Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-cand-4_04-cv-03318/USCOURTS-cand-4_04-cv-03318-0/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

JOHN P. O'NEIL,

Plaintiff,

v.

FIREMAN'S FUND AMERICAN RETIREMENT

PLAN; FIREMAN'S FUND LONG-TERM

DISABILITY PLAN; EMPLOYEE BENEFIT

ADMINISTRATION COMMITTEE; AND AETNA

LIFE INSURANCE COMPANY,

Defendants.

 /

No. C 04-03318 CW

ORDER DENYING

PLAINTIFF'S

MOTION FOR

JUDGMENT UNDER

RULE 52 AND

GRANTING

DEFENDANTS’

CROSS-MOTION FOR

JUDGMENT.

Plaintiff John O'Neil filed this lawsuit against Fireman's

Fund American Retirement Plan, Fireman's Fund Long-term

Disability Plan, the Employee Benefit Administration Committee,

and Aetna Life Insurance Company (collectively, Defendants),

alleging that Defendants violated his rights pursuant to the

Employee Retirement Income Security Act, 29 U.S.C. § 1001 et

seq. (ERISA) by denying his claim for retirement and long-term

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1 All claims against Defendant Aetna Life Insurance Company

were dismissed. See January 24, 2005 Stipulation and Order for

Voluntary Dismissal of Defendant Aetna Life Insurance Company. 

2

disability benefits.1 Plaintiff now moves, pursuant to Federal

Rule of Civil Procedure 52, for judgment by the Court. 

Defendants oppose the motion, and cross-move for judgment in

their favor. 

Having considered the parties’ papers and the evidence

cited therein, the Court DENIES Plaintiff’s motion for judgment

under Rule 52, and GRANTS Defendants’ cross-motion for judgment. 

BACKGROUND

Plaintiff worked as a systems analyst for Fireman's Fund

Insurance Company (FFIC) from October 6, 1975 through June 20,

1980, and again from February 24, 1982 through January 27, 1984. 

Soares Decl., Ex. C, FFIC 0015. 

As a full-time employee of FFIC, Plaintiff was covered by

FFIC's retirement and short-term and long-term disability plans,

which were administered by the Employee Benefit Administration

Committee (EBAC). The long-term disability plan (LTD Plan) paid

benefits to employees who had been “totally disabled” for at

least six months, and required that this six month period

commence while the employee was a participant in the Plan. 

Soares Decl., Ex. C, LTD, FFIC 0160-62. The LTD Plan defined

“totally disabled” as “unable to work because of disease or

injury” and under the care of a physician. LTD, FFIC 0159-60.

Since at least May, 1983, Plaintiff has experienced

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2 Somewhat in tension with Plaintiff’s March, 2002

declaration, in a July, 2001 letter to FFIC, Plaintiff’s counsel

stated that Plaintiff had returned to work on December 5 merely

on a "trial" basis. Soares Decl., Ex. C, FFIC 0025. However,

this assertion is not competent evidence, and is contradicted by

Dr. Mizroch's report clearing Plaintiff to return to work

without restrictions. 

3

symptoms of depression, including anxiety, fatigue and

difficulty concentrating. Soares Decl., Ex A, Chronology, FFIC

0007. On October 11, 1983, FFIC's Associate Medical Director

informed Plaintiff’s treating physician at Kaiser, Dr. Mizroch,

that Plaintiff was performing poorly at work due to his

depression, and Dr. Mizroch responded in a letter that Plaintiff

suffered from “chronic fatigue and depression.” Chronology,

FFIC 0007. On October 12, Plaintiff was placed on short-term

disability leave. Baum Decl., Ex. A, Staff Summary, FFIC 0004. 

However, on November 30, Dr. Mizroch noted that Plaintiff felt

“100% better” and cleared him to return work on December 5

without restrictions. Soares Decl., Ex. C, Kaiser Treatment

Verification, FFIC 0036; Chronology, FFIC 0008. 

The parties dispute whether Plaintiff actually returned to

work on December 5, and under what conditions. Plaintiff’s only

competent evidence on this point is a March, 2002 declaration,

in which he stated generally, “About the end of 1983 or early

1984 when I was out on disability for depression, I received a

letter from Fireman’s Fund saying that my job had been

eliminated.” Soares Decl., Ex. C, FFIC 0107.2 However,

Plaintiff’s declaration does not specifically state whether he

returned to work on December 5, 1983. EBAC understood

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Plaintiff’s declaration to mean that he went on a second

disability leave in late 1983 or early 1984, which is not

supported by other evidence in the administrative record. 

Soares Decl., Ex. B, Appeal Denial, FFIC 0563. The

administrative record contains no medical report placing

Plaintiff on a second disability leave, as it did for his leave

beginning October 12. Furthermore, Plaintiff’s FICA wage

records show that he received payments from Aetna in 1983,

presumably, according to EBAC's staff, for short-term disability

leave, but not in 1984. Staff Summary, FFIC 0005; FICA, FFIC

0041. 

According to FFIC staff, on January 27, 1984, Plaintiff

left FFIC's employment. Soares Decl., Ex. C, FFIC 0015. As

noted above, Plaintiff stated in his March, 2002 declaration

that his job was eliminated. Soares Decl., Ex. C, FFIC 0107. 

On January 27, 1984, the same day Plaintiff left FFIC, Dr.

Mizroch examined him and reported that he was “generally doing

well,” although he had experienced “2 recent brief (1-2")

‘anxiety attacks,’” and that he had a new job offer in sales. 

Soares Decl., Ex. C, Kaiser Progress Report, FFIC 0038. 

Plaintiff was next examined five months later, on May 10, 1984,

when Dr. Mizroch noted that he was working as an insurance

salesman, but was “not feeling well – having same symptoms.” 

Kaiser Progress Report, FFIC 0039. Plaintiff denies that he was

working as an insurance salesman, pointing to FICA wage records

for 1984. However, the FICA wage records show only that

Plaintiff earned a total of $4,424 in 1984, not where Plaintiff

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was employed. FICA, FFIC 40. FICA wage records show that from

1985 through 1995, when Plaintiff turned sixty-five, his

earnings never exceeded $2,400 annually. FICA, FFIC 40. 

On September 25, 1985, Social Security Administration (SSA)

medical personnel conducted a psychiatric evaluation of

Plaintiff. Baum Decl., Ex. A, Medical Summary, FFIC 0076-0083. 

On September 26, 1985, the SSA awarded Plaintiff disability

benefits. The SSA disability determination reported that

Plaintiff's diagnosis was "psychotic depression," and that his

condition had begun on May 15, 1983. Baum Decl., Ex. A,

Disability Determination, FFIC 0037. 

On May 7, 2001, Plaintiff filed a claim for retirement and

long-term disability benefits with FFIC, claiming benefits from

1984 onward. Soares Decl., Ex. C, FFIC 0018. On January 2,

2002, Plaintiff completed his claim submissions to EBAC. Soares

Decl., Ex. C, FFIC 0051-59. On February 8, 2002, EBAC denied

Plaintiff’s disability claim on the following grounds: (1) the

claim was too late; (2) Plaintiff was not “totally disabled” at

the time his employment ended, as required by the LTD Plan; (3)

Plaintiff did not complete the then-applicable six-month

elimination period; and (4) Plaintiff was not "under the care of

a physician" throughout his period of total disability, as

required by the LTD Plan. Soares Decl., Ex. A, Denial, FFIC

0094-97. EBAC also denied Plaintiff’s retirement claim, because

the sole basis for awarding such benefits was his claimed

entitlement to long-term disability benefits through retirement

age. Denial, FFIC 0096.

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On March 11, 2002, Plaintiff timely appealed the denial of

his claim, and submitted the declaration quoted above, in which

he stated that he was terminated while on disability leave in

late 1983 or early 1984. Soares Decl., Ex. C, FFIC 0106-07. On

April 3, 2002, EBAC invited Plaintiff to submit additional

information to support his appeal. Soares Decl., Ex. C, FFIC

0109-0111. Plaintiff declined EBAC’s invitation. Soares Decl.,

Ex. C, FFIC 0112. On June 28, 2002, EBAC affirmed its denial of

Plaintiff’s claim. Appeal Denial, FFIC 0563-64. 

On August 5, 2002, Plaintiff and his wife filed suit

against FFIC (Case No. C 02-3766 CW). After the Court dismissed

plaintiffs’ ERISA claims with leave to amend, they voluntarily

dismissed the suit. 

On June 21, 2004, Plaintiff requested that EBAC reconsider

its denial of his claims, and submitted two recent medical

evaluations. Baum Decl., Ex. A, FFIC 541-550. EBAC declined to

reconsider Plaintiff’s claim, because he had exhausted his

administrative remedies. Baum Decl., Ex. A, FFIC 0551. 

On August 13, 2004, Plaintiff filed this action. Plaintiff

seeks (1) disability benefits from January, 1984 through May,

1995, when Plaintiff turned sixty-five, under ERISA section

502(a)(1)(B); (2) an equitable order under ERISA section

502(a)(3)(B), which authorizes a suit for other appropriate

equitable relief, requiring Defendants to pay any benefits owed;

and (3) a declaration under section 502(a)(3)(B) of Plaintiff's

entitlement as a disability plan beneficiary to rights under the

Retirement Plan. 

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LEGAL STANDARD

ERISA provides Plaintiff with a federal cause of action to

recover the benefits he claims are due under the Plan. 29

U.S.C. § 1132(a)(1)(B). To evaluate Plaintiff’s claim, the

Court conducts a bench trial based on the administrative record. 

Kearney v. Standard Ins. Co., 175 F.3d 1084, 1094-95 (9th Cir.

1999) (en banc). The standard of review of a plan

administrator's denial of ERISA benefits depends upon the terms

of the benefit plan. 

DISCUSSION

I. Standard of Review

Plaintiff argues that, because the LTD Plan did not

explicitly reserve discretion to EBAC, the Court should review

EBAC's denial of his benefits de novo. Defendants contend that

the LTD Plan conferred discretionary authority on EBAC, and

EBAC's determination should be reviewed for abuse of discretion.

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). 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. Id.; Taft v. Equitable Life Assurance Soc’y, 9 F.3d

1469, 1471 (9th Cir. 1993). A plan administrator has discretion

"only where discretion [is] 'unambiguously retained.'" Kearney,

175 F.3d at 1090 (quoting Bogue v. Ampex Corp., 976 F.2d 1319,

1325 (9th Cir.1992)). The abuse of discretion standard has been

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3 The LTD Plan reads, in relevant part:

For the purposes of carrying out its responsibilities and

duties hereunder, the Committee shall have all necessary

and appropriate powers, including but not by way of

limitation, the following:

(1) To interpret the provisions of the Plan and to decide

any and all matters arising hereunder; including the right

to remedy possible ambiguities, inconsistencies or

omissions; providing, however, that all such

interpretations and decisions shall be applied in a uniform

manner to all participants similarly situated and shall not

discriminate in favor of shareholders, officers or highly

compensated Employees with respect to the class of

Employees eligible to participate in the Plan. . . .

(6) To determine the facts affecting the eligibility of any

Employee to be included in the Plan.

(7) To determine the manner in which benefits shall be paid

under the Plan, if discretionary, and the persons who are

entitled thereto and to authorize and direct all

disbursements of benefits and other sums under the Plan. 

LTD Plan, FFIC 0165-66.

8

referred to as an "arbitrary and capricious" standard. McKenzie

v. Gen. Tel. Co. of Cal., 41 F.3d 1310, 1314 & n.3 (9th Cir.

1994); Taft, 9 F.3d at 1471 n.2 (use of the term "arbitrary and

capricious" versus "abuse of discretion" is a "distinction

without a difference").

Here, the LTD Plan grants EBAC the power to "interpret the

provisions of the Plan," "determine the facts affecting the

eligibility of any Employee," and "determine the manner in which

benefits shall be paid under the Plan, if discretionary. . . ."3

LTD, FFIC 0165-66. Plaintiff criticizes Defendants' reliance on

case law predating Kearney, arguing that this decision marked a

shift away from the Ninth Circuit's more liberal approach to

finding grants of discretion. Kearney, 175 F.3d at 1090. The

court in Kearney insisted that a grant of discretion be

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4 The fourth case also held that discretion was clearly

conferred without using the word “discretion,” but Ingram found

its holding was “difficult to apply” because it did not analyze

the plan language at issue. Id.

9

"unambiguous," and held that a plan administrator's authority to

pay benefits upon "satisfactory written proof" of disability was

too ambiguous to merit abuse of discretion review. Id.

Even under the standard in Kearney, however, the LTD Plan

here unambiguously confers discretionary authority on EBAC. 

Relying on Ingram v. Martin Marietta Long Term Disability Income

Plan for Salaried Employees of Transferred GE Operations, 244

F.3d 1109, 1113-14 (9th Cir. 2001), Plaintiff argues that

explicit use of the word "discretion" is required for a grant of

discretion. However, Ingram, like Kearney, did not actually

require use of the word "discretion"; instead it required that

the grant of discretion be "unambiguous.” Kearney, 175 F.3d at

1090; Ingram, 244 F.3d at 1114. Ingram encouraged benefits

plans to use the word “discretion,” noting that it “is not

difficult to write, ‘The plan administrator has discretionary

authority to grant or deny benefits under this plan.’” Id. at

1113. The fact that this LTD Plan was written before Ingram’s

advice was given weighs in favor of Defendants’ interpretation. 

Further, Ingram also noted that, of four recent cases in which

the Ninth Circuit found an unambiguous grant of discretion, two

explicitly used the word "discretion," while a third

"unmistakabl[y]" conferred discretion without using the word

"discretion.” Id.4

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Plaintiff argues that here, as in Ingram, the plan

administrator retained decision-making authority, but not

discretion. In Ingram, the plan administrator was vested with

authority to "make all decisions on claims" and had "management

and control of the operation and administration of claim

procedures under the Plan." Id. at 1113. The court concluded

that an "allocation of decision-making authority to [the plan

administrator] is not, without more, a grant of discretionary

authority in making those decisions," and found that the plan

did not unambiguously confer discretion. Id. at 1112-13. 

Here, however, the LTD Plan does not simply grant EBAC the

authority to decide, manage or administer claims. Instead, the

LTD Plan grants EBAC the authority to "interpret provisions of

the Plan" and to make substantive determinations, including "the

facts affecting the eligibility of any Employee," and "the

manner in which benefits shall be paid under the Plan." 

Also, in another post-Kearney case, the Ninth Circuit

clarified that there "is no magic to the words 'discretion' or

'authority.'" Sandy v. Reliance Standard Life Ins. Co., 222

F.3d 1202, 1207 (9th Cir. 2000); but see Bode v. St. Joseph's

Health Sys. Home Health Agency Long Term Disability Plan, 298 F.

Supp. 2d 918, 920-21 (C.D. Cal. 2003) (holding that "full and

exclusive authority to control and manage the group policy, to

administer claims, and to interpret the group policy . . ." is

not a grant of discretion, because it does not explicitly confer

"discretion" as required by Ingram). Thus, the LTD Plan is not

ambiguous simply because it fails to use the word “discretion.” 

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5 Plaintiff argues that Bergt is not controlling because the

standard of review was not at issue. However, the standard of

review, although not the primary focus, was at issue in Bergt,

and its holding is applicable here. 293 F.3d at 1142.

11

The LTD Plan's grant of power to "interpret" the Plan and

"determine" eligibility and benefits payments resembles language

found to require abuse of discretion review in other Ninth

Circuit cases applying Kearney. See Bendixen v. Standard Ins.

Co., 185 F.3d 939, 943 n.1 (9th Cir. 1999) (finding that phrase

“full and exclusive authority to control and manage the Group

Policy, to administer claims, and to interpret the Group Policy”

clearly grants discretion); Bergt v. Ret. Plan for Pilots

Employed by MarkAir, Inc., 293 F.3d 1139, 1142 (9th Cir. 2002)

(holding that language granting "power" to "interpret the plan

and to resolve ambiguities, inconsistencies and omissions" and

to "decide on questions concerning the plan and the eligibility

of any Employee" is unambiguous).5

The LTD Plan's grant of discretion is less ambiguous than

the language in other post-Kearney Ninth Circuit cases receiving

de novo review. In Johnson v. Buckley, 356 F.3d 1067, 1075-1076

(9th Cir. 2004), the court found that a plan granting power to

"administer the Plan" and "make such rules, regulations,

interpretations, discussions, and computations as may be

necessary" did not unambiguously grant discretion, because it

said “nothing about the merits of [the plan administrator’s]

substantive claims decisions. . . .” Here, by contrast, EBAC is

vested with the power not only to “administer” the LTD Plan, but

also to make substantive determinations affecting benefits

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eligibility. 

For the foregoing reasons, abuse of discretion review is

appropriate in this case. However, as will be discussed below,

de novo review would not alter the result. 

II. Defendants' Objections to Evidence and Motion to Strike

Plaintiff relies in part on letters by two physicians,

written in 2004, that were not part of the administrative record

available to EBAC in its review of Plaintiff’s claims. Baum

Decl., Ex. A, FFIC 0542-0552. Defendants move to strike these

documents. Plaintiff opposes Defendants' motion. 

Evidence outside the administrative record is admissible

only if the court determines that de novo review is proper, and

that the evidence is necessary to conduct an adequate de novo

review. Mongeluzo v. Baxter Travenol Long Term Disability Ben.

Plan, 46 F.3d 938, 944 (9th Cir. 1995). Here, de novo review is

not proper, and therefore the physicians' letters are not

admissible. Therefore, the Court strikes the two physicians’

letters. Again, however, consideration of those letters would

not alter the result.

III. Denial of Benefits

A. Timeliness

Defendants argue that EBAC properly exercised its

discretion in denying Plaintiff's claim as untimely, because

Plaintiff submitted it seventeen years after he left FFIC's

employment. 

Under California's notice-prejudice rule, an insurer may

deny a claim as untimely if the insurer can show that (1) the

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claimant failed to submit timely proof of claim, and (2) the

delay actually caused the insurer substantial prejudice. 

Cisneros v. UNUM Life Ins. Co. of America, 134 F.3d 939, 944

(9th Cir. 1998) ("Prejudice is not presumed from the delay

alone."). 

Here, Defendants argue that Plaintiff failed to submit

timely notice of his claim as required by the LTD Plan. 

Plaintiff was given written notice in 1978 that disability

claims should be submitted "not later than the 20th day after

the first day for which benefits are payable," in this case,

February 16, 1984. Soares Decl., Ex. C, FFIC 0104. Plaintiff

disputes the twenty day deadline, pointing to an EBAC Staff

Summary which stated that the LTD Plan itself did not require

prompt filing of claims, and the 1978 employee notice “did not

amend the Plans." Although the parties dispute the correct

interpretation of the LTD Plan, EBAC had substantial support for

its finding that Plaintiff knew of the twenty day deadline, and

missed it by more than seventeen years. Therefore, EBAC’s

finding that Plaintiff failed to submit timely proof of his

claim was not arbitrary or capricious. Even if EBAC’s

determination were reviewed de novo, Plaintiff would be found to

have submitted an untimely claim. The 1978 employee notice

required that claims be filed in a timely manner, and

Plaintiff’s seventeen year delay failed to meet this

requirement.

However, even if Plaintiff failed to submit timely notice,

his claim cannot be denied as untimely unless FFIC has shown

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that his delay caused actual, substantial prejudice. EBAC

concluded that Plaintiff’s unexplained delay had caused

prejudice, because FFIC no longer had any records relating to

Plaintiff other than the dates of his employment, and because

FFIC could no longer accurately determine Plaintiff’s medical

condition as of January, 1984. Denial, FFIC 0095. EBAC’s

determination is supported by the administrative record, which

does not contain any FFIC documents relating to Plaintiff’s

employment other than a one-page email listing the dates of his

employment. Therefore, EBAC did not abuse its discretion in

denying Plaintiff's claim for untimeliness. Even under a de

novo standard, Plaintiff’s claim would be denied for

untimeliness.

B. Total Disability

Defendants argue that EBAC properly exercised its

discretion in denying Plaintiff’s claim because he was not

"totally disabled" on January 27, 1984, when he left FFIC. 

The LTD Plan states that employees can receive benefits

only during a period of "total disability," where "totally

disabled" is defined as "unable to work because of disease or

injury” and “under the care of a physician.” Here, the

administrative record does not show that Plaintiff was totally

disabled when he left FFIC. Plaintiff was placed on short-term

disability leave for "chronic fatigue and depression" from

October 12, 1983 to December 5, 1983. His physician cleared him

to return to work on December 5 without restrictions, noting

that he felt "100% better." There is no evidence to support

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Plaintiff's counsel’s assertion that he returned to work on a

"trial" basis, or that his doctor ordered a second disability

leave in late December, 1983 or early January, 1984. Instead,

FICA wage reports indicate that Plaintiff did not receive shortterm disability payments in 1984. Finally, Plaintiff's

physician noted on January 27, 1984, the day Plaintiff left

FFIC, that he was "generally doing well" and had a new job

offer. Plaintiff was next examined five months later. Thus,

EBAC's finding that Plaintiff was not totally disabled when he

left FFIC was based on substantial evidence, and was not an

abuse of discretion. 

Plaintiff argues that EBAC abused its discretion in its

finding, because it did not rely on the opinions of a medical

professional. A plan administrator abuses its discretion if it

rejects an employee’s medical evidence without a reasonable

basis. Zavora v. Paul Revere Life Ins. Co., 145 F.3d 1118,

1122-23 (9th Cir. 1998)(plan administrator abused its discretion

in relying on defendants’ medical personnel, none of whom were

ophthalmologists, over contrary opinion of plaintiff’s treating

ophthalmologist); Kunin v. Benefit Trust Life Ins. Co., 910 F.2d

534, 538 (9th Cir. 1990) (plan administrator abused its

discretion in relying on opinion of defendants’ doctors, who did

not adequately investigate matter or consult plaintiff’s

physicians or appropriate experts). 

Here, however, EBAC did not rely on its own judgment, or on

non-expert medical opinions, to contradict the reports of

Plaintiff’s treating physician. Instead, EBAC’s conclusion

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For the Northern District of California

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6 In his letter of January 2, 2002, Plaintiff’s counsel

stated that Plaintiff had additional medical appointments in

December, 1983 and January, 1984, but this is unsupported by the

record. 

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rested on the documentation provided by Plaintiff's own

physician. In the two months before Plaintiff left FFIC, Dr.

Mizroch noted that Plaintiff felt “100% better,” was cleared to

return to work without restrictions and was “generally doing

well.” Plaintiff points to his medical and earnings history as

evidence that his depression has left him unable to work for the

past two decades. However, Plaintiff’s general history does not

show that he was unable to work when he left FFIC on January 27,

1984. EBAC did not abuse its discretion in finding, based on

the opinions of Plaintiff’s treating physician, that he was not

totally disabled when he left FFIC. 

EBAC also denied Plaintiff’s claim for benefits because he

was not under the care of a physician, as required by the LTD

Plan. Medical reports indicate that Plaintiff visited a doctor

only once between November, 1983 and May, 1984.6 Therefore, EBAC

had substantial support for its conclusion that Plaintiff was

not under the care of a physician. 

Plaintiff further argues that the SSA determination in

September, 1985, dating his "psychotic depression" to May, 1983,

shows that he was totally disabled when he left FFIC in January,

1984. Contrary to Defendants’ assertion, the administrative

record does contain evidence of the basis for Plaintiff’s SSA

award. Plaintiff submitted not only the one-page SSA disability

determination, but also a seven-page psychiatric evaluation of

Case 4:04-cv-03318-CW Document 65 Filed 06/22/05 Page 16 of 20
United States District Court

For the Northern District of California

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Plaintiff by the SSA. Medical Summary, FFIC 0076-83. However,

an SSA award does not show that a plan administrator abused its

discretion in denying benefits. Madden v. ITT Long Term

Disability Plan for Salaried Employees, 914 F.2d 1279, 1285 (9th

Cir. 1990)(upholding plan administrator's denial of benefits as

based on substantial evidence, despite contrary SSA award);

Jordan v. Northrop Grumman Corp. Welfare Benefit Plan, 370 F.3d

869, 875 (9th Cir. 2004). Here, as in Madden, EBAC's denial

rested on substantial evidence in the administrative record, and

the subsequent, contrary SSA award does not render it arbitrary

or capricious.

For the foregoing reasons, EBAC did not abuse its

discretion in denying Plaintiff LTD benefits because he was not

totally disabled. Even if the Court were to conduct de novo

review, Plaintiff would be denied benefits, because Plaintiff

has not shown that he was totally disabled in January, 1984. 

The two physicians’ letters submitted by Plaintiff, which

would be admissible only for de novo review, also do not show

that Plaintiff was totally disabled when he left FFIC. Both

were written in 2004. The first, by Plaintiff’s treating

physician Dr. Mizroch, is a one-paragraph letter stating his

opinion that “Mr. O’Neil has been unable to perform with

reasonable continuity the duties of his occupation, as a

consequence of his mental and physical illnesses, throughout the

period from October, 1983 to the present.” It is based on Dr.

Mizroch’s periodic treatment of Plaintiff and his review of

Plaintiff’s medical records. It does not address or explain Dr.

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United States District Court

For the Northern District of California

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Mizroch’s inconsistent findings in December, 1983 and January,

1984. The second is an eight-page report by Dr. Hill, who first

examined Plaintiff in 1987 for Plaintiff’s SSA disability claim. 

It concludes that Plaintiff suffers from major depression, and

has been “continuously disabled” since October 1983. It is

based on Dr. Hill’s recent clinical examination of Plaintiff,

and his review of Plaintiff’s medical records (although he notes

that he was not provided with Kaiser psychiatric records prior

to 1995, except for an initial intake interview of Plaintiff in

May, 1983). Both letters confirm Plaintiff’s general history of

depression, which Defendants do not dispute, but they do not

show that he was totally disabled, and unable to work, due to

his depression in January, 1984. 

C. Six-Month Qualifying Period

Defendants argue that EBAC properly exercised its

discretion in denying Plaintiff's claim based on his failure to

complete the then-applicable six-month qualifying period. 

As Plaintiff concedes, under the LTD Plan, an employee

became eligible for benefits only after the employee had been

totally disabled for six months, and only if the six-month

disability period commenced while the employee was a Plan

participant. Contrary to Defendants' assertion, however, the

LTD Plan did not require that the employee receive short-term

disability benefits for six months, nor did it require that the

six-month period be completed before Plaintiff left FFIC’s

“active employment.” Nonetheless, the administrative record

does not show that Plaintiff's total disability continued for a

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United States District Court

For the Northern District of California

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six-month period that began before he left FFIC. Instead, the

record indicates that Plaintiff received short-term disability

payments from October 12 until December 5, 1984, at which time

he was cleared to return to work, and was no longer totally

disabled as defined by the LTD Plan. There is no evidence that

he became disabled again between December 5, 1983 and January

27, 1984, when he left FFIC. Therefore, EBAC did not abuse its

discretion in denying Plaintiff's claim for his failure to

fulfill the six-month qualifying period. Even if EBAC’s

decision were reviewed de novo, Plaintiff’s claim would be

denied, because Plaintiff has not shown that he was disabled for

at least six months. 

D. Procedural Requirements of ERISA

Plaintiff argues that EBAC's denial of his claim failed to

comply with ERISA procedural requirements.

ERISA requires that a plan administrator denying a benefits

claim must inform the claimant of the specific reasons for

denial, the plan language it relied upon, a description of

information needed to perfect the appeal, and appeal procedures. 

29 C.F.R. 

§ 2560.503-1(g).

Here, EBAC met ERISA’s procedural requirements. EBAC’s

five- page denial letter informed Plaintiff of the specific

reasons for its denial, and of appeal procedures. In response

to Plaintiff’s appeal, EBAC described, and invited Plaintiff to

submit, additional information needed to support his appeal. 

Furthermore, Plaintiff is entitled to relief only if he can

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United States District Court

For the Northern District of California

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show that procedural defects caused him substantive harm or

involved a substantive violation of ERISA. Bogue, 976 F.2d at

1326. Here, Plaintiff has not shown any substantive harm due to

the alleged procedural violations, and is not entitled to

relief. 

CONCLUSION

For the foregoing reason, the Court DENIES Plaintiff's

motion for judgment under Federal Rule of Civil Procedure 52

(Docket No. 54), and GRANTS Defendants’ cross-motion for

judgment (Docket No. 59). The Court GRANTS Defendants’ motion

to strike (Docket No. 58). Judgment shall enter accordingly. 

Each party shall bear its own costs.

IT IS SO ORDERED.

Dated: 6/22/05 /s/ CLAUDIA WILKEN 

CLAUDIA WILKEN

United States District Judge

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