Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-caed-2_01-cv-01933/USCOURTS-caed-2_01-cv-01933-0/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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UNITED STATES DISTRICT COURT

EASTERN DISTRICT OF CALIFORNIA

KAREN LaMANTIA,

NO. CIV. S-01-1933 LKK/GGH

Plaintiff,

v. O R D E R

VOLUNTARY PLAN ADMINISTRATORS

INC., et al.,

Defendants.

 /

Plaintiff, Karen Lamantia (“plaintiff”), filed this action

against Hewlett-Packard Company Employee Benefits Organization

pursuant to the Employee Retirement Income Security Act (“ERISA”)

to recover benefits provided under an employee income protection

plan. This matter comes before the court on cross-motions for

summary judgment. I decide the motions based on the papers and

pleadings filed herein and after oral argument.

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26 1 Unless otherwise noted, these facts are undisputed.

2

I.

FACTUAL BACKGROUND1

A. THE PLAN

Plaintiff, who held a full-time position as Account

Representative in Hewlett-Packard’s Customer Support department,

was a member of the Hewlett-Packard Company Employee Benefits

Organization Income Protection Plan (“Plan”). The Plan was

adopted by Hewlett-Packard Company (“HP”) to provide its

employees with income in the event of certain disabilities. HP

sponsors the plan through the Hewlett-Packard Company Employee

Benefits Organization (“the Organization”). The Plan is selffunded by HP, rather than insured through an insurance company,

and is administered pursuant to the Administrative Services

Contract it has with Voluntary Plan Administrators, Inc.

(“VPA”), which acts as the claim administrator for the Plan. 

For VPA to approve a claim for Plan benefits, a member must

establish that he or she is “Totally Disabled” as defined under

the Plan. Def’s Ex. E at HP00354-00355. The requirements for

Total Disability vary, depending upon whether the member seeks

short or long term disability benefits. Where the member seeks

short-term disability (“STD”) benefits, Total Disability means

that, “following the onset of injury or sickness, the member is

continuously unable to perform each and every duty of his or her

Usual Occupation.” A member’s Usual Occupation is defined as

the normal work assigned to the member by HP. Def’s Ex. E at

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3

HP00358. The Plan also provides that a member must be under the

care of a licensed physician and be examined at a frequency

consistent with the Member’s condition. Def’s Ex. E at HP00355. 

If a member qualifies, the member is entitled to up to a maximum

of 39 weeks of STD benefits. 

By contrast, after the initial 39 week period, where a

member seeks long-term disability (“LTD”) benefits, Total

Disability means that, “the Member is continuously unable to

perform any occupation for which he or she is or may become

qualified by reason of his or her education, training or

experience.” Def’s Ex. E at HP00355. Certain conditions are

excluded under the Plan from consideration for LTD benefits. 

First, the Plan provides:

Any condition diagnosed as, or without regard to its

designation is equivalent to, (1) attention deficit

disorder (ADD), or (2) chronic fatigue syndrome,

Epstein-Barr Virus, or infectious mononucleosis shall

be disregarded in determination of Total Disability 

. . . .

Def’s Ex. E at HP00355. The Plan also provides:

[I]n the case of a disability resulting from a nervous

or mental disorder, the Member shall be considered

Totally Disabled only if he or she is confined to a

hospital or other licensed long-term care facility for

the treatment of such disability or has been so

confined for fourteen (14) or more consecutive days

during the preceding three (3) months.

Def’s Ex. E at HP00356. Under the Plan, an illness is

considered a nervous or mental disorder if:

1. The illness has psychologic or behavioral

manifestations or results in impairment of mental

functioning due to any causes including, but not

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4

limited to, social, psychological, genetic, physical,

chemical or biological; and

2. The illness has a primary diagnosis that either is

listed in the American Psychiatric Association’s

Diagnostic and Statistical Manual of Mental Disorders,

Third Edition-Revised, or falls within diagnostic

codes 290 through 319 in the International

Classification of Diseases, 9th Revision.

Id.

The Plan’s claims administrator, VPA, must make the

determination of Total Disability on the basis of “objective

medical evidence,” which the Plan defines as “evidence

establishing facts or conditions as perceived without distortion

by personal feelings, prejudices or interpretations.” Def’s Ex.

E at HP00355. It is the member seeking benefits who is “solely

responsible for submitting the claim form and any other

information or evidence on which the Member intends the Claims

Administrator to consider in order to render a decision on the

claim.” Def’s Ex. E at HP00375.

Where a claim for benefits is denied, the Plan provides

that the member is permitted to appeal the denial by submitting

a written request for review. Def’s Ex. E at HP00377. With

respect to an appeal of a denial of benefits, the Organization

“is the named fiduciary which has the discretionary authority to

act with respect to any appeal from a denial of benefits. The

Organization’s discretionary authority includes the authority to

determine eligibility for benefits and to construe the terms of

the Plan.” Id. 

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5

Upon appeal of a denial of benefits, the claims

administrator must “give the claimant (or the claimant’s

representative) an opportunity to review pertinent documents 

. . . in preparing a request for review.” Id. The Plan

provides, however, that the claimant is “solely responsible for

submitting a written request for review of the claim and any

other information or evidence on which the Member intends the

Claims Administrator to consider in order to render a decision

on review.” Def’s Ex. E at HP00377. The claims administrator

may require the claimant to seek additional information or

evidence as it deems appropriate to its review. Id. 

The Plan provides that, absent special circumstances, a

request for review should be “act[ed] upon” “within sixty (60)

days after the receipt thereof,” and “[i]n no event shall the

decision of the Claims Administrator be rendered more than one

hundred twenty (120) days after it receives the request for

review.” Def’s Ex. E at HP00378. The Plan further provides

that a claimant should receive written notice of a denial of the

appeal and the specific bases for denial. It also provides,

however, that, absent written notice that additional time for

review is required, “within sixty (60) days of the date his or

her request for review is reached by the Claims Administrator,

the claim shall be deemed to have been denied on review.” Even

where a claimant is given notice that additional time is

required for review, the Plan provides that where the claimant

“does not receive written notice of the Claims Administrator’s

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decision with respect to his or her claim within one hundred

twenty (120) days after the date the Claims Administrator

receives the request for review, the claim shall be deemed to

have been denied.” Def’s Ex. E HP00379. 

Should the claimant wish to file suit regarding the denial

of benefits, the Plan provides that the claimant must first

exhaust the so-called administrative remedies set forth in the

Plan. Def’s Ex. E at HP00379. The Plan also contains a time

limitation for bringing suit. It provides that “[N]o action at

law or equity shall be brought to recover benefits under the

Plan unless the action is commenced within four (4) years after

the occurrence of the loss for which the claim is made.” Id.

The Summary Plan Description provides plan members with

information concerning the exhaustion requirement and the

limitations for suit. It reads: “No legal action may be taken

until all the claim review procedures have been completed. No

legal action may be taken to gain benefits from the Plan after

four years from when the disability occurred.” Def’s Ex. E at

HP00441.

II.

PROCEDURAL BACKGROUND

A. PLAINTIFF’S BENEFITS CLAIM 

On August 19, 1996, plaintiff filed her initial claim for

STD benefits under the Plan. She described her disability as

anemia, hysterectomy, and stress. In the Physician’s

Certification of Disability, her doctor explained that

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2 Fibromyalgia has been recognized in this Circuit as a physical

rather than a mental disease. Jordan v. Northrop Grumman Corp.

Welfare Benefit Plan, 370 F.3d 869 (9th Cir. 2004). In Jordan, the

court held that: 

This syndrome . . has traditionally been used for an

ill-defined, poorly understood set of symptoms,

consisting of aching pain and stiffness in one or

several parts of the body. As we have previously

explained, fibromyalgia's cause or causes are unknown,

there is no cure, and, of greatest importance to

disability law, its symptoms are entirely subjective.

There are no laboratory tests for the presence or

severity of fibromyalgia. The 'consensus' construct of

fibromyalgia identifies the syndrome as associated with

generalized pain and multiple painful regions .... Sleep

disturbance, fatigue, and stiffness are the central

symptoms, though not all are present in all patients.

The only symptom that discriminates between it and other

syndromes and diseases is multiple tender spots, which

we have said were eighteen fixed locations on the body

that when pressed firmly cause the patient to flinch.

The diagnosis is now based on patient reports of a

7

plaintiff’s primary diagnosis was iron deficiency and anemia,

and listed “chronic immune deficiency fatigue syndrome” as a

secondary diagnosis. Plaintiff was awarded short-term benefits.

On February 27, 1997, plaintiff filed a claim for long-term

disability benefits in which she listed a number of symptoms

including nausea, muscle and joint pain, stress, chronic

bronchitis, headaches, anxiety, depression, and panic attacks. 

The VPA denied plaintiff’s claim for LTD benefits by letter

dated May 14, 1997. In the letter, Dee Goodenough, a VPA

employee with the title “Disability Benefit Specialist,”

addressed the limitations on disability claims based on mental

health issues and chronic fatigue syndrome. She then asserted

that the objective medical records supported that plaintiff was

being treated for chronic fatigue syndrome, fibromyalgia,2

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history of pain in five parts of the body, and patient

reports of pain when at least 11 of 18 points cause pain

when palpated by the examiner's thumb. Although . . .

the syndrome [may not be] []either “progressive” []or

"crippling," the symptoms can be worse at some times

than others. Objective tests are administered to rule

out other diseases, but do not establish the presence or

absence of fibromyalgia.

Id. (omitting internal quotations and citations). 

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depression, and chronic bronchitis, but did not support a

limitation in function due to these conditions. Goodenough

concluded that, in her opinion, the objective medical evidence

in the file did not support any limitation in function due to

bronchitis. She also stated that, as to the diagnosis of

fibromyalgia, the medical records contained no supporting data

that plaintiff’s symptoms were the result of an organic

impairment. Goodenough noted that plaintiff had a right to

request review, and informed plaintiff that she would receive a

written decision within 120 days of the date of her request for

review. Goodenough also noted that if plaintiff did not receive

a written decision within 120 days, “the appeal can be

considered denied.” Def’s Ex. E at HP00067.

In a letter dated June 10, 1997, plaintiff appealed the

denial of benefits, alleging that she was disabled due to

fibromyalgia, chronic fatigue syndrome, immune deficiency

syndrome, pulmonary problems, and depression. She stated that

she was appealing on the basis that her fibromyalgia, pulmonary

problems, and immune deficiency syndrome were disabling. Def’s

Ex. E at HP00062-63. 

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On July 1, 1997, copies of the Plan were sent to

plaintiff’s attorney, along with most of plaintiff’s medical

records. VPA informed plaintiff’s counsel that any additional

information plaintiff wished to submit should be submitted

within 30 days. Def’s Ex. E HP00005-6, 00061. On July 24,

1997, plaintiff’s attorneys requested additional time to acquire

additional medical documentation to support her appeal. VPA

agreed to extend the appeal submission date another thirty days

to September 3, 1997. VPA sent copies of additional medical

reports to plaintiff’s counsel on August 11, 1997, and gave

plaintiff until September 8, 1997 to submit her information. On

September 18, 1997, plaintiff’s counsel sent VPA a copy of a

report from Dr. Agresti dated September 16, 1997, and stated

that an additional report would be forthcoming. The following

day, in a telephone conversation with Lance Tomei of VPA,

plaintiff’s counsel stated that it might take another month to

schedule plaintiff for a medical evaluation. On October 3,

1997, plaintiff’s counsel sent a letter to Tomei purporting to

“memorializ[e] our agreement that the appeal review . . . will

not conclude until such time as Ms. LaMantia has obtained a

report from an evaluator of her choice and submitted said

report.” Pl.’s Evidence in Oppo. to Def’s Motion at 403. 

Plaintiff’s counsel wrote that he hoped to obtain the report in

two months. 

Whether plaintiff’s counsel continued seeking to

communicate with VPA over the next three years is in dispute. 

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In any event, it appears that the dialogue resumed in August of

2000. At that time, VPA received a letter from plaintiff’s

current counsel asking for a response to materials that

plaintiff’s counsel had allegedly sent in 1999. VPA responded

that they had not received the materials and asked for copies,

along with an explanation as to why there had been a delay

between October 1997 and 1999. There is no record of any

explanation for the delay, but plaintiff’s counsel did send

copies of the missing materials. 

It was another year before VPA sent a letter to plaintiff’s

counsel stating that her appeal was denied. Claims Manager,

Janet Curry, asserted that plaintiff’s medical file did not

support a conclusion that plaintiff could not work on the basis

of chronic bronchitis and fibromyalgia, but that the symptoms

alleged are “those of depression, chronic fatigue syndrome, and

Epstein Barr virus and in the absence of these symptoms, she

could return to her job at Hewlett-Packard Company.”

B. PLAINTIFF BRINGS THIS FEDERAL ACTION

Plaintiff filed suit on October 17, 2001. On December 20,

2002, this court determined that the VPA improperly denied

plaintiff long term disability benefits. The defendant appealed

and, on March 23, 2005, the Ninth Circuit reversed in part and

remanded. See LaMantia v. Voluntary Plan Administrators, Inc.,

401 F.3d 1114 (9th Cir. 2005). The Circuit court held that, in

this case, the correct standard of review is that of abuse of

discretion, instead of the de novo standard applied by this

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3 Under that rule, the opinions of a claimant’s treating

physicians were given special deference and could be disregarded

only for clear and convincing reasons based on substantial evidence

in the record. See Regula v. Delta Family-Care Disability

Survivorship Plan, 266 F.3d 1130 (9th Cir. 2001), vacated, 539 U.S.

901 (2003).

11

court. Further, the Circuit explained that, subsequent to

issuance of this court’s decision, the “treating physician

rule3,” applied in this case, was rejected by the High Court and

is no longer good law. See Black & Decker Disability Plan v.

Nord, 538 U.S. 822(2003). Accordingly, this court now reviews

the parties’ summary judgment motions consistent with the Ninth

Circuit’s instructions. 

III.

STANDARDS

A. SUMMARY JUDGMENT

The purpose of summary judgment "is to isolate and dispose

of factually unsupported claims or defenses." Celotex v.

Catrett, 477 U.S. 317, 323-24(1986). To obtain summary judgment,

a party must demonstrate that no genuine issue of material fact

exists for trial, and that based on the undisputed facts he is

entitled to judgment as a matter of law. Id. at 322.

The moving party "bears the initial responsibility of

informing the district court of the basis for its motion, and

identifying those portions of 'the pleadings, depositions,

answers to interrogatories, and admissions on file, together

with the affidavits, if any' which it believes demonstrate the

absence of a genuine issue of material fact." Id. at 323. The

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 4 The Ninth Circuit has used the term "arbitrary and

capricious" to describe this deferential standard of review. Taft

v. Equitable Life Assur. Soc., 9 F.3d 1469(9th Cir. 1993)(citing

Dytrt v. Mountain State Tel. & Tel. Co., 921 F.2d 889, 894 (9th

Cir. 1990); Madden v. ITT Long Term Disability Plan, 914 F.2d 1279,

1284 (9th Cir. 1990), cert. denied, 498 U.S. 1087 (1991)). The

Circuit has explained that, because the court “employed review in

those cases consistent with the strictures of the abuse of

discretion standard, however, [the] use of a different term was ‘a

distinction without a difference.’” Id. at n.2 (quoting Cox v. MidAmerica Dairymen, Inc., 965 F.2d 569, 572 n.3 (8th Cir. 1992))

12

court must draw all justifiable inferences in favor of the nonmoving party. Masson v. New Yorker Magazine, Inc., 501 U.S. 496,

520 (1991).

If the moving party meets its initial burden, then the nonmoving party "must set forth specific facts showing that there

is a genuine issue for trial." Fed. R. Civ. P. 56(e). However,

"[i]f a moving party fails to carry its initial burden of

production, the non-moving party has no obligation to produce

anything, even if the nonmoving party would have the ultimate

burden of persuasion." Nissan Fire & Marine Ins. Co. v. Fritz

Cos., 210 F.3d 1099, 1102-03 (9th Cir.2000).

B. REVIEW OF PLAN ADMINISTRATOR'S DECISION UNDER ERISA

A district court reviews an ERISA plan benefits denial 

"under a de novo standard unless the benefit plan gives the

administrator or fiduciary discretionary authority to determine

eligibility for benefits or to construe the terms of the plan."

Firestone Tire and Rubber Co. v. Bruch, 489 U.S. 101, 115(1989).

Where a plan does give the administrator such discretionary

authority, courts review a claim denial under an abuse of

discretion standard.4 LaMantia v. Voluntary Plan Administrators,

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(citing Block v. Pitney Bowes Inc., 952 F.2d 1450, 1454 (D.C. Cir.

1992)("The distinction, if any, between 'arbitrary and capricious

review' and review for 'abuse of discretion' is subtle.")).

 5 The LaMantia panel explained that the Plan does in fact give

VPA “‘the discretionary power to construe the language of the Plan

and make the decision on review,’” and that the VPA did actually

exercise that discretion.

 

6 The defendant argues that evidence subject to this court’s

review is limited to that before VPA pertaining to plaintiff's

condition as of the end of the short-term disability ("STD") period

when VPA made its decision on her claim for LTD benefits ("LTD

decision date"). In other words, it maintains that the court may

only review evidence before the VPA before May 14, 1997. However,

the decision being challenged and reviewed here is the final

decision made by the VPA after reviewing plaintiff’s appeal of the

May, 1997 denial. As the Ninth Circuit explained, defendant “never

considered LaMantia's claim to be fully denied until August 24,

2001, when a final decision on the merits was rendered.” LaMantia

at 1119. That “final decision . . . analyz[ed] all the medical

evidence VPA [received up to that date] and reaffirm[ed] its 1997

initial denial.” Id. at 1123. Accordingly, the court will review

all of the evidence before the VPA as of the date of the final

decision. 

13

Inc., 401 F.3d 1114 (9th Cir. 2005). As the Ninth Circuit has

already determined, “[t]he circumstances of this case fall into

the . . . exception for when an abuse of discretion standard of

review will apply.”5 Id. at 1123. Accordingly, this court may

review only the evidence presented to the Plan trustees. Id. at

1471.6

In assessing whether a claim administrator abused its

discretion, the court considers whether the claim denial was

unreasonable. Clark v. Washington Teamsters Welfare Trust, 8

F.3d 1429, 1432 (9th Cir.1993). ERISA plan administrators abuse

their discretion when they "construe provisions of the plan in a

way that conflicts with the plain language of the plan." Eley v.

Boeing Co., 945 F.2d 276, 278 (9th Cir.1991). An abuse of

discretion will also be found if the administrator relies on

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clearly erroneous findings of fact in making benefit

determinations, Taft v. Equitable Life Assur. Soc., 9 F.3d 1469,

1473 (9th Cir. 1993), or the decision is unsupported by

substantial evidence. Johnson v. District 2 Marin Eng’rs.

Beneficial Ass’n., 857 F.2d 514, 516 (9th Cir. 1988). 

When the discretionary authority is granted to an

administrator who is operating under a conflict of interest,

however, that conflict must be considered in determining whether

there is an abuse of discretion. Eley, 945 F.2d at 278-79. If

a conflict of interest is found, the “decision will be entitled

to some deference, but this deference will be lessened to the

degree necessary to neutralize any untoward influence resulting

from the conflict." Doe v. Group Hospitalization & Medical, 3

F.3d 80, 87 (4th Cir. 1993). The courts have been less that

clear as to when a conflict actually arises and what the

correspondent heightened standard should be. The Ninth Circuit

has instructed generally that the deference should be lessened

“when the administrator is not entirely impartial or objective,

and may have a vested interest in denying benefits.” Kunin v.

Benefit Trust Life Ins. Co., 910 F.2d 534, 536 (9th Cir. 1990). 

The “lesser deference standard” should “only apply . . ,

however, if the . . . decision implicates a serious conflict

between the interests of the employer and the beneficiaries.” 

Oster v. Barco of California Employees' Retirement Plan, 869

F.2d 1215, 1217-18 (9th Cir. 1988); Jordan v. Northrop Grumman

Corp. Welfare Benefit Plan, 370 F.3d 869, 875 (9th Cir.

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 7 The defendant asserts that the court need not examine whether

a heightened abuse of discretion standard applies because the Ninth

Circuit already made that determination. I cannot agree. There

is nothing in the record suggesting that the Ninth Circuit

considered whether a conflict of interest existed as to warrant a

less deferential review or that the question was even before it.

Rather, the scope of the Ninth Circuit’s discussion of the standard

of review was limited to explaining why the abuse of discretion and

not a de novo standard applies. Accordingly, this court not only

can, but must, resolve the question before going any further. 

15

2004)(“the standard of review changes with the existence of a

‘serious’ conflict only”). A conflict of interest can be

evidenced by a showing that the plan administrator acted in bad

faith. Jung v. FMC Corp., 755 F.2d 708 (9th Cir. 1985). 

IV. 

ANALYSIS

A. HEIGHTENED STANDARD OF REVIEW

Before reaching the merits, I must address a threshold

issue concerning the applicable standard of review. Plaintiff

contends that the court should apply a modified abuse of

discretion standard because the VPA allegedly operated under a

conflict of interest.7 I examine this contention below.

Plaintiff first asserts that a less deferential standard

should apply because defendant acted in bad faith when it failed

to render a timely decision of her appeal of the denial of longterm disability benefits. The Ninth Circuit has already

addressed this issue and foreclosed this argument. The panel

determined that the delays in making a final determination on

plaintiff’s appeal were not a result of defendant’s bad faith

because it was plaintiff “who sought an extension of time which

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caused the deadline to file documents to occur beyond the

deemed-denial date.” LaMantia at 1123. 

Plaintiff next argues that defendant acted in bad faith

because the VPA arranged for her to be evaluated by more than

one doctor. According to plaintiff, this demonstrates that the

VPA “acted more as an advocate for denial, than a fair and

impartial third party looking to make the right decision.” This

argument is unsupported by any legal authority and is less than

convincing. Nothing in the record supports a finding that the

independent medical examinations were impermissible. 

Finally, plaintiff asserts that there was a conflict of

interest because the Company, the Organization, the Plan and VPA

are all agents of each other. Plaintiff attempts to show the

Organization exercised complete control over the VPA and that

the impartiality of the VPA is therefore questionable. The

parties agree that the benefits are paid by the Organization out

of a trust fund. Pl.’s SUF 5, 6. The VPA is a third-party

claims administrator that receives and processes claims for

benefits and computes claim payments. Id. at 14, 15. The

Organization has discretionary authority with respect to any

appeal from a denial of benefits to determine eligibility for

benefits and to construe the terms of the plan. Pl.’s SUF 8. 

Here, plaintiff concedes that the final decision made on August

24, 2001, was made by Janet Curry, claims manager for VPA. 

Pl.’s Oppo. to Def.’s Mot. at 5. 

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From what the court can tell, it appears that the premise

of plaintiff’s contention is that the defendant was selfinterested in reducing the amount of benefits it was required to

pay out. The Ninth Circuit has rejected this argument. In

Oster v. Barco of California Employees' Retirement Plan, 869

F.2d 1215, 1217-18 (9th Cir. 1988), the court explained that,

“[t]o some extent, a potential conflict of interest” inherently

exists in these types of benefit plans because “[a]ny action

that enhances the financial viability of the Plan tends to

reduce the potential contributions of the company.” According

to the Oster panel, “[a] contrary conclusion would mean that we

must always consider [administrators] of a defined benefit plan

as subject to a conflict of interest, which we are unwilling to

do.” Id. at 1217-18. The Circuit affirmed this position in

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

869 (9th Cir. 2004). There, the court stated that, where an

“insurance policy is both issued and administered by the same

party, in order to establish a ‘serious’ conflict of interest 

. . . ‘the beneficiary has the burden to come forward with

material, probative evidence, beyond the mere fact of the

apparent conflict, tending to show that the fiduciary's selfinterest caused a breach of the administrator's fiduciary

obligations to the beneficiary.’” Id. at 875-76 (quoting

Bendixen v. Standards Ins. Co., 185 F.3d 939, 943 (9th Cir.

1999)). 

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Accordingly, plaintiff’s contention that she “ha[d] a

financial interest in getting the money, while the plan ha[d] a

financial interest in keeping it, . . . cannot [alone] establish

[a] conflict of interest in the administrator, because it would

leave no cases in the class receiving deferential review . .”

Id. at 876. Plaintiff fails to alert the court to other

circumstances which may constitute the types of serious

conflicts of interest recognized in this Circuit. See, e.g.,

Dytrt v. Mountain States Tel. & Tel. Co., 921 F.2d 889 (9th Cir.

1990). The court will therefore not modify the abuse of

discretion standard.

B. DEFENDANT’S INITIAL DENIAL

The parties agree that plaintiff, as an eligible California

employee, was entitled to receive state income disability

benefits for a 52 week period beginning in August of 1996. See

Cal. Un. Ins. Code §§ 2601 et seq. Plaintiff complains that VPA

wrongfully evaluated her eligibility for long-term disability

benefits as of May, 1997, at the end of the Plan’s 39 week

short-term disability period, instead of August 1997, at the end

of the 52 week period. According to her, it was “serious error”

for VPA to make a determination of total disability for the

purposes of long term benefits after 39 weeks of receiving short

term benefits, instead of 52 weeks, and that such error warrants

reversal of its decision. Although plaintiff’s argument is less

than clear, she appears to contend that defendant was required

to provide her with short-term disability benefits for the

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entire 52-week period and was precluded from evaluating or

instituting long-term disability benefits before that period. 

As I explain below, plaintiff’s contention fails for various

reasons. 

First, plaintiff’s contention that defendant violated state

law when it evaluated her application for long-term disability

benefits at the end of the 39-week period is unpersuasive and

unsupported by any legal authority. The defendant maintains

that state law requires only that the employer provide

California employees with benefits for the minimum of 52 weeks,

but that it does not restrict employers from meeting this

requirement by paying long-terms benefits during that time. 

Specifically, defendant explains that, under state law,

employers may elect to assume administration and payment of the

additional California benefits through a voluntary plan, for a

fee paid to the State, and that HP has elected such a voluntary

plan, as described in Supplement C to the Plan. Supp. Curry

Decl. ¶ 3. Defendant asserts that HP has elected to fund and

administer the state disability benefits as a voluntary plan,

and claims are processed by VPA in accordance with the state

regulations and are paid through the HP payroll system at the

rate set by the state. According to defendant, this simply

means that HP's California employees who qualify for short-term

disability benefits under the Plan are entitled to at least the

amount of benefits payable under the California state disability

plan, regardless of whether they meet the stricter definition of

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Total Disability under the Plan for the period after the 39th

week. Thus, if a California employee does not meet the

definition for LTD benefits after the 39th week, his or her

benefits continue but are limited to the weekly state benefit

set out the California Unemployment Insurance Code. See Cal.

Un. Ins. Code § 2655; Supp. Curry Decl. ¶4. Plaintiff does not

dispute defendant’s contentions. Further, she concedes that she

was paid short-term disability benefits for the entire 52-week

period. 

In any event, plaintiff was in no way prejudiced by

defendant’s evaluation of her application at the end of the 39-

week period rather than after 52 weeks. There is no indication

that any new documents were available at the end of the 52 week

period that were not available at the end of the 39 week period. 

Therefore, any procedural error committed by defendant was

harmless, since waiting an additional 13 weeks to assess

plaintiff’s status would have been inconsequential. 

More importantly, VPA’s initial assessment has no bearing

on the larger issue now before the court, that is, whether or

not VPA’s ultimate denial of benefits was an abuse of

discretion. The final determination of her long-term

application was not made until August of 2001, which included a

review of plaintiff’s medical reports from September 1997 to

1999. Accordingly, the medical reports reviewed by VPA were not

limited to those dated before May 1997, as claimed by plaintiff. 

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C. FUNCTIONAL LIMITATION TO ESTABLISH TOTAL DISABILITY

I now examine defendant’s contention that, notwithstanding

the cause of plaintiff’s disability, it reasonably found that

she was not “functionally limited in any objectively measurable

degree” such that she could be found disabled from performing

any occupation consistent with her training and experience. 

The Plan places the burden of proof in establishing "Total

Disability" on the member. The Plan explicitly provides that

the member is "solely responsible for submitting the claim form

and any other information or evidence on which the Member

intends the Claims Administrator to consider in order to render

a decision on the claim." Plan § 7(b); Curry Decl. ¶ 9 and Ex.

E, HP00375. Accordingly, plaintiff had to show that she was

"continuously unable to perform any occupation for which he or

she is or may become qualified by reason of his or her

education, training or experience." Plan § 2(q)(ii); Curry Decl.

¶ 7 and Ex. E, HP00355. Defendant maintains that, even assuming

that plaintiff’s diagnoses of chronic bronchitis and

fibromyalgia were correct, the medical records before it did not

support plaintiff's contention that she was functionally limited

from working. Accordingly, I review the record to determine the

reasonableness of defendant’s conclusion that there was no

objective medical evidence to support a determination that

plaintiff was functionally disabled from performing any job as

defined by the Plan.

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 8 Plaintiff also points to a report written by Dr. Agresti on

August 23, 2002 concluding that “LaMantia is totally disabled from

all forms of occupations for which she is reasonably qualified

based on her education, training and experience, due to Chronic

bronchitis, Fibromyalgia, and Chronic Immune Deficiency.” Pl.’s

Tr. 108h. This report is outside of the administrative record and

cannot be considered by the court. 

22

The record includes documentation from her treating

physicians, Dr. Agresti and Dr. Herman, both of whom wrote

letters in June of 1997 discussing her diagnoses of chronic

respiratory infections and fibromyalgia. In her letter, Dr.

Agresti stated that “due to the persistence of her symptoms she

has been advised that she needs to be off work. Her treatment

plan is for Intravenous gamma globin therapy, be off work until

symptoms diminish, in order that she may be able to tolerate a

work schedule.” See Pl.’s Ex. 2 at 000103. Dr. Herman stated

that “she remain off of work at this time until her symptoms are

under control . . .” Pl.’s Ex. 6 at 000126. 

On July 3, 1997, Dr. Agresti again reported that “LaMantia

may not return to work . . . due to fibromylagia and immune

deficiency syndrome.” The report contains the additional

comment that she “[c]annot return to any type of work even

outside of Hewlett Packard.” Pl.’s Tr. 105. Again in September

of 1997, Dr. Agresti wrote a letter stating that plaintiff’s

“medical condition has affected her so that she has not been

able to attain her goals and have debilitated her to the point

that she cannot work.” Pl.’s Ex. 15 at 402.8 

According to the defendant, this documentation was

insufficient to allow it to find that plaintiff was functionally

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disabled from performing any job, as described by the Plan,

because the doctor’s statements related to her functional

abilities were conclusory. Defendant maintains that these

conclusions did not satisfy plaintiff's burden to produce

"objective medical evidence" of "Total Disability," and it was

prohibited, under the terms of the Plan, to treat these

conclusory statements as objective medical evidence of Total

Disability. In addition to its contention that the only

evidence of her functional abilities consisted of conclusory

statements, it also presents three additional grounds to support

its ultimate decision. First, it asserts that VPA contacted Dr.

Agresti to request specific information regarding plaintiff’s

functional limitations due to any disability, but that Dr.

Agresti failed to respond. Defendant presents evidence that on

November 27, 1996, it specifically requested that Dr. Agresti

define plaintiff’s capabilities and specific restrictions. The

evidence reflects that VPA wrote to Dr. Agresti requesting that

Dr. Agresti "please call . . . to discuss the importance of

defining Karen LaMantia's capabilities to help her in returning

to work." Curry Decl. ¶ 20 and Ex. E, HP00263 (emphasis added). 

This request included a copy of plaintiff’s job description

along with a form to complete defining her "specific

restriction." Id., HP00264-00266. There is nothing in the

record showing that Dr. Agresti ever replied to this request. 

////

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Defendant further points to physician reports which

disagree that plaintiff was disabled from doing any type of job

which she is qualified or may be qualified for, and which, on

the contrary, indicate the possibility of her ability to work. 

In a Physician's Status Questionnaire signed on December 18,

1996, Dr. Agresti vaguely indicated that plaintiff's physical

restrictions are "activity as tolerated – rest." Curry Decl. 

¶ 21 and Ex. E, HP00260. Dr. Agresti made an identical comment

as to plaintiff's limitations on a March 3, 1997 note, id.,

HP00198, and again on April 7, 1997, answered the question about

plaintiff’s functional limitations and/or restrictions on

activities of daily life with the following conclusion: "limited

to level she can tolerate depending on her pain and level of

fatigue." Id., HP00104. 

Defendant also explains that, although Dr. Nagua, a UC

Davis rheumatologist hired by VPA to do an Independent Medical

Evaluation (“IME”) in January 1997, noted that Ms. LaMantia was

limited in her physical abilities, VPA chose to reject that

statement because it was qualified and inconclusory. The record

supports defendant’s contention. Dr. Naguwa stated that

“[t]hough the patient has had at least a 50% decrease in her

usual ability to function, there is insufficient data as to the

completeness of her evaluation to seek an organic cause for her

symptoms." HP00233. Dr. Naguwa also concluded that Ms.

LaMantia's "condition may be improved," and recommended a "more

precise definition of her condition." Id.

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Defendant also contends that it was reasonable for it to 

reject plaintiff’s physicians’ conclusory statements because the

record included evidence bringing the diagnoses of chronic

bronchitis and fibromyalgia, the conditions allegedly causing

her physical limitations, into doubt. Dr. Neil Wood, a

rheumatologist who performed an IME on July 17, 1997, opined

that he did not believe that plaintiff had fibromyalgia as a

clinical entity and ultimately concluded that the diagnosis of

fibromyalgia was unwarranted. Curry Decl. ¶ 34 and Ex. E,

HP00011; HP00047-HP00050. Further, regarding the diagnosis of

chronic immune deficiency based on decreased levels of IGG and

DHEA, Dr. Wood opined that the clinical significance of the

“slight decrease in IGG” and “low S-DHEA” has never been

completely established. Curry Decl. ¶ 2 and Ex. E, HP00048. 

Similarly, in a report plaintiff's counsel provided to VPA

during the appeal of her claim, Dr. David Kneapler, a Boardcertified internist and rheumatologist, stated that "[t]he role

of her selective IG3 deficiency is still unclear, as, when that

is problematic, it usually causes recurrent infections, and her

clinical history has not been characterized by that." Curry

Decl. ¶ 2 and Ex. E., HP00019-HP00023. According to defendant,

these reports reasonably cast doubt on plaintiff’s conditions,

which consequently cast doubt on her functional limitations due

to these conditions. 

The Ninth Circuit has recently reviewed questions similar

to the ones the court faces here. In Jordan v. Northrop Grumman

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Corp. Welfare Benefit Plan, 370 F.3d 869 (9th Cir. 2004), the

plaintiff challenged the denial of long-term disability benefits

based on fibromyalgia. The defendant there denied the

application for benefits on the grounds that plaintiff did not

present objective evidence that the condition of fibromyalgia

rendered her “completely unable to engage in any occupation or

employment for which [she was] or [would] become qualified.” Id.

at 872. The evidence submitted by the plaintiff there included

a treating physician’s statement that “patient can't function

even sedentary work at present because of flare up of her

fibromyalgia and intensity of pains." Id. at 873. Another of

plaintiff’s physicians submitted that “under her current state

of affairs, she is medically disabled from her job as a

secretary.” Id. at 874.

In reviewing plaintiff’s appeal of the district court’s

disposition in favor of the defendant, the Ninth Circuit first

reiterated that courts “cannot substitute [their] judgment for

the administrator's. [They] can set aside the administrator's

discretionary determination only when it is arbitrary and

capricious.” Id. at 875. It explained that “a decision grounded

on any reasonable basis is not arbitrary or capricious, and that

in order to be subject to reversal, an administrator's factual

findings that a claimant is not totally disabled must be clearly

erroneous. Id. (internal quotations and citations omitted). 

The Ninth Circuit determined that the denial of the

plaintiff’s benefits was not unreasonable. First, it concluded

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that the evidence submitted by her physicians regarding her

physical work limitations were “nothing but their ipse dixit to

substantiate the claim.” Id. at 877. Although these doctors’

reports stated that she was unable to work due to her medical

condition, they never “explain[ed] why.” Id. at 874. The court

gave great weight to the fact that the defendant requested from

plaintiff’s physicians objective evidence to support their

conclusory statements and that they failed to comply with this

request. The court explained that “the failure of an employee's

physician to respond to inquiries by the plan administrator

undermine[s] evidence in the petitioner's favor.” Id. at 878. 

Accordingly, the court was “bound to treat [plaintiff’s]

treating physicians' opinions that she was disabled by her

fibromyalgia as undermined, which is to say less reliable or

unreliable.” Id. The court then evaluated the record

consisting of: (1) plaintiff’s physicians’ conclusory

statements, which did not explain why or for how long plaintiff

was unable to work, (2) the physicians’ failure to respond to

defendant’s specific request as the functional limitations,

which undermined their reliability, and (3) evidence from

defendant’s independent physicians stating that plaintiff was

not physically limited from all work. It then held that it

could not conclude that the defendant had acted unreasonably in

denying plaintiff long-term disability benefits. 

Defendant contends that Jordan should guide this court’s

decision as to its finding that plaintiff was functionally

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9 Plaintiff contends that defendant erred by not considering

her continuing receipt of Social Security benefits for fibromyalgia

and chronic bronchitis because they are compelling evidence that

she was entitled to LTD benefits. When a court finds substantial

evidence in the administrator’s decision lacking, the court may

weigh a Social Security award in plaintiff’s favor. Madden v. ITT

LTD Plan, 914 F.2d 1279 (9th Cir. 1990); Pierce v. American

Waterworks Co., 683 F.Supp. 996, 1000 (W.D. Pa. 1988).

Here, however, given Dr. Kneapler’s report, the court cannot

find that there was no substantial evidence to support the

administrator’s decision. Thus, the prerequisite for weighing the

Social Security award was lacking.

28

limited from all employment. I must agree. As in Jordan,

plaintiff’s physicians’ statements concluded that her condition

precluded her from working, but never explained what objective

medical evidence supported those conclusions.9 Similarly,

defendant made a specific request to Dr. Agresti to provide it

with the specific information that was missing, and Dr. Agresti

failed to respond. Following Jordan, it was reasonable for

defendant to render Dr. Agresti’s conclusory statements less

reliable. Finally, defendant also had before it medical

evidence casting the diagnoses of the alleged debilitating

conditions into question. Finally, the terms of the Plan made

it clear that it was plaintiff’s burden to produce objective

medical evidence of a Total Disability. As in Jordan, given the

method of analysis mandated, this court cannot conclude that it

was unreasonable for defendant to deny her application for LTD

benefits on the basis that she failed to prove that she was

completely unable to work at any job for which she was or could

become qualified for. Therefore, this court cannot disturb

defendant’s conclusion and replace it with its own judgment,

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because under current doctrine, VPA was within its discretion to

deny the claim. See also Bolling v. Eli Lilly & Co., 990 F.2d

1028, 1029-30 (8th Cir. 1993) ("The [administrator] did not

abuse its discretion merely because there was evidence before it

that would have supported an opposite decision."); Eley, 945

F.2d at 279 (no abuse of discretion to deny benefits despite

expert evidence showing that a certain procedure was diagnostic

and therefore was covered by the plan); Sandoval v. Aetna Life

and Cas. Ins. Co., 967 F.2d 377 (10th Cir. 1992)(no abuse of

discretion to deny benefits despite report by one doctor

concluding that plaintiff was totally disabled).

V.

CONCLUSION

Defendant’s motion for summary judgment is GRANTED and

plaintiff’s motion for summary judgment is DENIED. If reopened

on remand from the Circuit, the Clerk is directed to close the

case.

IT IS SO ORDERED.

DATED: August 18, 2005.

/s/Lawrence K. Karlton 

LAWRENCE K. KARLTON

SENIOR JUDGE

UNITED STATES DISTRICT COURT

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