliance on Caplan, however, is also

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misplaced. In Caplan, the Court dismissed the plaintiff's claim

under 29 U.S.C. section 1332(a)(3)to the extent that it was

duplicative of the plaintiff's section 1132(a)(1)(B) claim. But

the Court found that the "the equitable relief Plaintiff seeks

under section 1132(a)(3) . . . may be different than the relief

available under section 1132(a)(1)(B), and such relief might not be

available to Plaintiff under the section 1132(a)(1)(B) claim

alone." 479 F. Supp. 2d at 1112-13. Therefore, the Court

determined that it would be "premature" to dismiss the plaintiff's

entire claim under section 1132(a)(3). 

Here, however, the only issue is Plaintiff's claim for

disability benefits. Indeed, her complaint alleges that

"Defendants breached their fiduciary duties under ERISA by failing

properly to investigate and administer plaintiff’s claim for

disability benefits, by failing to provide a full and fair review

of plaintiff’s appeal of the denial of her benefits, and by failing

to administer the Plan in accordance with the purposes of the Plan

and for the exclusive benefit of its beneficiaries." Although

Plaintiff states that, if the Court rules in her favor, she will

seek equitable relief if CGLIC refuses to pay, any relief she seeks

would not be different than the relief available under section

1132(a)(1)(B). Therefore, the Court finds that Plaintiff's breach

of fiduciary duty claim fails as a matter of law against all

Defendants. In addition, the Court concludes that Plaintiff failed

to establish that Defendant Cigna was a fiduciary and, therefore,

the claim fails against Defendant Cigna for that reason as well.

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4

Plaintiff originally brought her third cause of action

against all three Defendants. On June 13, 2007, however, the Court

signed Plaintiff's and Defendant Alltel Plan's stipulation,

dismissing without prejudice Plaintiff's third cause of action

against Alltel Plan.

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III. Third cause of action for statutory penalties

ERISA requires that, upon written request of any plan

participant, the plan administrator "shall" furnish a copy of

certain documents including the "latest updated summary," "plan

description," or "other instruments under which the plan is

established or operated." 29 U.S.C. § 1024(b)(4); see also Moran

v. Aetna Life Ins. Co., 872 F.2d 296, 298 (9th Cir. 1989). Failure

to provide such documents may result in daily fines, and recovery

of costs and attorneys' fees under sections 1132(c) and (g). 

Moran, 872 F.2d at 298. Plaintiff contends that Defendants Cigna

and CGLIC did not send her the required documents and, therefore,

she asks that the Court impose statutory penalties against them.4

But, as Defendants Cigna and CGLIC point out, the Ninth

Circuit has held that only the administrator, as defined by ERISA,

can be sued for failing to provide plan documents. Id. at 299-300. 

Plaintiff's argument that the Ninth Circuit has not definitively

decided the issue is unavailing, as is her reliance on Younkin v.

Prudential Ins. Co., 2006 U.S. Dist. LEXIS 65345 (D. Mont.). As

explained in Rodriguez v. Reliance Standard Ins. Co., 2004 U.S.

Dist. LEXIS 18485, *6-7 (N.D. Cal.), "the Ninth Circuit has

expressly held that only those entities designated by the statute

as the administrator can be held liable as the administrator for

failure to provide plan documents." 

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ERISA defines an administrator as “the person so designated by

the terms of the instrument under which the plan is operated” or

“if an administrator is not so designated, the plan sponsor.” 29

U.S.C. § 1002(16)(A). The “plan sponsor” is “the employer in the

case of an employee benefit plan established or maintained by a

single employer.” 29 U.S.C. § 1002(16)(B)(i). Plaintiff does not

provide evidence that either CGLIC or Cigna are named as

administrators under the plan, nor does she contend that either are

plan sponsors. Therefore, they are not liable under ERISA for

failure to provide documents. Moran, 872 F.2d 296; see also

Rodriguez, 2004 U.S. Dist. LEXIS 18485 (holding that "an entity

which only de facto operates as an administrator cannot be held

liable as the administrator" under ERISA for failure to provide

documents). Therefore, Plaintiff's third cause of action fails as

a matter of law.

CONCLUSION

For the foregoing reasons, Plaintiff's motion for judgment

(Docket No. 29) is GRANTED IN PART and DENIED IN PART; Defendants

CGLIC's and Alltel Plan's cross-motion for judgment (Docket No. 62)

is also GRANTED IN PART AND DENIED IN PART. Defendant Cigna's

cross-motion for judgment (Docket No. 63) is GRANTED. Plaintiff is

entitled to an award of benefits against CGLIC and the Plan, but

not against Cigna. Her benefits shall be restored immediately and

Defendants CGLIC and the Plan are ordered to pay Plaintiff's

benefits until and unless new facts indicate that Plaintiff no

longer meets the definition of disability under the long-term

disability plan. Plaintiff's benefits may be terminated, if

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appropriate in the future, only in accordance with the Plan.

Plaintiff's second cause of action, however, fails as a matter of

law against all Defendants. Plaintiff's third cause of action

against Cigna and CGLIC also fails. Plaintiff shall recover her

costs of action from Defendants CGLIC and Alltel Plan. Defendant

Cigna shall bear its own costs. 

As ordered at the hearing, the parties shall submit a proposed

judgment. This shall be submitted one week from the date of this

order. If they are unable to agree on the proposed judgment, each

party shall submit a proposed judgment with no more than two pages

of argument in support of that judgment. These shall be submitted

two weeks from the date of this order. Judgment shall enter

accordingly.

IT IS SO ORDERED.

8/7/07

Dated: ________________________ 

CLAUDIA WILKEN

United States District Judge

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