Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-caed-2_03-cv-02306/USCOURTS-caed-2_03-cv-02306-1/pdf.json

Nature of Suit Code: 110
Nature of Suit: Insurance
Cause of Action: 29:1001 E.R.I.S.A.: Employee Retirement

---

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

1

IN THE UNITED STATES DISTRICT COURT

FOR THE EASTERN DISTRICT OF CALIFORNIA

ROY TANIGUCHI,

Plaintiff, No. CIV S-03-2306 KJM 

vs.

THE PRUDENTIAL INSURANCE ORDER

COMPANY OF AMERICA,

Defendant.

 /

Defendant’s motion for summary judgment came on regularly for hearing on

August 24, 2005. Michael Babitzke appeared for plaintiff. Dennis Rhodes appeared for

defendant. Upon review of the documents in support and opposition, upon hearing the

arguments of counsel, and good cause appearing therefor, THE COURT FINDS AS FOLLOWS:

I. Facts

Plaintiff, Roy Taniguchi, worked as a process operator for Corn Products, Inc.

which required plaintiff to monitor a product line. Pl.’s Resp. to Statement of Undisputed

Case 2:03-cv-02306-KJM Document 48 Filed 10/28/05 Page 1 of 8
1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

1

 “DF” is used here to reference disputed facts or plaintiff’s explanations in response to

undisputed facts. 

2

 Pages of the Record Transcript are attached to the Decl. of Laura Hannan, lodged on

May 19, 2005. 

2

Material Facts (“DF”1), no. 27. Over the course of sixteen years, plaintiff took 1-2 hour naps

during his work shifts. Record Transcript (“RT”)2 0151-0152. After being advised by his

employer that he would be terminated for falling asleep on the job one more time, plaintiff

sought long-term disability leave. Def’t’s Statement of Undisputed Material Facts (“SUF”), no.

17. Defendant awarded disability benefits to plaintiff in August 2000 based on plaintiff’s

diagnosis of narcolepsy. SUF, no. 24. However, after learning that plaintiff’s diagnosis had

changed to sleep apnea and that plaintiff was being treated with a CPAP mask, defendant

terminated plaintiff’s disability benefits in August 2001. SUF, nos. 28, 37.

Three times plaintiff appealed defendant’s decision to terminate plaintiff’s

benefits. On the appeal, plaintiff also indicated medical conditions other than sleep disorders that

made him unable to perform his job. SUF, nos. 29-31. Defendant denied each appeal and

plaintiff filed this suit under ERISA, 29 U.S.C. § 1132(a)(1)(B). 

II. Standard of Review

The parties dispute the applicable standard of review. Defendant seeks

application of the abuse of discretion standard under which the court will uphold the plan

administrator’s denial of benefits unless the determination was made in an arbitrary and

capricious manner. Alternatively, plaintiff seeks de novo review.

When a party challenges a denial of benefits under 29 U.S.C. § 1132(a)(1)(b), the

standard of review is de novo “unless the benefit plan gives the administrator or fiduciary

discretionary authority to determine eligibility for benefits or to construe the terms of the plan,”

in which case the standard is abuse of discretion. Firestone Tire & Rubber Co. v. Bruch, 489

U.S. 101, 115 (1989); see also Atwood v. Newmont Gold Co., Inc., 45 F.3d 1317 (9th Cir. 1995). 

Case 2:03-cv-02306-KJM Document 48 Filed 10/28/05 Page 2 of 8
1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

3

 The ERISA Statement is a five page document beginning on page 26 of the Plan

Booklet. The first paragraph of the first page of the ERISA Statement states:

This Group Contract underwritten by The Prudential Insurance

Company of America provides insured benefits under your

Employer’s ERISA plan(s). The Prudential Insurance Company of

America as Claims Administrator has the sole discretion to

interpret the terms of the Group Contract, to make factual findings,

and to determine eligibility for benefits. The decision of the

Claims Administrator shall not be overturned unless arbitrary and

capricious. 

RT0041. 

3

The benefit plan must explicitly state or clearly imply that the administrator has discretionary

authority, in order for the court to apply the discretionary standard of review. Walker v.

American Home Shield Long Term Disability Plan, 180 F.3d 1065, 1070 (9th Cir. 1999) (“When

an ERISA plan administrator cannot exercise discretionary power because the plan confers none,

the more deferential standard of review is inappropriate. Because the UNUM plan at issue does

not state or imply that the administrator’s factual findings or determinations of eligibility are

entitled to deference, we will not read such terms into the plan.” (citation omitted)). 

In the instant case, the court reviews de novo the decision to terminate benefits. In

attempting to prove that the discretionary standard applies, defendant relies on the disclosure in

the ERISA Statement,3 which purports to give the administrator discretionary authority to

determine eligibility for benefits. However, for the reasons described below, the court finds that

the ERISA Statement is not part of the benefit plan document. Therefore, in accordance with

Walker, the de novo standard applies. Id. 

Ambiguity in an ERISA insurance contract is construed against the drafter. 

McClure v. Life Ins. Co., 84 F.3d 1129, 1134 (9th Cir. 1996). In this case, defendant created 

/////

Case 2:03-cv-02306-KJM Document 48 Filed 10/28/05 Page 3 of 8
1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

4

 The Foreword of the Booklet states:

We are pleased to present you with this Booklet. It describes the

Program of benefits we have arranged for you and what you have

to do to be covered for these benefits. ... IMPORTANT NOTICE ...

This Booklet and the Certificate of Coverage made a part of this

Booklet together form your Group Insurance Certificate. 

RT0016. 

5

 The Group Insurance Certificate consists of the Booklet and the Certificate of Coverage.

The Booklet does not specify what purpose the Group Insurance Certificate serves. See

RT 0016.

6

 The page of the Booklet immediately preceding the ERISA Statement contains a total of

three lines of text, in large bold font, stating, “This ERISA Statement is not part of the Group

Insurance Certificate.” RT 0040.

4

ambiguity in two ways. First, by including the ERISA statement in the Booklet,4 which

comprises part of the Group Insurance Certificate,5 while stating that the ERISA Statement is not

part of the Group Insurance Certificate,6 defendant created an ambiguity as to whether the ERISA

Statement is intended to be a binding document. Second, it is unclear whether the Group

Insurance Certificate alone is the benefit plan document. By pointedly excluding the ERISA

Statement from the Group Insurance Certificate, defendant appears to treat the Group Insurance

Certificate as a special group of documents. A reasonable person could conclude that such a

special group of documents likely constitutes the benefit plan. Winterrowd v. Am. Gen. Annuity

Ins. Co., 321 F.3d 933, 938-39 (9th Cir. 2003) (“An ERISA plan . . . must enable reasonable

persons to ‘ascertain the intended benefits, beneficiaries, source of financing, and procedures for

receiving benefits.’” (citation omitted)). At the very least, an ambiguity is created, which the

court construes against defendant in determining the Group Insurance Certificate to be the benefit

plan document, from which the ERISA Statement is excluded. Because the only indication of the

administrator’s discretionary authority is not included in the benefit plan document, the de novo

standard of review applies. 

Applying the de novo standard in a motion for summary judgment regarding

Case 2:03-cv-02306-KJM Document 48 Filed 10/28/05 Page 4 of 8
1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

7

 In certain circumstances the court may exercise its discretion to consider additional

evidence. “The district court should exercise its discretion, however, only when circumstances

clearly establish that additional evidence is necessary to conduct an adequate de novo review of

the benefit decision.” Mongeluzo, 46 F.3d at 944 (quoting Quesinberry v. Life Ins. Co., 987 F.2d

1017, 1025 (4th Cir.1993)). In this case, plaintiff conceded at hearing that there is no other

material evidence.

5

ERISA, the court views the evidence in the light most favorable to the non-moving party, and

determines whether there are any genuine issues of material fact based on the record before the

plan administrator.7 Mongeluzo v. Baxter Travenol Long Term Disability Benefit Plan, 46 F.3d

938, 942 (9th Cir. 1995) (under de novo standard, court does not consider whether there was

substantial or ample evidence to support the plan administrator’s decision). 

III. Analysis

In the present case, plaintiff fails to raise a triable issue of material fact. 

Defendant considered plaintiff’s claims that he suffered from diabetes 2, high blood pressure,

high cholesterol, arthritis, neuropathy in legs and feet, stomach disorder, depression, poor eye

sight, a history of pain in his back and neck, hepatitis A, difficulty breathing, and sleep apnea. 

The record contains the independent review of plaintiff’s medical records regarding these

conditions, which was conducted by Douglas W. Martin, M.D.; Dr. Martin provided an in-depth

analysis consisting of eleven pages. RT0127-0137. Dr. Martin found “there is insufficient

medical documentation to support limitations from performing the job that has been described by

the company [plaintiff] works for.” RT0127. Plaintiff submitted no further medical

documentation after Dr. Martin’s review. SUF, no. 67; RT0103-0104. Moreover, plaintiff

previously had worked with all of the above-mentioned health conditions and there had not been

a significant worsening of his conditions since the onset of disability. SUF, no. 39. 

In the administrative appeals and in the briefing before this court, plaintiff has

pressed that the basis of his disability is a sleep disorder. Plaintiff asserts that he still suffers

from “episodes of sleepiness” that prevent him from substantially performing his job, which is

largely sedentary in nature and conducive to sleeping. DF, no. 37. Plaintiff was warned prior to

Case 2:03-cv-02306-KJM Document 48 Filed 10/28/05 Page 5 of 8
1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

8

 Plaintiff told Dr. Kim he has been taking “naps” while on the job for about 16 years,

that he took naps when he felt sleepy, and that he “never fell asleep at the wheel.” RT0151-0152. 

9

 As to the alleged medical conditions other than sleep apnea, as noted above, Dr. Martin

reviewed plaintiff’s specific job description and found these conditions would not limit plaintiff

in performing his job. RT0127. Moreover, plaintiff had successfully performed the very job for

which he was claiming he was disabled, with the same medical conditions that remained

unchanged. SUF, no. 39.

6

his disability leave that he would be terminated if he fell asleep on the job one more time. SUF,

no. 17. However, plaintiff admits that the CPAP mask has been effective and that he does not

suffer from “sleep attacks.” SUF, no. 37. Thus, there is no evidence to create an issue of

material fact regarding whether plaintiff has narcolepsy or unavoidably falls asleep after use of

the CPAP mask and/or medication. 

No treating physician has opined that plaintiff cannot perform his job due to a

sleep disorder. The most recently documented medical examination of plaintiff was conducted

by Karen Kim, M.D. on October 29, 2001. Dr. Kim wrote a “functional assessment” of plaintiff,

which did not indicate plaintiff’s sleep apnea would limit his ability to work.8 RT0156. Plaintiff

also submitted questionnaires completed by three of his treating physicians: Dr. Ali, Dr. Kobrin,

and Dr. Kake. The court finds these doctors’ opinions, as expressed in the questionnaires, do not

raise a triable issue of material fact. On the questionnaires, each of these three doctors checked a

“no” box for the question, “When just considering the cardiac condition, sleep disorder, and

severe neuropathy in his extremities, do you believe that Mr. Taniguchi is capable of being

competitive in an 8 hour per day work environment on a regular 5 day per week basis?” 

RT0157-0159. Because this question lists three possible causes of disability, however, these

doctors’ opinions are inconclusive as to plaintiff’s sleep disorder being disabling.9 Moreover,

none of the doctors reviewed a specific description of plaintiff’s job duties; such a review would

have been necessary to determine whether plaintiff could perform his job. RT0157-0159. More

specifically, each doctor fails to indicate that the plaintiff is being treated by that doctor for a

sleep disorder. Dr. Ali states that he defers to the neurologist. RT0157. Dr. Kobrin does not

Case 2:03-cv-02306-KJM Document 48 Filed 10/28/05 Page 6 of 8
1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

7

make reference to plaintiff’s sleep disorder at all. RT0158. Dr. Kake states that plaintiff is being

treated for narcolepsy by another medical doctor. RT0159. For these reasons, these doctors’

evaluations do not raise a triable issue as to whether plaintiff has a disabling sleep condition. 

Plaintiff was found eligible for Social Security Disability benefits effective

December 29, 1999. However, there is no evidence in the record regarding the basis for the

award of Social Security Disability. The standards for determining disability under Social

Security are different from those under ERISA. Black & Decker Disability Plan v. Nord, 538

U.S. 822, 831 (2003). An award of Social Security benefits alone does not compel a finding that

plaintiff is entitled to benefits under the specific terms of an ERISA plan.

IV. Attorney’s Fees

Defendant moves for an award of attorney’s fees under 29 U.S.C. § 1132(g)(1).

There are five factors for determining whether to award attorney’s fees: 1) whether there is a

requisite degree of opposing party’s culpability or bad faith; 2) whether the opposing party has

the ability to satisfy an award of fees; 3) whether an award of fees against the opposing party

would deter others from acting under similar circumstances; 4) whether the party requesting fees

sought to benefit all participants and beneficiaries of an ERISA plan or to resolve a significant

legal question regarding ERISA; and 5) whether the relative merits of the parties’ positions

warrant an award of fees. Hummell v. S.E. Rykoff & Co., 634 F.2d 446, 453 (9th Cir. 1980.) 

Upon review of these factors, the court finds an award of attorney’s fees is not

warranted in this case. There is no indication plaintiff has brought the action in bad faith; 

defendant previously had placed plaintiff on disability leave for narcolepsy and it appears that

plaintiff still suffers from episodes of sleepiness. Plaintiff has succeeded in persuading the court

that the ERISA statement is not part of the plan document, which has resulted in the de novo

review plaintiff sought. There is no reason to deter litigation of this nature through an award of

fees.

/////

Case 2:03-cv-02306-KJM Document 48 Filed 10/28/05 Page 7 of 8
1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

8

For the foregoing reasons, IT IS HEREBY ORDERED that:

1) Defendant’s motion for summary judgment is granted;

2) Defendant’s motion for attorney’s fees is denied; and

3) This action is dismissed. 

DATED: October 27, 2005.

______________________________________

UNITED STATES MAGISTRATE JUDGE

Case 2:03-cv-02306-KJM Document 48 Filed 10/28/05 Page 8 of 8