Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-cand-3_03-cv-04666/USCOURTS-cand-3_03-cv-04666-0/pdf.json

Nature of Suit Code: 791
Nature of Suit: Employee Retirement Income Security Act (ERISA)
Cause of Action: 29:1132 E.R.I.S.A.: Employee Benefits

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At the pretrial conference conducted on November 2, 2004, the Court advised the

parties the motions would be taken under submission on the papers.

United States District Court

For the Northern District of California

IN THE UNITED STATES DISTRICT COURT

FOR THE NORTHERN DISTRICT OF CALIFORNIA

GEORGE MOSKOWITE,

Plaintiff,

 v.

EVEREN CAPITAL CORPORATION

GROUP DISABILITY INCOME PLAN,

Defendant /

No. C-03-4666 MMC (MED)

ORDER GRANTING IN PART AND

DENYING IN PART PLAINTIFF’S

MOTION FOR SUMMARY JUDGMENT;

ORDER GRANTING IN PART AND

DENYING IN PART DEFENDANT’S

MOTION FOR SUMMARY JUDGMENT;

SETTING STATUS CONFERENCE

Before the Court are two motions: (1) plaintiff George Moskowite’s motion for

summary judgment, pursuant to Rule 56 of the Federal Rules of Civil Procedure, and (2)

defendant Everen Capital Corporation Group Disability Income Plan’s motion for summary

judgment or, in the alternative, summary adjudication, pursuant to Rule 56. Having

considered the papers filed in support of and in opposition to the motions, the Court hereby

rules as follows.1

BACKGROUND

On October 24, 1997, plaintiff filed with defendant a claim form, seeking long-term

disability benefits under an employee benefits plan, available through plaintiff’s then-

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The claim file (“CF”) is Exhibit B to the Declaration of Lisa Jellerson Gray.

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employer, Everen Securities. (CF 1023.)2

 In order to be eligible for long-term benefits

under the plan, the claimant must be “disabled,” which is defined in the plan as follows:

i. If the Covered Person is eligible for 24 Month Own Occupation Benefit, “Disability”

or “Disabled” means during the Elimination Period and the next 24 months of

Disability the covered Person is unable to perform all the material and substantial

duties of his occupation on an Active Employment basis because of an Injury or

Sickness; and 

ii. After 24 months of benefits have been paid is unable to perform, with reasonable

continuity, all of the material and substantial duties of his own or any other

occupation for which he is or becomes reasonably fitted by training, education,

experience, age and physical and mental capacity. 

(Gray Decl. Ex. A at P-006.) 

On the claim form, plaintiff stated his impairments began March 10, 1996 as a result

of an automobile accident, and that his last date of employment had been April 28, 1997. 

(CF 1023.) In an accompanying Physician’s Statement, S.I. Spreiter, M.D., described

plaintiff’s diagnosis as “Thoracic Disc Syndrome[;] Depression.” (CF 1024.)

On January 6, 1998, defendant approved plaintiff’s claim for long-term disability

benefits, effective October 24, 1997, based on a finding plaintiff was unable to perform the

duties of his occupation. (CF 961-962.) Thereafter, on July 6, 2000, defendant informed

plaintiff by letter that defendant was discontinuing his long-term disability benefits, effective

July 7, 2000. (CF 95-101.) On July 19, 2005, plaintiff’s wife, on behalf of plaintiff,

requested that defendant review the decision to discontinue benefits. (Gray Decl. Ex. G at

G-4.)

On January 3, 2001, defendant informed plaintiff that it was adhering to its decision

to discontinue plaintiff’s long-term disability benefits. (CF 80-84.) On October 23, 2003,

plaintiff filed the instant action, alleging in his complaint that, pursuant to the Employee

Retirement Income Security Act (“ERISA”), he is entitled to benefits under the plan.

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As was discussed at the pretrial conference, to the extent defendant’s motion

addresses the merits of plaintiff’s claim for benefits and defendant’s defense of unclean

hands, the motion is premature, and, accordingly, is DENIED without prejudice.

3

DISCUSSION

The motions for summary judgment address defendant’s limitations defenses,

plaintiff’s argument as to estoppel, and the appropriate standard for reviewing the merits of

plaintiff’s claim for benefits.3

 The Court addresses these issues, in turn.

A. Limitations Defense

In its answer, defendant alleges as its Fifth Affirmative Defense that plaintiff’s ERISA

claim is barred by “legal and contractual statute[s] of limitations.” (See Answer, filed

December 8, 2003, at 4:28-5:5.) Plaintiff argues that defendant cannot establish either

component of its limitations defense.

1. Statute of Limitations

“[I]n ERISA actions the federal courts employ a state statute of limitations.” Wang

Laboratories, Inc. v. Kagan, 990 F. 2d 1126, 1128 (9th Cir. 1993) (internal quotation and

citation omitted). “The limitations period applicable to ERISA claims is the one for breach

of written contract.” Id. Where an ERISA plan includes a choice of law provision, the

selected forum’s statute of limitations for breach of written contract applies. See id. at

1129.

Here, the plan contains a provision expressly stating that the plan is governed by

Illinois law. (See Gray Decl., filed October 8, 2004, Ex. A at 1.) The Illinois limitations

period for an action on a written contract is ten years. See Jenkins v. Local 705 Int’l

Brotherhood of Teamsters Pension Plan, 713 F. 2d 247, 251 n. 6 (7th Cir. 1983) (citing Ill.

Rev. Stat. ch. 110, § 13-206). The earliest date that plaintiff’s claim could have accrued

was July 6, 2000, when he was first informed that defendant was discontinuing his benefits. 

Because plaintiff filed the instant action within ten years of July 6, 2000, his claim is not

barred by the statute of limitations. See id. at 254 (holding ERISA claim not time-barred,

where plaintiff filed complaint within ten-year Illinois statute of limitations for action on

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The contractual provision at issue herein and the provision interpreted in Mogck

differ only in that the limitations period set forth in the provision addressed in Mogck was

three years. See id. at 1028.

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written contract).

Accordingly, plaintiff is entitled to summary judgment on the Fifth Affirmative

Defense, to the extent it is based on the statute of limitations.

2. Contractual Limitations

The plan, in a section titled “Legal Proceedings,” includes a provision limiting the

time within which a claimant can institute legal action: “A claimant or the claimant’s

authorized representative cannot start any legal action: 1. until 60 days after proof of claim

has been given; nor 2. more than one year after the time proof of claim is required.” (See

Gray Decl., filed October 8, 2004, Ex. A at 28.) Additionally, in a section titled “Notice and

Proof of Claim,” the plan provides that “[p]roof of continued [d]isability . . . must be given to

[defendant] within 30 days of the request for the proof.” (See id. Ex. A at 27.)

The Ninth Circuit, in Mogck v. Unum Life Ins. Co., 292 F. 3d 1025 (9th Cir. 2002),

interpreted a contractual limitation provision indistinguishable in any material respect from

the provision at issue herein,4

 and held that where a claimant seeks “continued disability

benefits, not initial disability benefits,” the district court, “in order to determine when the

contractual limitation period began, [ ] must first determine when” the plan administrator

made “a ‘request for the proof,’” or asked for “a ‘proof of claim.’” See id. at 1028 (emphasis

in original). A contractual limitation period does not begin to run until the plan administrator

utilizes the specific terms set forth in the limitation provision. See id. at 1028-29 (stating

plan administrator “must utilize those basic terms and procedures “in order for the policy

provision to be triggered”). Thus, in Mogck, where the plan administrator notified the

claimant that benefits were being terminated, and stated that the claimant could submit

“new additional information to support [his] request for disability benefits” and request

review of the denial, see id. at 1027, but did not utilize the plan terms “proof,” “request for

the proof” or “proof of claim,” the “time limitation provision was never rendered operative,”

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see id. at 1028-29.

Here, defendant argues that the sixth page of its July 6, 2000 letter to plaintiff, by

which letter defendant informed plaintiff he was no longer eligible for long-term disability

benefits, (see CF 100), constituted the requisite “request for the proof” or request for “proof

of claim” to trigger the running of the one-year contractual limitation period. The cited page

advised plaintiff of his right under ERISA to “request a review,” and informed plaintiff that

such request must “state the reasons” plaintiff believed his benefits should not be

discontinued. (See CF 100.) Additionally, in discussing the content of such a request for

review, the letter, at that page, stated: “Include documentation such as diagnostic test

results, neurosurgical consultations, psychiatric consultations, neuropsychological test

results, psychotherapy records, Physical Therapy records or other objective medical

information which you think will support your claim.” (See id.) Neither the sixth page of the

July 6, 2000 letter nor any other part of the letter, however, utilizes the plan language; in

other words, defendant never made a “request for the proof” or asked for “proof of claim.” 

(See id.) Consequently, “the policy’s time limitation provision was never rendered

operative.” See Mogck, 292 F. 3d at 1028-29; see also Skipper v. Claims Service Int’l, 213

F. Supp. 2d 4, 8 (D. Mass. 2002) (“It would be ridiculous, and grossly unfair, to suggest that

defendants’ mere expression of a willingness ‘to review pertinent additional information,’ [as

stated in the letter terminating benefits], should be construed as a request for ‘proof of loss’

or as notice of the commencement of the [contractual] limitation period.”) As a result, the

language included in defendant’s July 6, 2000 letter is, as a matter of law, insufficient to

trigger the running of the one-year contractual limitations period.

Accordingly, plaintiff is entitled to summary judgment on the Fifth Affirmative

Defense, to the extent it is based on the contractual limitations provision.

B. Social Security Award

On July 8, 2000, the Social Security Administration (“SSA”) found plaintiff was, for

purposes of the Social Security Act, disabled. (See Corrected Rosati Decl. Ex. 22.) On

August 30, 2000, the SSA notified plaintiff that he would receive benefits retroactive to

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The Court notes, however, that a denial of benefits under such circumstances may

be deemed “inconsistent,” see Darland, 317 F. 3d at 530, and may “cast additional doubt

on the adequacy of [the plan’s] evaluation of [the plaintiff’s] claim,” see Ladd, 148 F. 3d at

533.

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October 1997. (See id. Ex. 23.) As noted, defendant determined plaintiff was, for

purposes of the plan, disabled as of October 1997, but not disabled as of July 7, 2000.

Plaintiff argues that, irrespective of the standard of review, he is, as a matter of law,

entitled to continued plan benefits in light of the SSA’s decision that he is disabled. Plaintiff

also argues that defendant is, as a matter of law, estopped from denying plaintiff is disabled

because defendant “encourage[d]” plaintiff to apply for Social Security disability benefits,

(see CF 258-260), and defendant, after plaintiff received such benefits, asserted an off-set,

(see CF 18; Corrected Rosati Decl. Ex. 10). The Court disagrees.

A decision by the SSA to award a claimant Social Security benefits is not binding on

a plan administrator. See, e.g., Madden v. ITT Long Term Disability Plan, 914 F. 2d 1279,

1285 (9th Cir. 1990) (affirming plan administrator’s decision denying disability benefits,

even though claimant received SSA benefits, because claim file contained evidence in

support of plan administrator’s decision); Calvert v. Firstar Finance, Inc., 266 F. Supp. 2d

578, 585-86 (W.D. Ky.) (noting one reason SSA decisions are not binding on plan

administrators is that SSA applies “treating physician rule” while plan administrators are not

limited thereby).

Further, plaintiff cites no case, and the Court has located none, in which a court has

determined a claimant to be entitled to plan benefits solely because the plan administrator

encourages a claimant to apply for SSA benefits and thereafter offsets plan benefits by

SSA benefits. Rather, courts have held such conduct “‘does not provide an independent

basis’” for judgment in favor of the claimant. See Darland v. Fortis Benefits Ins. Co., 317 F.

3d 516, 530, 533 (6th Cir. 2003) (quoting Ladd v. ITT Corp., 148 F. 3d 753, 755-56 (7th Cir.

1998)).5

Accordingly, plaintiff has not shown that he is entitled, as a matter of law, to

judgment based on the fact that the SSA determined plaintiff to be disabled or that

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defendant encouraged plaintiff to seek Social Security benefits.

C. Standard of Review

The parties disagree as to whether the Court should review defendant’s termination

of plaintiff’s benefits de novo or for abuse of discretion.

“Depending upon the language of an ERISA plan, a district court reviews a plan

administrator’s decision to deny benefits either de novo or for abuse of discretion.” Ingram

v. Martin Marietta Long Term Disability Income Plan, 244 F. 3d 1109, 1112 (9th Cir. 2001). 

“The de novo standard is appropriate unless the benefit plan gives the administrator or

fiduciary discretionary authority to determine eligibility for benefits or to construe the terms

of the plan.” Id. (internal quotation and citation omitted). 

Here, the plan language includes language that unambiguously provides the

administrator with authority to determine eligibility for benefits and to construe the terms in

the plan: “[Defendant] shall possess the authority, in its sole discretion, to construe the

terms of this policy and to determine eligibility hereunder.” (See Gray Decl. Ex. A at P025.) Plaintiff argues, however, that irrespective of the above-quoted plan language, he is

entitled to de novo review, on the ground that discretionary clauses are unenforceable

under state law or, alternatively, that defendant acted with an actual conflict of interest.

1. Enforceability of Discretionary Clauses

In February 2004, the California Department of Insurance (“DOI”) issued a notice in

which it expressed the opinion that “discretionary clauses” are “objectionable” under

California law and stated that the DOI would, subject to the outcome of an administrative

hearing, revoke approval of certain policies that included discretionary clauses. (See

Corrected Rosati Decl., filed October 29, 2004, Ex. 24 at 1.) Although the DOI’s notice

does not refer to the policy at issue herein, plaintiff argues that the notice establishes that

“discretionary clauses” are illegal under California law and that, accordingly, defendant

cannot rely on the discretionary clause in the plan. The Court disagrees.

//

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Initially, the Court notes that the Supreme Court has held that a “benefit plan [may]

give[ ] the administrator or fiduciary discretionary authority to determine eligibility for

benefits or to construe the terms of the plan.” See Firestone Tire & Rubber Co. v. Bruch,

489 U.S. 101, 115 (1989). In any event, the DOI has explained that its notice “does not

effect policies already sold,” see Davison v. Hartford Life and Accident Ins. Co., 2005 WL

807045, *1 (N.D. Cal. 2005); thus, the DOI’s notice is inapplicable to the instant policy,

which was issued in 1995, (see Gray Decl. Ex A at P-001). Further, defendant should be

entitled to rely on any prior approval of the policy by the DOI, because such approval

necessitated a finding by the DOI that said policy did not contain provisions that are

“unintelligible, uncertain, ambiguous, or abstruse, or likely to mislead a person to whom the

policy is offered, delivered or issued.” See Cal. Ins. Code § 10291.5(b)(1).

Accordingly, plaintiff has not shown that the discretionary policy is unenforceable.

2. Conflict of Interest

Defendant is both the insurer of the plan and the plan administrator. (See Curry

Decl., filed October 7, 2004, ¶ 3.) As such, defendant has an apparent “conflict of interest.” 

See Tremain v. Bell Industries, Inc., 196 F. 3d 970, 976 (9th Cir. 1999). Plaintiff argues

that, in the instant case, defendant’s conflict of interest affected its decision-making, and,

consequently, he is entitled to de novo review.

Where a claimant offers “material, probative evidence, beyond the mere fact of the

apparent conflict, tending to show that the fiduciary’s self-interest caused a breach of the

administrator’s fiduciary obligations to the beneficiary,” a presumption arises that the

administrator, in fact, breached its fiduciary obligations to the beneficiary. See Hensley v.

Northwest Permanente P.C. Retirement Plan & Trust, 258 F. 3d 986, 995 (9th Cir. 2001). 

“[M]aterial, probative evidence may consist of inconsistencies in the plan administrator’s

reasons, insufficiency of those reasons, or procedural irregularities in the processing of the

beneficiaries claims,” Nord v. Black & Decker Disability Plan, 356 F. 3d 1008, 1010 (9th

Cir.) (internal quotation and citation omitted), cert. denied, 125 S. Ct. 62 (2004), as well as

the failure to provide a claimant a “‘full and fair’ appeals procedure,” see Friedrich v. Intel

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Plaintiff has identified approximately 25 documents he believes are missing from

the record. (See Pl.’s Mot., filed October 7, 2004, at 6:19 - 8:10.) Defendant concedes the

record is missing at least 21 documents. (See Def.’s Opp. to Pl.’s Mot., filed October 29,

2004, at 3:8.)

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Corp., 181 F. 3d 1105, 1110 (9th Cir. 1999) (quoting 29 U.S.C. § 1133(2)). Where a

plaintiff meets his initial burden, “the plan must rebut the presumption by producing

evidence to show that the conflict of interest did not affect its decision to deny or terminate

benefits.” See Hensley, 258 F. 3d at 995. If the plan fails to rebut the presumption, the

district court reviews the administrator’s decision to deny benefits under the de novo

standard. See id.

Here, plaintiff argues that because the claim file is missing certain documents and

because defendant, in handling plaintiff’s appeal, violated certain ERISA regulations, he is

entitled to a presumption that defendant breached its fiduciary obligations to him.

a. Missing Documents

The parties agree that the claim file is missing documents.6

 Although plaintiff argues

that defendant intentionally destroyed or removed the documents, plaintiff has not offered

evidence, let alone the requisite material, probative evidence, tending to prove any

intentional act. In the absence of such evidence, it would appear defendant’s failure to

provide a complete claim file is a result of negligence or inadvertence.

Plaintiff does not offer any authority, and the Court has located none, in support of

an argument that a plan administrator’s negligent or inadvertent loss of records constitutes

material, probative evidence tending to show a breach of fiduciary duty. Further, as it

appears the loss of documents occurred after the final decision to terminate benefits had

been made, there does not appear to be any causal connection between the loss and the

decision. In any event, it appears the deficiencies can be cured by supplementation of the

record. Indeed, plaintiff has offered, without objection by defendant, a number of

documents plaintiff states are copies of documents that initially were in the claim file and

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To the extent there are other documents plaintiff states are missing, and of which

plaintiff does not have copies, plaintiff may seek to supplement the file by other means. In

ERISA cases where a defendant offers an incomplete claim file, district courts have allowed

the plaintiff considerable leeway in bringing before the district court the material contained

in the missing documents. For example, in Cannon v. Unum Life Ins. Co., 219 F.R.D. 211

(D. Me. 2004), where the claim file was missing a “medical update” authored by a physician

hired by the defendant, the district court ordered that if the defendant was unable to

produce that document, plaintiff would be allowed to depose the claim reviewer to learn the

content of the document. See id. As another example, in Sheehan v. Metropolitan Life Ins.

Co., 368 F. Supp. 2d 228 (S.D.N.Y. 2005), where the record was missing “several medical

documents relevant to [the plaintiff’s] claim,” the district court allowed the plaintiff, at a court

trial, to present testimony from physicians who had authored the missing documents. See

id. at 254.

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Former § 2560.503-1(h)(1) is applicable to plaintiff because he filed his claim for

benefits prior to 2002. See Gatti v. Reliance Standard Life Ins. Co., — F. 3d — , 2005 WL

1705509, *2 n. 1 (9th Cir. 2005) (observing § 2560.503-1(h)(1) applicable to claims filed

before 2002).

10

are now missing. (See Corrected Rosati Decl., filed October 29, 2004, Exs. 7-22.)7

Accordingly, defendant’s failure to provide the district court with a complete record

does not, under the circumstances herein, warrant a change in the standard of review.

b. Untimely Issuance of Appeal Decision 

Defendant issued its decision denying plaintiff’s appeal 168 days after plaintiff

requested review. In doing so, defendant violated a federal regulation providing that a

decision determining an appeal must be issued no later than 120 days from the date of the

plan’s receipt of the request. See former 29 C.F.R. § 2560.503-1(h)(1)(i) (providing 60-day

time limit for plan to issue decision on request for review, and providing such limit may,

under certain circumstances, be extended an additional 60 days).8

Plaintiff argues that defendant’s failure to comply with former § 2560.503-1(h)(1)(i)

entitles him to a presumption that defendant breached its fiduciary duties. This argument,

however, is foreclosed by recent Ninth Circuit authority holding that a plan administrator’s

violation of § 2560.503-1(h)(1)(i) does not implicate the standard of review. See Gatti v.

Reliance Standard Life Ins. Co., — F. 3d — , 2005 WL 1705509 (9th Cir. 2005) (holding

where plan administrator fails to comply with time limit in former § 2560.503-1(h), plaintiff

entitled to deem administrative remedies exhausted, but not entitled to de novo review

because “violations of the time limits established in 29 C.F.R. § 2560.503-1(h) are

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The Ninth Circuit issued its decision in Gatti after the briefing on the instant motions

was complete.

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insufficient to alter the standard of review”).9

c. Right to Review Documents

Plaintiff argues that defendant violated former 29 C.F.R. § 2560.503-1(g)(1)(ii) when

it did not advise him, in the initial denial letter, of his right to review the documents upon

which defendant based its initial denial.

At the time plaintiff filed his claim and the claim was initially denied, the Code of

Federal Regulations provided as follows:

Every plan shall establish and maintain a procedure by which a claimant or

his duly authorized representative has a reasonable opportunity to appeal a

denied claim to an appropriate named fiduciary or to a person designated by

such fiduciary, and under which a full and fair review of the claim and its

denial may be obtained. Every such procedure shall include but not be

limited to provisions that a claimant or his duly authorized representative may:

(i) Request a review upon written application;

(ii) Review pertinent documents; and

(iii) Submit issues and comments in writing.

See former 29 C.F.R. § 2560.503-1(g).

Under the above-cited regulation, defendant argues, it is not required to advise a

claimant of the right to “review pertinent documents,” but only to allow a claimant to review

such documents if the claimant affirmatively requests to do so. Courts that have

considered defendant’s argument, however, have rejected it. See Ellis v. Metropolitan Life

Ins. Co., 126 F. 3d 228, 237 (4th Cir. 1997) (“A plan administrator or fiduciary must inform a

claimant that, should she desire to submit her claim for review following an initial denial,

she is entitled to review the pertinent documents upon which the initial denial decision was

predicated.”); Soron v. Liberty Life Assurance Co., 318 F. Supp. 2d 19, 27 (N.D.N.Y. 2004)

(holding former 29 C.F.R. § 2560.503-1(g) “require[s] an administrator to inform a claimant,

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10Even before the regulation on which plaintiff relies was enacted, courts had

interpreted ERISA itself to require that a plan administrator, when it denied a claim for

benefits, “invite [the claimant] to examine [the] evidence” on which the plan administrator

had relied. See, e.g., Grossmuller v. International Union, United Automobile Aerospace

and Agricultural Implement Workers of America, Local 813, 715 F. 2d 853, 858 (3rd Cir.

1983) (citing 29 U.S.C. § 1133, by which plan administrator is required to afford

“reasonable opportunity to any participant whose claim for benefits has been denied for a

full and a fair review [of the denial]”).

11The policy, which is only the plan document offered by defendant, does not

address, even in passing, the appeal process. Thus, even if plaintiff had a copy of the

policy at the time his claim was initially denied and had reviewed the policy in an attempt to

determine what appeal rights he had, he would have learned nothing.

12

at whatever level, of her right to review pertinent documents”).10

The Court agrees with the above-cited authorities. As noted, the regulation requires

that an ERISA plan include a procedure allowing claimants to “review pertinent

documents.” See former 29 C.F.R. § 2560.503-1(g). If, as defendant argues, the

regulation merely requires a plan administrator to permit such review when a claimant

affirmatively requests review, the regulation would have little substance, particularly where,

as here, a claimant is not represented by counsel at the time of the denial and the plan

documents are silent as to the appeal process.11

As noted, “material, probative evidence” sufficient to satisfy the plaintiff’s initial

burden to show a breach of fiduciary duty can include “procedural irregularities in the

processing of the beneficiaries claims.” See Nord, 356 F. 3d at 1010. Defendant’s failure

to comply with its obligation to inform plaintiff of his right to review the documents on which

defendant based its initial decision to terminate benefits constitutes a procedural

irregularity. Accordingly, plaintiff is entitled to a rebuttable presumption that defendant

breached its fiduciary obligations to him. See Hensley, 258 F. 3d at 995.

In rebuttal, defendant argues it took other action that sufficed to fully apprise plaintiff

of the bases for the initial denial.

With respect to medical reports cited in support of the initial denial, defendant

provided copies thereof directly to plaintiff’s treating psychiatrist, Michael H. Moskowitz,

M.D. (“Dr. Moskowitz”), and to plaintiff’s treating orthopedic surgeon, James B. Reynolds

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(“Dr. Reynolds”), and asked both physicians to state any disagreements therewith, (see CF

168-69, 232); both physicians responded with comments and disagreements, (see

Corrected Rosati Decl. Exs, 9, 15). Had defendant informed plaintiff of his right to obtain

copies of the above-referenced medical reports, and had plaintiff then requested such

reports, it is difficult to conceive how plaintiff would have made better use of those reports

than by asking his treating physicians to respond thereto.

With respect to a vocational study cited as evidence in support of its initial denial,

defendant sent plaintiff, along with the initial denial letter, a copy of that study, (see CF

101), and, consequently, plaintiff clearly was not harmed by defendant’s failure to advise

plaintiff of his right to review such study.

The initial denial also sets forth “observations” made of plaintiff on specific dates. 

(See, e.g., CF 97 (“On May 12, 2000, you were observed driving to the Vintage Bank and

Moss Creek Winery.”).) As to each date of “observation,” the initial denial letter sets forth

the particular observation(s) made, thus providing plaintiff with notice of the particular

activities defendant was of the view supported a denial of benefits. (See CF 96-97.)

Accordingly, defendant having shown that its failure to inform plaintiff of his right to

review the documents on which the denial was based did not result in any substantive harm

to plaintiff or affect defendant’s decision-making, defendant’s violation of the regulation

does not warrant a change in the standard of review.

d. Consideration of Documents Submitted on Appeal

Plaintiff argues that defendant failed to provide plaintiff with a full and fair appeal

because defendant did not consider certain documents submitted by plaintiff in support of

his appeal. Rather, according to plaintiff, defendant acknowledged receipt of them, but did

not analyze or evaluate them. Specifically, plaintiff argues that defendant did not consider

plaintiff’s undated letter setting forth his daily activities and discussing his experiences with

pain, (see Corrected Rosati Decl. Ex. 14), an April 17, 2000 letter authored by Dr.

Reynolds, (see id. Ex. 9), Dr. Reynolds’s office notes dated June 22, 2000 and September

26, 2000, (see id. Ex. 20), and a July 6, 2000 letter authored by Dr. Moskowitz, (see id. Ex.

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12Further, although the burden has not shifted to defendant as to this issue, the

Court notes that defendant offered affirmative evidence in the form of notes to establish

that the above-referenced letters authored by Dr. Reynolds and Dr. Moskowitz were

analyzed by defendant’s neuropsychological consultant. (See CF 92.)

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15).

Defendant, in its final denial letter, stated that it had conducted a “review” of “all” of

the evidence submitted by plaintiff in support of the appeal. (See CF 74.) Although not

directly expressed, plaintiff appears to contend that such statement is false. Plaintiff,

however, fails to offer any material, probative evidence to support a finding that defendant,

after receiving the above-referenced documents, ignored them instead of considering

them.12

Accordingly, plaintiff has not shown that the manner in which defendant addressed

documents submitted in support of plaintiff’s appeal warrants a change in the standard of

review.

CONCLUSION

For the reasons stated above, plaintiff’s motion for summary judgment is GRANTED

in part and DENIED in part, and defendant’s motion for summary judgment is GRANTED in

part and DENIED in part, as follows:

1. Plaintiff is entitled to summary judgment with respect to defendant’s Fifth

Affirmative Defense, alleging that plaintiff’s claim is barred by statutory and contractual

periods of limitation. In all other respects, plaintiff’s motion is denied.

2. Defendant’s decision to deny plaintiff’s claim for benefits will be reviewed for

abuse of discretion. In all other respects, defendant’s motion is denied.

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13In the joint statement, the parties should address, inter alia, the appropriate

procedure(s) by which to supplement the record, to the extent copies of missing documents

cannot be located, as well as the procedure by which the merits of the defense of unclean

hands should be determined.

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The Court will conduct a case management conference on October 21, 2005, at

10:30 a.m. A joint case management conference statement shall be filed no later than

October 14, 2005.13

IT IS SO ORDERED.

Dated: August 10, 2005 

MAXINE M. CHESNEY

United States District Judge

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