Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-caed-2_01-cv-00878/USCOURTS-caed-2_01-cv-00878-2/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

----oo0oo----

BRUCE KNIESPECK, 

CIV. NO. S-01-0878 WBS PAN

Plaintiff,

v. FINDINGS OF FACT, CONCLUSIONS

OF LAW, AND ORDER

UNUM LIFE INSURANCE COMPANY OF

AMERICA, et al.,

Defendants.

----oo0oo----

Plaintiff Bruce Kniespeck brings this action under the

Employee Retirement Income Security Act (“ERISA”) to recover

benefits under an employee benefits plan. See 29 U.S.C. §

1132(a)(1)(B). More specifically, plaintiff contends that he

was wrongfully denied benefits on a group long-term disability

policy issued by defendant UNUM Life Insurance Company of

America (“UNUM”).

By stipulation, the trial of this case was bifurcated

into two phases, the second phase being a calculation of

benefits due. On December 18, 2006, trial on the second phase

was held by this court, sitting without a jury, on the

administrative record according to the procedure set forth in

Kearney v. Standard Ins. Co., 175 F.3d 1084 (9th Cir. 1999) (en

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The following facts are undisputed. They are all derived 1

from the administrative record (hereinafter “UACL”). (UACL 00013 -

02439, UAPO 001 - 025.)

2

banc), cert denied, 528 U.S. 964 (1999). This court, having

read and considered the documentary evidence and the written

submissions of the parties, now makes the following Findings of

Fact and Conclusions of Law pursuant to Rule 52 of the Federal

Rules of Civil Procedure.

FINDINGS OF FACT1

1. Plaintiff Kniespeck was employed as a Master

Scheduler/Planner for Nevada Western Supply, Inc. (“Nevada

Western”). (UACL 00429.)

2. At all relevant times, plaintiff was insured

under a group long-term disability insurance policy (“the

Policy”) issued by defendant UNUM to Nevada Western. (UACL

01866 - 01890.)

3. The relevant portions of the Policy are as

follows:

SECTION II - DEFINITIONS

For the purposes of this policy:

“Disability” and “disabled” mean that because of

injury or sickness:

1. the insured cannot perform each of the material

duties of his regular occupation; and

2. after benefits have been paid for 24 months, the

insured cannot perform each of the material

duties of any gainful occupation for which he is

reasonably fitted by training, education or

experience.

* * *

“Partial disability” and “partially disabled” mean

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that because of injury or sickness the insured, while

unable to perform all the material duties of his

regular occupation on a full-time basis, is:

1. performing at least one of the material duties of

his regular occupation or another occupation on a

part-time or full-time basis; and

2. earning currently at least 20% less per month

than his indexed pre-disability earnings due to

that same injury or sickness.

* * *

SECTION IV - BENEFITS

DISABILITY

When the Company receives proof that an insured is

disabled due to sickness or injury and requires the

regular attendance of a physician, the Company will

pay the insured a monthly benefit after the end of the

elimination period. The benefit will be paid for the

period of disability if the insured gives the Company

proof of continued:

1. disability; and

2. regular attendance of a physician.

The proof must be given upon request and at the

insured’s expense.

* * *

PARTIAL DISABILITY

When proof is received that an insured is partially

disabled within 31 days of the end of a period during

which he received disability benefits the Company will

pay a monthly benefit. The partial disability must

result from the injury or sickness that caused the

disability.

* * *

MONTHLY BENEFIT

* * *

Proof of the insured’s monthly earnings must be given

to the Company on a quarterly basis. Benefit payments

will be adjusted upon receipt of this proof of

earnings.

* * *

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SECTION VI - GENERAL POLICY PROVISIONS

F. NOTICE AND PROOF OF CLAIM

* * *

2. Proof

a. Proof of claim must be given to the

Company. This must be done no later

than 90 days after the end of the

elimination period.

* * *

c. Proof of continued disability and

regular attendance of a physician must

be given to the Company within 30 days

of the request for the proof.

* * *

G. EXAMINATION

The Company, at its own expense, will have the

right and opportunity to have an employee, whose

injury or sickness is the basis of a claim:

1. examined by a physician, other health

professional, or vocational expert of its

choice; and/or

2. interviewed by an authorized Company

representative.

(UACL 01866 - 01890.)

4. On July 6, 1989, plaintiff was injured when he

fell down a set of stairs at work. (UACL 02312.)

5. As a result of spinal and other injuries

sustained in the fall, plaintiff ceased working on September 13,

1989. (UACL 00429.)

6. Plaintiff was certified as disabled by a board

certified neurosurgeon, Dr. Stanton Schiffer, M.D., on September

14, 1989, and again on October 30, 1989, as a result of lumbar

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cervical radiculopathy, lumbar disc protrusion, and cervical

disc protrusion. (UACL 02249.)

7. On November 22, 1989, plaintiff filed a claim,

with an attached Attending Physician Statement (“APS”) by Dr.

Schiffer, for disability benefits with UNUM. (UACL 00429,

02311.)

8. Plaintiff’s claim was granted, and on December

13, 1989, plaintiff began receiving disability benefits

supported by the necessary certifications, APSs, and other

documents submitted to UNUM. (Id.)

9. Over the course of the next five or six years,

plaintiff underwent four surgeries related to his injuries,

including:

a. lumbar percutaenous discectomy at L4-5 in

December, 1989;

b. left shoulder impingement operation in October,

1990;

c. bilateral laminectomy and bilateral disc excision

and lumbar laminectomy at L4-5 and L5-S1 in

March, 1991; and

d. anterior cervical discectomy and interbody fusion

at C6-7 in October, 1995. 

(UACL 00699.)

10. On December 12, 1992, plaintiff’s treating

neurosurgeon, Dr. Schiffer, provided a detailed medical history

and evaluation of plaintiff’s disability status, in which he

indicated that “[i]t has now been three and a half years since

Mr. Kniespeck’s original date of injury. I feel that he has

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reached a level of permanent disability where there will be

minimal changes in improvement . . . Chances of future

employment for Mr. Kniespeck are practically nil. With his

history of neck pain which continues to persist and his prior

surgeries of the left shoulder and the lumbar spine, there are

few employers who would be interested in assuming the liability

of hiring such an individual. (UACL 01850 - 01851.)

11. On June 1, 1993, as part of a supplemental claim

statement (UACL 01834), plaintiff’s primary care physician, Dr.

Rajiv Pathak, M.D., submitted an APS, which indicated ongoing

neck, arm, and lower-back pain, as well as weakness in

plaintiff’s left shoulder and both legs. (UACL 01835.) Dr.

Pathak also indicated that plaintiff had a “fair” prognosis for

recovery, but that significant changes, if any, would not occur

within six months. (Id.)

12. In a subsequent September 2, 1993, letter, Dr.

Pathak noted that plaintiff was experiencing pain in his neck,

lower back, and left shoulder and a limited range of motion in

his shoulder. As a result, he “can sit for a total of six hours

but not more than 30 minutes at a time. I would recommend at

least 10-15 minutes rest thereafter. He can walk for a total of

four hours with rest. He can lift up to 20 pounds on occasion,

and can occasionally bend, stoop, squat, kneel and climb steps.” 

(UACL 01812-01813.) Dr. Pathak refused, however, to opine as to

patient’s ability to perform the duties of several occupations,

including “assistant buyer, production planner, and purchasing

agent,” as complete job descriptions thereof had not been

provided to him. (Id.)

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a non-existent “Dr. Kujir.” (Pl.’s Trial Brief 21.)

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13. On January 6, 1994, plaintiff was discharged from

Fit to Work, a work hardening program, which indicated in its

discharge summary that plaintiff’s physical limitations rendered

him incapable of meeting the job requirements of a Master

Scheduler/Planner. (UACL 01671.)

14. On January 27, 1994, Dr. Pathak diagnosed

plaintiff with: 1) cervical strain; 2) trapezius myositis; 3)

left shoulder strain; 4) muscle contraction headache; and 5)

mild bilateral carpal tunnel syndrome. Dr. Pathak further

stated that he did not foresee any significant improvement in

the near future. (UACL 01672.)

15. On August 10, 1994, plaintiff submitted a

supplemental claim statement, with an APS by Dr. Pathak echoing

his previous determination. (UACL 01669.)2

16. On June 22, 1995, neurosurgeon Dr. Franklin

Wagner, M.D., prepared a “physical capacities evaluation form”

for UNUM regarding plaintiff, which noted various limitations in

sitting, standing and lifting, and concluded that plaintiff was

disabled and incapable of performing even part-time work. (UACL

01581-01582.)

17. On October 25, 1995, Dr. Wagner performed a neck

surgery (a C6-7 anterior cervical discectomy and interbody

fusion) on plaintiff. (UACL 01560.) Dr. Wagner indicated to

UNUM that the “surgery was successful and the prognosis is good

for the patient to return to full time employment. The normal

recovery period for this type of surgery is two months.” (Id.)

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18. On April 26, 1996, Dr. Wagner provided a

certificate of disability to UNUM, indicating that plaintiff was

completely disabled, but that recovery was expected around

approximately September 1, 1996. (UACL 01552.)

19. On May 24, 1996, the Social Security

Administration issued a decision regarding plaintiff’s appeal of

the denial of his claim for disability benefits under the Social

Security Act. (UACL 01526-01537.) The Administrative Law Judge

concluded that plaintiff became disabled as a result of his July

6, 1989, injury, but that his disability ceased as of December

21, 1995. (UACL 01537.) 

20. The judge commented that the “medical evidence

establishes that the claimant has experienced significant

improvement in his left shoulder and neck symptomology

following” the October 25, 1995, surgery. (UACL 01536.) 

Although plaintiff continued to experience lower back pain and

discomfort, the judge determined that plaintiff had the

“capacity to perform a full range of sedentary work.” (Id.)

21. On February 25, 1997, Pride Industries, a

vocational rehabilitation program, reported on a four-day

vocational evaluation, and concluded that plaintiff was likely

not “feasible for full time employment.” (UACL 01391.) The

report did indicate, however, plaintiff’s “desire to work” and

his “willingness to work in a flexible schedule” that might

enable him to work part time.

22. On May 1, 1997, plaintiff notified UNUM that he

was claiming “partial disability,” based on the fact that he had

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begun working part-time for his self-run company Comp-U-Mart. 

(UACL 01080.)

23. On September 10, 1998, defendant UNUM closed

plaintiff’s file, and terminated his claim for disability

benefits. (UACL 00944, 01143.)

24. UNUM’s denial was based on plaintiff’s “failure

to provide proof of an ongoing impairment,” citing the portion

of the Policy under “DISABILITY” which required that he “be

under the regular care of a physician” and that he “provide

proof of a continuing disability.” (UACL 01143.)

25. On January 4, 2000, plaintiff submitted a

supplemental claim statement, along with a doctor’s certificate

by a chiropractor, Dr. Marvin Abbott, M.D., stating that

plaintiff was permanently disabled, and without possibility for

recovery. (UACL 00886-00887.)

26. Plaintiff appealed UNUM’s denial of his claim for

disability benefits, which was subsequently denied on May 18,

2000. (UACL 00959.)

27. Thereafter, plaintiff filed this action under

ERISA, 29 U.S.C. § 1132(a)(1)(B), for breach of the Policy,

seeking to recover disability benefits. (Compl.)

28. This court bifurcated the trial: the first phase

was limited to the issue of the correctness of UNUM’s decision

to terminate plaintiff’s benefits for failure to prove continued

disability and regular attendance of a physician, while the

second phase was reserved for determining benefits, if any, due

plaintiff. (March 19, 2002 Pretrial Order.)

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28 Plaintiff did not file tax returns for these two years, 3

because his income was below the minimum amount required to file.

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29. On May 29, 2002, this court ruled in the first

phase of trial that defendant’s denial of plaintiff’s disability

claim was improper. (May 29, 2002 Order.) Specifically, the

court determined that after May 1, 1997, plaintiff’s claim

should have been processed as one for “partial disability” not

“total disability,” and that under the Policy a claim for

partial disability does not require plaintiff to submit proof of

continued disability and regular attendance of a physician. 

(Id.) The court remanded the matter back to defendant for

reconsideration consistent with its findings. (Id.)

30. Pursuant to this court’s order, defendant

commenced a reconsideration of plaintiff’s claim for partial

disability by requesting information related to his work

activities. (UACL 00897.)

31. In response, plaintiff provided tax returns for

1997, 1998, and 1999, which indicated gross revenues of $4,250,

$11,851, and $14,451, respectively. (UACL 00836 - 00837.)

32. Plaintiff further informed defendant that a

reasonable estimate of his monthly earnings in 2000 - 2001 was

approximately $100 per month, but that the loss of his computer

prevented him from providing documentation to that effect.3

(UACL 00838 - 00840).

33. On November 2, 2002, Vicki Riggs, UNUM’s internal

CPA, did a calculation based on the income information provided

by plaintiff, and concluded that because plaintiff sustained an

overall earnings loss, he would be entitled to full monthly

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benefits of $1,717.20 per month after May 1, 1997. (UACL 00837,

001625.)

34. In a subsequent letter, plaintiff provided

defendant with a receipt book for 2002 and 2003, evidencing 18

sales transactions between June, 2002, and September, 2003, each

averaging approximately $10 - $15. (UACL 00737 - 00755.)

35. On January 19, 2004, Dr. Frank Kanovsky conducted

a brief overview of the case and concluded that there was

insufficient evidence to make a determination as to work

capacity. He recommended that plaintiff undergo an independent

medical examination (“IME”) as well as a functional capacity

evaluation (“FCE”). (UACL 00691.)

36. Because of difficulties scheduling an IME, on

April 8, 2004, Dr. Kanovsky performed a comprehensive review of

plaintiff’s medical file. Dr. Kanovsky noted plaintiff’s

significant complaints of pain, but observed that plaintiff did

not take any regular pain medication, and that his symptoms

indicated a “non-anatomical distribution.” Dr. Kanovsky again

indicated his opinion that an IME as well as other diagnostic

studies would aid in a more complete analysis. (UACL 00700.) 

37. On July 13, 2004, an IME and medical record

review was conducted by Dr. Ronald Wolfson, M.D., a board

certified orthopedic surgeon. (UACL 00525.)

38. Dr. Wolfson’s August 11, 2004, report indicated

that plaintiff presented significant subjective complaints, but

that the “objective factors of disability are more difficult to

determine.” (UACL 00536.) While he noted that there were no

clear-cut signs of exaggeration, “clearly the subjective

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complaints are much worse than they were ever noted even before

surgery.” (Id.) Dr. Wolfson suggested that additional x-ray

and MRI diagnostic tests be performed. (Id.)

39. On September 24, 2004, plaintiff underwent

multiple x-ray and MRI tests, which showed mild impingment of

the left shoulder (UACL 00489), narrowing of the C5-C6 disk

space (UACL 00491), mild disc bulge at C5-C6 (UACL 00485),

fusion of C6 and C7 (Id.), a small amount of spurring

posterolaterally to the left side of C4-C5 with slight

encroachment upon the left neural foramen (UACL 00487),

spondylolisthesis of L4 upon L5 and slight posterior

sublixuation of L5 upon S1 (Id.), and soft tissue intrusion into

the anterior epidural space to the left of midline of L4-L5.

(Id.)

40. Dr. Wolfson reviewed these diagnostic studies,

and issued a supplemental report, in which he concluded that

“Mr. Kniespeck’s subjective complaints are way out of proportion

to his objective findings on the diagnostic studies. It is my

belief, after reviewing the studies that this man is able to

work full-time in the computer repair business . . . .” (UACL

00494.)

41. On January 21, 2005, Dr. Kanovsky reviewed Dr.

Wolfson’s reports, as well as the x-ray and MRI films. (UACL

00479.) He noted that for someone with his symptoms,

plaintiff’s lack of the need for pain medication, as well as his

decision to limit his treatment to occasional chiropractic

visits, undermined the credibility of his subjective complaints. 

(Id.) Dr. Kanovsky indicated his agreement with Dr. Wolfson’s

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Plaintiff contends that Mr. Gray’s report was issued on 4

November 2, 2005, however, the document itself shows a date of

November 2, 2003.

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conclusions that plaintiff was capable of working eight hours a

day, five days a week. (UACL 00471.) 

42. On February 9, 2005, Dr. Lee Snook M.D.,

conducted a full independent medical examination, in which he

reviewed the file and complete medical record and conducted a

physical evaluation of plaintiff. (UACL 00463 - 00468.) Dr.

Snook concluded that plaintiff “is permanently disabled and is

unable to return to the work force in a full-time capacity.” 

(UACL 00467.)

43. On March 15, 2005, Dr. Wolfson reviewed Dr.

Snook’s report, and disagreed with his conclusions. (UACL

00092.) Dr. Wolfson stated that “Dr. Snook has given an opinion

based on Mr. Kniespeck’s subjective complaints of pain and may

have overlooked the objective findings in the case.” (Id.)

44. On May 11, 2005, UNUM issued its decision to deny

further benefits to plaintiff based on the reports of Drs.

Kanovsky and Wolfson, concluding that plaintiff was neither

partially nor totally disabled because he was capable of working

on a full-time basis in a sedentary to light occupation. (UACL

00429-00443.) UNUM also concluded that plaintiff did not

qualify as “partially disabled” because he failed to

sufficiently prove that he was in fact working part-time. (Id.)

45. Plaintiff appealed UNUM’s denial, largely by

providing an FCE performed by a physical therapist, Larry Gray,

two years prior. (UACL 00261 - 00268.) 4

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46. Mr. Gray’s report indicated that plaintiff

likely: 1) could sit for no more than 30 minutes at a time

without a 10 minute rest period; 2) could stand in one position

for no more than 15 minutes without being allowed to change

position; 3) could not reach above 56 inches with his left arm;

4) could not lift certain heavy loads; and 5) could not perform

tasks below knee level. (UACL 00267.) Based on these

limitations, Mr. Gray concluded that plaintiff “would likely

only tolerate part-time work.” (Id.)

47. On December 21, 2005, Dr. Wolfson issued a

supplemental report reviewing Mr. Gray’s FCE report, in which he

disagreed with Mr. Gray’s conclusions. (UACL 00237 - 00239.) 

In relevant part, Dr. Wolfson opined that the FCE was not

objective, and expressed nothing more than Mr. Gray’s opinion

based on plaintiff’s subjective reporting. (Id.)

48. On December 28, 2005, Dr. Snook reviewed Dr.

Wolfson’s supplemental report, and expressed his disagreement

with Dr. Wolfson’s critiques of the FCE procedure. (UACL 00208

- 00210.) Dr. Snook stated “[t]here is multiple evidence on the

MRI and x-rays of spondylosis with degenerative disk disease,

degenerative joint disease, and previous surgeries. These alone

in a chronic pain practice are strongly correlated with chronic

pain presentations and attendant limitations.” (UACL 00210.) 

Dr. Snook also noted that pain “is in large part a subjective

perception,” and thus is not something which can easily be

objectified or quantified. (Id.)

49. On January 6, 2006, Dr. Charles Sternberg, a

board certified neurosurgeon, performed a review of plaintiff’s

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medical history and claim file, and determined that plaintiff

was capable of sustaining “sedentary/light work with

accommodation to prevent overhead reaching with the left upper

extremity, minimize repetitive flexion-extension movements of

the neck, and allow changes in position as necessary for

comfort.” (UACL 00219.) Dr. Sternberg also indicated his

opinion that the FCE report performed by Mr. Gray “did not

provide standardized measures of validity testing in any way.” 

(Id.)

50. On February 27, 2006, Mr. Gray responded to Dr.

Wolfson’s critiques of the FCE, by noting that he employs a

“kinesio-psychological” method, which means that a trained

professional “is in total control of the tests and results at

all time” and that “subjective reports are taken into

consideration, but if they are not associated with objective

findings and observations they then have no value.” (UACL

00083.)

51. On March 14, 2006, Dr. Sternberg responded to Mr.

Gray’s letter of February 27, 2006, and noted that Mr. Gray’s

style of FCE depends on the client’s “self reporting of ability

combined with the evaluator’s observation of performance. Mr.

Gray’s system does not document objective physiological

parameters . . . nor does it provide documentation of the

claimant’s consistency of effort.” (UACL 00037 - 00038.) He

further states that much of the report lacks “medical

credibility,” and fails to give a “credible objective evaluation

of the claimant’s functional capacity.” (Id.)

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52. At some point in March, 2006, Richard Byard, a

vocational rehabilitation consultant, conducted a review of

plaintiff’s restrictions and limitations, as well as his work

history, and concluded that plaintiff would be a viable

candidate for several occupations for which he had adequate

training and experience. (UACL 00087 - 00088.)

53. On April 5, 2006, UNUM denied plaintiff’s appeal

of his adverse claim determination, based again on their belief

that: 1) he was capable of performing sedentary to light work

full-time; and 2) that his activities selling computer parts did

not constitute part-time work.

CONCLUSIONS OF LAW

1. ERISA provides for judicial review of a decision

to deny benefits to an ERISA plan beneficiary. See 29 U.S.C. §

1132(a)(1)(B).

2. ERISA creates federal court jurisdiction to hear

such a claim. See 29 U.S.C. § 1132(e).

3. ERISA benefits determinations are to be reviewed

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.” Firestone v.

Burch, 489 U.S. 101, 115 (1989). An administrator has

discretion only where it is “unambiguously retained.” Kearney,

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

1325 (9th Cir. 1992)). As per this court’s previous order, both

parties agree that the Policy contains no such language, and

thus UNUM’s denial is to be reviewed de novo. (May 29, 2002

Order.)

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4. In a de novo review, determining whether

plaintiff is entitled to disability benefits requires the court

to interpret the plan by looking “first to the terms of the plan

itself.” Nelson v. EG & G Energy Measurements Group, Inc., 37

F.3d 1384, 1389 (9th Cir. 1994).

5. “When faced with questions of insurance policy

interpretation under ERISA, federal courts should apply federal

common law.” Padfield v. AIG Life Ins. Co., 290 F.3d 1121, 1125

(9th Cir. 2002) (citing Firestone, 489 U.S. at 110).

6. Under federal law, courts should then interpret

plan terms “in an ordinary and popular sense as would a [person]

of average intelligence and experience.” Allstate Ins. Co. v.

Ellison, 757 F.2d 1042, 1044 (9th Cir. 1985).

7. As this court determined in trial phase one,

plaintiff’s claim should have been considered as one for

“partial disability” benefits after May 1, 1997. (May 29, 2002

Order.) Because defendants did not terminate plaintiff’s

benefits until after that date (September 10, 1998), the

relevant analysis is whether plaintiff was, and continues to be,

entitled to partial disability benefits at the time of their

termination.

8. Unlike “total disability,” a claim for “partial

disability” does not require that plaintiff submit proof of

continued disability or regular attendance of a physician. (May

29, 2002 Order.)

9. Nonetheless, a claimant receiving partial

disability benefits is still subject to the requirement that he

be “unable to perform all the material duties of his regular

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See Riedl v. General Am. Life Ins. Co., 248 F.3d 753, 759 5

n.4 (8th Cir. 2001) (“Although the Social Security Administration’s

determination is not binding, it is admissible evidence to support

an ERISA claim for long-term disability benefits [on de novo

review].”) 

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occupation on a full-time basis” due to “sickness or illness.” 

(UACL 01874.) It is for this reason the Policy provides that,

at its own expense, UNUM has the “right and opportunity to have

an employee, whose injury or sickness is the basis of a claim .

. . examined by a physician.” (UACL 01886.)

10. After review of the administrative record,

including all of plaintiff’s relevant medical history, the court

concludes that plaintiff was and remains unable to perform all

the material duties of his regular occupation on a full-time

basis.

11. The evidence seems clear (and defendant does not

appear to dispute) that prior to plaintiff’s October 25, 1995,

surgery, plaintiff was “totally disabled.” This conclusion is

well supported by numerous reports and disability certifications

by Drs. Schiffer, Pathak, Abbot, and Wagner, as well as the Fit

To Work discharge report and the findings of the Social Security

Administration.5

12. After May 17, 1997, however, plaintiff stopped

submitting regular proof of disability, and apparently the only

regular medical care he sought was an occasional chiropractic

visit to Dr. Abbott.

13. With regard to plaintiff’s physical capabilities,

this court finds plaintiff’s complaints of pain, and

corresponding functional limitations, to be credible, and

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sufficiently supported both by the medical evidence as well as

the evidence of plaintiff’s functional capacity.

14. “On de novo review, a district court may, in

conducting its independent evaluation of the evidence in the

administrative record, take cognizance of the fact (if it is a

fact in the particular case) that a given treating physician has

a ‘greater opportunity to know and observe the patient’ than a

physician retained by the plan administrator.” Jabian v.

Hewlett-Packerd Co., 349 F.3d 1098, 1105 (9th Cir. 2003)

(quoting Black & Decker Disability Plan v. Nord, 538 U.S. 822,

834 (2003)).

15. Counseling against a finding of disability

(either partial or total) are reports by Drs. Kanovsky, Wolfson,

and Sternberg, all of which conclude that plaintiff is capable

of returning to full time work. Notably, of the three, only Dr.

Wolfson examined plaintiff in person, while Drs. Kanovsky and

Sternberg’s reviews were limited to consideration of plaintiff’s

claim file and medical history. 

16. As defendant points out, these doctors’ reports

emphasize the lack of probative objective measures of

plaintiff’s disability, focusing on the diagnostic MRIs and xrays taken in 2004. (Def.’s Trial Br. 21-22.) However,

plaintiff has continued to exhibit physical manifestations of

his injuries.

17. Specifically, in 2004, plaintiff’s x-rays and

MRIs indicated mild impingement of the left shoulder (UACL

00489), narrowing of the C5-C6 disk space (UACL 00491), mild

disc bulge at C5-C6 (UACL 00485), fusion of C6 and C7 (Id.), a

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small amount of spurring posterolaterally to the left side of

C4-C5 with slight encroachment upon the left neural foramen

(UACL 00487), spondylolisthesis of L4 upon L5 and slight

posterior sublixuation of L5 upon S1 (Id.), and soft tissue

intrusion into the anterior epidural space to the left of

midline of L4-L5. (Id.)

18. While defendant, as well as Drs. Kanovsky,

Wolfson, and Sternberg, thus all admit that plaintiff does have

some objective indicators of physiological neck, back, and

shoulder problems (Id. at 8), they contend that these objective

measures do not comport with plaintiff’s subjective pain

complaints.

19. However, a claimant need not present clinical or

diagnostic evidence to support the severity of his pain.

Gonzalez v. Sullivan, 914 F.2d 1197, 1201 (9th Cir. 1990)

(observing that “it is the very nature of excess pain to be out

of proportion to the medical evidence”).

20. In support of his claim for disability, plaintiff

presents the certifications and/or reports of three individuals,

all of whom personally evaluated and treated plaintiff. First,

plaintiff submitted the certification by Dr. Abbott, his regular

treating chiropractor, which concluded that plaintiff was

permanently disabled. Second is the report of Dr. Snook, who

conducted a complete medical history review and IME in 2005, and

concluded that plaintiff was permanently disabled. Finally,

plaintiff submitted a report by Mr. Gray, prepared after a

functional capacity evaluation, which indicated plaintiff’s

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specific limitations and the conclusion that he could likely

only tolerate part-time work.

21. In addition to the physician reports above,

plaintiff also presented the findings of a vocational

rehabilitation program, Pride Industries, which focused

specifically on what tasks and/or jobs plaintiff would be

capable of performing given his physical limitations. As with

the three individuals above who examined plaintiff in person,

the report concluded that plaintiff was not capable of full time

employment.

22. A finding that the claimant lacks credibility

cannot be premised wholly on a lack of medical support for the

severity of his pain. Lester v. Chater, 81 F.3d 821, 834 (9th

Cir. 1995) (“Once the claimant produces medical evidence of an

underlying impairment, the Commissioner may not discredit the

claimant’s testimony as to subjective symptoms merely because

they are unsupported by objective evidence”).

23. While some of the evidence supporting plaintiff’s

claim for disability is admittedly more subjective, it is the

very nature of pain that it cannot be easily measured or proven. 

Cotton v. Bowen, 799 F.2d 1403, 1407 (9th Cir. 1986) (“‘Excess

pain’ is, by definition, pain that is unsupported by objective

medical findings.”) 

24. In this respect, plaintiff presents the more

credible and probative evidence, which focuses specifically on

showing not what objective indicators exist, but what the

effects of those objective indicators are. In particular,

plaintiff’s FCE by Mr. Gray as well as the report by Pride

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Industries go directly to demonstrating what plaintiff would be

capable of in a work environment.

25. This court thus finds that, under the meaning of

the Policy, “because of injury or sickness” plaintiff is “unable

to perform all the material duties of his regular occupation on

a full-time basis.”

26. In addition to this requirement, for “partial

disability” the Policy requires that plaintiff be: 1) performing

at least one of the material duties of his regular occupation or

another occupation on a part-time or full-time basis; and 2)

earning currently at least 20% less per month than his indexed

pre-disability earnings due to that same injury or sickness.” 

(UACL 01874.)

27. Defendant contends that plaintiff’s sales of

spare computer parts after 1999 do not constitute part-time

work, but are instead merely “a hobby or past-time,” and that

plaintiff has failed to provide sufficient “proof” of his

monthly earnings so as to support a claim for partial

disability. (Def.’s Trial Br. 20.)

28. For the years 1997 through 1999, plaintiff

submitted tax returns evidencing gross revenues of $4,250,

$11,851, and $14,451. After 1999, however, plaintiff’s parttime activities suffered a noticeable decline in profitability,

during which asserts he averaged roughly $100 per month in

income over the next two years. In 2002 and 2003, as evidenced

by the receipts in the administrative record, plaintiff’s

business activities were limited one or two sales a month of

various scrapped computer parts, costing between $10 and $20.

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“Proof of the insured’s monthly earnings must be given 6

to the Company on a quarterly basis. Benefit payments will be

adjusted upon receipt of this proof of earnings.” (UACL 01877.)

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29. Reading the language of the Policy in its

“ordinary and popular sense,” Allstate, 757 F.2d at 1044, this

court finds these activities to constitute “part-time” work. 

Undoubtedly, plaintiff’s business transactions are minimal, but

they are nonetheless activities, of the exact same sort that he

carried out with more frequency in years prior, that utilize

plaintiff’s particular area of expertise in order to produce

income. 

30. Plaintiff’s efforts at returning to some sort of

work in spite of his injury cannot act to preclude his claim for

partial disability--indeed, this would run counter to the entire

purpose of the Policy. The success of plaintiff’s claim for

disability benefits cannot be made to turn on the relative

financial success or failure of his part-time venture.

31. Defendant is of course correct that the Policy

requires plaintiff to submit proof of monthly earnings.6

However, the purpose of this requirement is simply to allow UNUM

to properly adjust any benefits, given plaintiff’s supplemental

income.

32. While plaintiff’s evidence of part-time work for

2000 through 2003 is indeed sparse, and does indicate that his

part-time work did not yield a substantial amount of income, it

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Neither party disputes that plaintiff’s part-time income 7

falls well below the Policy requirement of being no more than 80%

of his indexed pre-disability income.

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is nonetheless sufficient to allow UNUM to appropriately adjust

plaintiff’s disability benefits.7

33. Defendant contends that, as a result of this

court’s previous order, plaintiff can now circumvent the

requirements of continuing proof of disability and regular care

of a physician under “total disability,” by simply bringing a

claim for partial disability. (Def.’s Trial Br. 20.)

34. As this court noted in that prior order, however,

such lowered requirements “make[] sense in the overall scheme of

the policy. An insured who is ‘disabled,’ as defined by the

policy, would not be working and therefore more likely to be

under the care of a doctor than someone who is ‘partially

disabled.’” (May 29, 2002 Order.)

35. These are the terms of the Policy, interpreted in

their “ordinary and popular sense,” Allstate, 757 F.2d at 1044,

and it would not be proper for this court to establish an

arbitrary cut-off point at which “part-time” work ceases to be

“part-time” work but instead a hobby or past-time.

36. If at some point it becomes clear that plaintiff

is not engaged in any part-time work, then of course UNUM has a

right to demand proof of continuing disability and regular care

of a physician.

37. However, for the reasons stated above, this court

finds that defendant’s denial of plaintiff’s claim for partial

disability benefits was improper.

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38. Plaintiff’s monthly disability benefits are

$1,717.20 per month, and the period between September 1998 and

December 2006 constitutes 100 months unpaid.

IT IS THEREFORE ORDERED THAT plaintiff’s claim for

partial disability benefits be, and the same hereby is, GRANTED,

in the sum of $171,200.00.

IT IS FURTHER ORDERED THAT plaintiff is entitled to

benefits going forward, conditioned on the requirements of the

Policy as interpreted by this order.

LET JUDGMENT BE ENTERED ACCORDINGLY.

DATED: December 19, 2006

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