Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-azd-2_09-cv-00099/USCOURTS-azd-2_09-cv-00099-0/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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Manriquez’s request for oral argument is denied because oral argument will not aid

the Court’s decision. See Lake at Las Vegas Investors Group, Inc. v. Pac. Malibu Dev., 933

F.2d 724, 729 (9th Cir. 1991).

WO

NOT FOR PUBLICATION

IN THE UNITED STATES DISTRICT COURT

FOR THE DISTRICT OF ARIZONA

Donna Manriquez, 

Plaintiff, 

vs.

Abbott Laboratories Extended Disability

Plan, 

Defendant. 

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No. CV-09-00099-PHX-GMS

ORDER

Pending before the Court are Motions for Summary Judgment filed by Plaintiff Donna

Manriquez (“Manriquez”) (Doc. 42) and Defendant Abbott Laboratories Extended Disability

Plan (“the Plan”) (Doc. 41). As set forth below, the Court denies both Motions and remands

for proceedings consistent with this Order.1

 

BACKGROUND

In November 2005, Manriquez began working as an Occupational Health Nurse at an

Abbott Laboratories (“Abbott”) facility. (Doc. 43 at ¶ 4). As an Abbott employee,

Manriquez was covered by the Plan, which was established for providing both short-term and

long-term disability benefits to eligible employees. (Id. at ¶ 6). Abbott funds the Plan

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through company contributions, which are held in a trust fund and used to pay benefits and

operating expenses. (Id. at ¶ 7). Under the terms of the plan, Lois Lourie (“Lourie”),

Divisional Vice President of Benefit and Wellness at Abbott Laboratories, is the Plan

Administrator. (Id. at ¶ 9). The terms state,

The Plan Administrator will have full power to administer the Plan in all of its

details, subject, however, to requirements of ERISA. Plan benefits will be

paid only if the Plan Administrator decides, in his or her sole discretion, that

the applicant is entitled to them.

(Id. at ¶ 21). Additionally, the Plan gives the Administrator authority to delegate Claim

Administration to a third party. (Doc. 29, Ex. 1). Pursuant to this authority, the Plan

Administrator delegated Claim Administration to Matrix Absence Management, Inc.

(“Matrix”) and gave Matrix discretionary authority to make initial determinations relating

to claims for benefits under the Plan. (Doc. 43 at ¶¶ 11–12). 

According to the Plan, an employee receives benefits if the Plan Administrator

concludes, based on the relevant evidence, that the employee is disabled. The Plan states that

“disabled” or “disability” means:

[T]hat the Participant requires Regular Care and medical evidence indicates

that, due to a Sickness or Injury, the Participant is completely prevented from

performing all the duties required to be performed in the Participant’s own

occupation or employment. 

(Id. at ¶ 15). Under the Plan, a Participant receives “Regular Care” when he or she,

[P]ersonally visits a Physician as often as is medically required, according to

generally accepted medical standards and consistent with the stated severity

of his or her medical condition to effectively manage and treat his or her

Sickness or Injury.

(Id. at ¶ 17). The Plan defines a “Physician” as “a legally qualified and licensed Physician

recognized by the state board to practice medicine in a designated field or specialty who is

practicing within the scope of his or her license.” (Id. at ¶ 16). Provided that each of these

requirements is met, the Plan Administrator has discretion under the Plan to grant or deny

benefits. (Id. at ¶ 21). 

On December 1, 2006, Manriquez filed a request for a Short Term Leave of Absence

with Matrix. (Id. at ¶ 61). Ten days later, Manriquez’s treating physician, Dr. Deborah

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Metzger (a gynecologist), submitted a certification letter describing Manriquez’s alleged

disabling conditions, including Lyme disease, babesiosis, migraines, fatigue, and debilitating

pain. (Id. at ¶ 62, Doc. 42, Ex. 1 at ¶ 2). On December 14, Matrix, with authority from the

Plan Administrator, approved Manriquez’s request. (Doc. 43 at ¶ 63). The next day, Matrix

requested copies of Dr. Metzger’s reports to determine whether Manriquez was eligible for

benefits under the Short Term Medical Leave of Absence Program. (Id. at ¶ 64). Upon

review of the reports, Matrix indicated that it was unable to determine what had caused

Manriquez to become unable to work in November 2006; nonetheless, Manriquez was

approved for short term benefits. (Id. at ¶¶ 66–67). 

On April 13, 2007, Manriquez filed for Long Term Disability under the Plan. (Id. at

¶ 69). In connection with her application for Long Term Disability, Manriquez underwent

a series of medical tests, including blood draws, SPECT scans, MRI scans, and several

physical exams. As of June 2007, Manriquez’s treating physicians, Dr. Metzger, Dr. Steven

Harris (a family practitioner), and Dr. Stephen Flitman (a neurologist), each concluded that

she was unable to work due to debilitating pain and mental anxiety stemming from a slew

of potential infectious diseases, primarily Lyme disease. (Doc. 42, Ex. 1 at ¶¶ 27–48). On

two separate occasions, Manriquez tested positive for Lyme disease using a non-CDC

approved test. (Id. at ¶ 2). 

Manriquez, however, also tested negative for Lyme disease under a Center for Disease

Control test. (Doc. 28, Ex. 2). Thus, Matrix sought an independent evaluation of

Manriquez’s condition and, through a third-party provider, retained Dr. Gary J. Dilla (a

physical medicine and rehabilitation specialist) to conduct an Independent Medical Exam

(“IME”) of Manriquez. (Doc. 43 at ¶ 80). Dr. Dilla performed the IME on June 7 and

concluded that, “[f]rom a pure physical medicine and rehabilitation perspective, and for that

matter, from a neurological perspective based on the clinical evaluation of Dr. Flitman, there

appears to be no evidence of a ‘disabling condition’ as outlined in the referral letter.” (Doc.

30, Ex. 1). Dr. Dilla noted, however, that “[t]he subjective complaints of this individual, and

the diagnoses outlined in the medical records, [were] beyond the scope of [his] medical

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practice” because he lacked the requisite knowledge about Lyme disease and babesiosis to

render an informed diagnosis. Id. Dr. Dilla accordingly recommended that Manriquez seek

advice and treatment from an internal medicine specialist or infectious disease specialist to

confirm whether her Lyme disease and babesiosis diagnoses rendered her disabled. Id.

On June 29, Matrix denied Manriquez’s claim for Long Term Disability Benefits. In

its denial Letter, Matrix summarized the medical reports and concluded that there was

insufficient evidence to support a disability claim. The letter stated,

The basis of our decision, in large part, comes down to your self-reported

complaints versus how those complaints have been objectively quantified to

support a disability. The IME confirms that your claim is essentially based on

those self-reported complaints and could not correlate those complaints to any

objective medical evidence.

(Doc. 30, Ex. 2). The denial further stated, “It is unclear how appropriate treatment for

[L]yme disease can be determined or established by a ‘gynecological medical practice for

women.’” (Doc. 30, Ex. 2). The letter permitted Manriquez to file a written request for

review of the denial and to submit additional medical information from an “appropriate

medical provider for your claimed conditions, such as an internal medicine specialist with

extensive training and experience in the subspecialty of infectious disease.” Id.

On November 4, 2007, Manriquez appealed the denial of benefits and provided

supplemental medical information from Drs. Metzger and Flitman. Additionally, Manriquez

included medical reports from Dr. Stephen Fry (a general practitioner), Richard Randall (a

physical therapist), Marc Walter, Ph.D. (a neuropsychologist), and Robin Generauz, Ph.D.

(a vocational expert). All of these individuals indicated that Manriquez suffered from a

series of medical ailments preventing her from performing any job. (Doc. 42, Ex. 1 at ¶¶

37–57). In considering Manriquez’s appeal, Matrix, through a third party provider,

employed Dr. Howard Choi (a physical medicine and rehabilitation specialist) to conduct

peer reviews of her physicians’ conclusions. (Doc. 43 at ¶ 118). Upon review, Dr. Choi

concluded that there was no objective medical evidence indicating that Manriquez was

physically or mentally impaired. (Id. at ¶ 131). He further concluded that Manriquez’s tests

had been misinterpreted and that she had been receiving improper treatment for her alleged

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ailments. (Id. at ¶ 135). Dr. Choi conceded, however, that Manriquez’s infectious disease

diagnoses were “beyond [his] area of training and expertise to make a firm determination on

this issue.” (Doc. 31, Ex. 3). Matrix subsequently retained Dr. Leonid Topper (a

neurologist) to conduct additional peer reviews of Manriquez’s case. (Id. at ¶ 143). Dr.

Topper came to similar conclusions as Dr. Choi, determining that Manriquez’s medical

evidence gave no clear indication as to why she became unable to work or that she was

functionally impaired from performing her job. (Id. at ¶ 151). Dr. Topper also noted,

“considering [that Manriquez is] suspected [of having] three infectious diseases (Lyme,

Babesiosis, and Bartonelliasis), a consultation with [an] infectious disease specialist would

be expected.” (Doc. 32, Ex. 3). Following the peer reviews, Manriquez’s physicians

reaffirmed their original diagnosis that she had Lyme disease and was functionally impaired

from performing her job.

Matrix denied Manriquez’s appeal on April 21, 2008. (Doc. 43 at ¶ 163). In the

denial letter, Matrix summarized the evidence from all of the aforementioned medical

professionals and concluded that the evidence did not provide “support for what changed to

cause Ms. Manriquez to stop working [on] November 30, 2006. The medical information

does not support a functional impairment that would have caused her to stop working.”

(Doc. 32, Ex. 3). The letter also stated, 

It does not appear that Ms. Manriquez is receiving appropriate treatment for

her medical conditions. While Ms. Manriquez’s providers may be practicing

within the scope of their licensing, the peer reviewers do recommend that Ms.

Manriquez be treated or at least evaluated by an infectious disease specialist.

Id. Nine days later, Manriquez filed a final appeal directly to the Plan, but she provided no

additional medical evidence. (Doc. 43 at ¶ 170). 

During the course of the final appeal, the Plan asked Dr. Dilla to review the

information that Manriquez had submitted since his examination of her in June 2007. (Id.

at ¶ 178). After his August 8, 2008 review, Dr. Dilla concluded that, in spite of her new

evidence, his original conclusion that she was not functionally disabled was still correct. (Id.

at ¶180). The Plan then retained, through MES Solutions, Dr. Peter Mosbach (a

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When, as here, “a plan administrator has failed to follow a procedural requirement

of ERISA, the court may have to consider evidence outside the administrative record.”

Abatie v. Alta Health & Life Ins. Co., 458 F.3d 955, 972–73 (9th Cir. 2006). Accordingly,

on review, this Court may consider not only the administrative record submitted by the

parties, but also evidence that would “recreate what the administrative record would have

been had the procedure been correct.” Id. at 973. 

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neuropsychologist) to review Manriquez’s claim. Dr. Mosbach concluded that Manriquez’s

medical records did not indicate a physical impairment that would prevent her from

performing the essential functions of her job. (Id. at ¶ 186). On September 22, 2008 the Plan

Administrator reviewed Manriquez’s entire case and affirmed the denial of benefits. Prior

to the final decision, neither party consulted with an infectious disease specialist to more

definitively determine whether Manriquez had Lyme disease, whether she was receiving

proper treatment for her alleged infectious diseases, or whether those diseases were disabling.

In the final denial letter, the Plan reasoned that, “[b]oth the IME physician in his original

report and addendum and a peer reviewer opined there are no functional impairments

precluding [Manriquez] from performing [her] own occupation.” (Doc. 33, Ex. 1 at 62).

Pursuant to her rights under the Employee Retirement Income Security Act of 1974

(“ERISA”), Manriquez timely appealed the Plans’s decision to this Court on January 15,

2009. 

DISCUSSION2

I. Full and Fair Review

Manriquez alleges that the Plan did not provide her with a full and fair review as

required by ERISA. Specifically, Manriquez alleges that the Plan violated 29 C.F.R. §

2560.503-1(h)(3) because it did not consult with the proper medical personnel in making an

adverse determination and because it consulted with Dr. Dilla during both the initial denial

and the final appellate decision. Manriquez further alleges that the Plan denied her a full and

fair review because it improperly construed the term “Physician” to require her to consult

with an infectious disease specialist. The Court agrees. 

First, it appears that the Plan misconstrued the term “Physician” to require Manriquez

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to consult with an infectious disease specialist prior to being eligible for benefits. The Ninth

Circuit has been very clear that a plan “administrator lacks discretion to rewrite the Plan.”

Saffle v. Sierra Pac. Power Co. Bargaining Unit Long Term Disability Income Plan, 85 F.3d

455, 460 (9th Cir. 1996) (citing Florence Nightingale Nursing Serv., Inc. v. Blue Cross/Blue

Shield of Ala., 41 F.3d 1476, 1484 (11th Cir. 1995) (holding that a “claims administrator’s

decision is arbitrary and capricious where new requirements for coverage are added to those

enumerated in the plan”)). The Plan defines “Physician” as “a legally qualified and licensed

Physician recognized by the state board to practice medicine in a designated field or specialty

who is practicing within the scope of his or her license.” (Doc. 43 at ¶ 16). 

In considering Manriquez’s initial claim for benefits, Matrix stated, “It is unclear how

appropriate treatment for Lyme disease can be determined or established by a ‘gynecological

medical practice for women.’” (Doc. 30, Ex. 2). In its second denial letter, Matrix conceded

that Manriquez’s providers “may be practicing within the scope of their licensing,” but

nonetheless denied Manriquez’s claim because “the peer reviewers [recommended] that [she]

be treated or at least evaluated by an infectious disease specialist.” (Doc. 32, Ex. 3). In the

final denial letter, the Plan denied benefits because “there [was] no evidence from an

infectious disease specialist to support” Manriquez’s claims. (Doc. 33, Ex. 1). In effect, the

Plan denied Manriquez’s claims not because she was receiving improper treatment, but rather

because her claim was not supported by the diagnosis of an infectious disease specialist.

Nothing about the plan language, however, prohibits a claim from being based on the

professional opinion of a physician as opposed to a board-certified specialist. Thus, the Plan

unfairly interpreted the plain language to require Manriquez to produce additional evidence

from medical experts. Similarly, in Saffle, the Ninth Circuit found that an interpretation of

“completely unable” to include “even with reasonable accommodations” was inconsistent

with the plain language of the plan, which warranted a remand. 85 F.3d at 459. The Plan’s

interpretation of the plan appears to have rewritten the plain language in a manner expressly

forbidden by the Ninth Circuit, and therefore denied Manriquez a full and fair review of her

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The Plan’s assertion that this Court cannot address Manriquez’s argument that the

Plan misapplied the term “Physician” because she did not raise it below is without merit.

The Plan’s reliance on Taft v. Equitable Life Assurance Soc’y, 9 F.3d 1469 (9th Cir. 1994)

to the contrary is misplaced, as Taft was recently abrogated by the Ninth Circuit in Abatie

v. Alta Health & Life Ins. Co., 458 F.3d 955 (9th Cir. 2006). Contrary to Taft, Abatie holds

that “if the administrator did not provide a full and fair hearing, as required by ERISA . . .

the court must be in a position to assess the effect of that failure and, before it can do so,

must permit the participant to present additional evidence.” Id. at 973. Accordingly, the

Court finds that its consideration of Manriquez’s argument is valid. 

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claim.3

 

Next, Manriquez alleges that the Plan violated 29 C.F.R. 2560.503-1(h)(3)(iii). That

section states a plan administrator must, 

Provide that, in deciding an appeal of any adverse benefit determination that

is based in whole or in part on a medical judgment . . . the appropriate named

fiduciary shall consult with a health care professional who has appropriate

training and expertise in the field of medicine involved in the medical

judgment. 

29 C.F.R. § 2560.503-1(h)(3)(iii). Although the Court disagrees with Manriquez’s assertion

that this provision affirmatively imposed a burden on the Plan to consult with an infectious

disease specialist, it does appear that the admissions of the Plan’s own doctors indicate that

they do not have “appropriate training and expertise in the field of medicine involved in the

medical judgment” to satisfy the requirements of the regulation. 

For instance, in his IME report, Dr. Dilla stated that Manriquez’s complaints are

“beyond the scope of my medical license.” (Doc. 30, Ex. 1). Dr. Choi stated that “it is

beyond my area of training and expertise, however, to make a firm determination” as to

whether Manriquez had disabling infectious diseases. (Doc. 31, Ex. 3). And although Dr.

Topper does not explicitly say he is not qualified to assess Manriquez’s infectious diseases,

he indicates that a “consultation with an infectious disease specialist would be expected.”

(Doc. 32, Ex. 3). Thus, it appears that the Plan has relied on doctors who, by their own

admission, are not capable of rendering an informed decision as to whether Manriquez

suffers from debilitating infectious diseases. Accordingly, the Plan violated the terms of

ERISA by relying on unqualified medical opinions in making its adverse decision. This does

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not necessarily mean that the Plan must engage a board-certified specialist to evaluate

Manriquez’s claims or that the Plan’s doctors cannot render a judgment as to whether

Manriquez’s doctors are qualified. Instead, the Court finds only that the Plan is required to

consult with medical practitioners who have “appropriate training and expertise” in the

medical fields pertinent to their review. See Lafleur v. La. Health Serv. & Indem. Co., 563

F.3d 148, 158 (5th Cir. 2009) (ordering remand where the plan failed to consult with the

proper medical personnel). 

Finally, Manriquez asserts that consultation with Dr. Dilla in both the initial claim

denial and in the final appeal violated 29 C.F.R. §2560.503-1(h)(3)(v). That provision

provides that a plan administrator must,

Provide that the health care professional engaged for the purposes of consultation

under paragraph h(3)(iii) of this section shall be an individual who is neither an

individual who was consulted in connection with the adverse benefit determination

that is the subject of the appeal, nor the subordinate of any such individual . . . .

29 C.F.R. §2560.503-1(h)(3)(v). It appears that the Plan violated paragraph (h)(3)(v) by

consulting with Dr. Dilla at two levels of Manriquez’s claim. The final denial letter to

Manriquez stated, “Abbot requested that Dr. Dilla review all medical records” that were

submitted during the development of Manriquez’s case and that Dr. Dilla’s opinion

“remained unchanged.” (Doc. 33, Ex. 1). The letter further stated, “the IME physician [Dr.

Dilla] in his original report and addendum . . . opined there are no functional impairments

precluding [Manriquez] from performing [her] own occupation.” Id. (emphasis added).

Although the Plan asserts in its briefing that the final decision was not impacted by Dr.

Dilla’s opinion, the denial letter itself contradicts that assertion and instead indicates that the

Plan’s final decision was unduly influenced by a second consultation with Dr. Dilla. In Pitts

v. Prudential Ins. Co. of Am., the Southern District of Ohio found that it “is the most

fundamental of procedural defects” where an insurer “base[s] its decision on the opinion of

its hired health care professional during the initial review and on appeal.” 534 F. Supp. 2d

779, 791 (S.D. Ohio 2008). Though the Plan also consulted with new physicians on appeal,

the potential violation of consulting with Dr. Dilla on two occasions, combined with the other

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procedural violations discussed supra, demonstrates that the Plan denied Manriquez a full

and fair review. Because the Plan has not complied with the terms of ERISA, it is not

entitled to Summary Judgment. 

II. Summary Judgment For Manriquez Is Inappropriate

When reviewing a plan administrator’s decision, “[t]he Supreme Court has held that

a denial of benefits ‘is to be reviewed under a de novo standard unless the benefit plan gives

the administrator . . . discretionary authority to determine eligibility for benefits or to

construe the terms of the plan.’” Burke v. Pitney Bowes Inc. Long-Term Disability Plan, 544

F.3d 1016, 1023 (9th Cir. 2008) (quoting Firestone Tire & Rubber Co. v. Bruch, 489 U.S.

101, 115 (1989)). Where, as here, the plan “does grant such discretionary authority, [courts]

review the administrator’s decision for abuse of discretion.” Saffron v. Wells Fargo & Co.

Long Term Disability Plan, 522 F. 3d 863, 866 (9th Cir. 2008). In ERISA cases, procedural

violations “do not alter the standard of review unless those violations are so flagrant as to

alter the substantive relationship between the employer and employee, thereby causing the

beneficiary substantive harm.” Gatti v. Reliance Standard Life Ins. Co., 415 F.3d 978, 985

(9th Cir. 2005). A reviewing court “must consider numerous case-specific factors, including

the administrator’s conflict of interest, and reach a decision as to whether discretion has been

abused by weighing and balancing those factors together.” Montour v. Hartford Life &

Accident Insurance Co., 588 F.3d 623, 630 (9th Cir. 2009).

Based on the present record, entering Summary Judgment for Manriquez would be

premature. Although the record indicates that the Plan has committed procedural violations

that have altered the substantive relationship between the parties, thus potentially altering the

standard of review, those violations operate in a unique manner. Here, the Plan’s decision

to consult with Dr. Dilla, during both the initial and final rejections of Manriquez’s claim,

and to consult with unqualified medical personnel denied her a full and fair review. Without

this full and fair review the Court is unable to evaluate whether Manriquez is entitled to

benefits under an abuse of discretion standard or a de novo review. Thus, insofar as further

factual development is necessary to make an informed decision, the Court finds that granting

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Summary Judgment would be premature and therefore denies Manriquez’s Motion. 

III. Remedy

A district court has discretion in its choice of remedy in ERISA benefits denial cases.

See Grosz-Salomon v. Paul Revere Life Ins. Co., 237 F.3d 1154, 1163 (9th Cir. 2001); see

also Buffonage v. Prudential Ins. Co. of Am., 426 F.3d 20, 31 (1st Cir. 2005) (holding that

“the court must have ‘considerable discretion’ to craft a remedy after finding a mistake in the

denial of benefits”). Additionally, an “ERISA claimant whose initial application for benefits

has been wrongfully denied is entitled to a different remedy than the claimant whose benefits

have been terminated.” Pannebecker v. Liberty Life Assurance Co. of Boston, 542 F. 3d

1213, 1221 (9th Cir. 2008) (citing Hackett v. Xerox Corp. Long-Term Disability Income

Plan, 315 F.3d 771, 775–76 (7th Cir. 2003)). “Where an administrator’s initial denial of

benefits is premised on a failure to apply plan” or ERISA provisions correctly, “courts

remand to the administrator to apply the terms correctly in the first instance.” Pannebecker,

542 F.3d at 1221 (citing Saffle, 85 F.3d at 461 (ordering remand where an ERISA

administrator “misconstrued the plan and applied a wrong standard to a benefits

determination.”)); see also Shelby County Health Care Corp. v. Majestic Star Casino, 581

F.3d 355, 373 (6th Cir. 2009) (holding that “where the plan administrator fails to comply

with ERISA[] . . . the proper remedy is to remand the case to the plan administrator so that

a full and fair review can be accomplished.”) (citing Gagliano v. Reliance Standard Life Ins.

Co., 547 F.3d 230, 240 (4th Cir. 2008) (internal quotations omitted); Miller v. United

Welfare Fund, 72 F.3d 1066, 1073–1074 (2d Cir. 1995) (remanding a case to plan

administrator where the factual evidence was insufficiently developed). 

The Plan failed to apply the terms of its plan properly by not following the explicit

guidelines of ERISA for providing Manriquez a full and fair review of her claim. To the

extent that the Plan violated 29 C.F.R. § 2560.503-1(1)(h)(3), the Plan must conduct a further

review of Manriquez’s claim in a manner consistent with this Order. To be clear, because

Manriquez’s claim is supported by physicians, the Plan may not determine that her claim

fails to meet plan requirements because it is not supported by the diagnosis of an infectious

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disease specialist. Furthermore, the Plan must consult with medical personnel who have

some basis for rendering a judgment as to Manriquez’s conditions before it denies her claim

based on the absence of those conditions, and it may not consult with the same physician

during both denial and review. 

CONCLUSION

For the forgoing reasons, the Court finds that neither party has presented sufficient

evidence to warrant Summary Judgment. Instead, the evidence indicates that the Plan’s

numerous ERISA violations prevented Manriquez from receiving a full and fair review.

Accordingly, the Court remands her claim to the Plan Administrator for further proceedings

consistent with this Order.

IT IS THEREFORE ORDERED:

1. Manriquez’s Motion for Summary Judgment (Doc. 42) is DENIED

2. The Plan’s Motion for Summary Judgment (Doc. 41) is DENIED

3. Manriquez’s claim is REMANDED to the Plan Administrator to be

adjudicated in a manner consistent with this Order.

4. Directing the Clerk of the Court to terminate this action. 

Dated this 30th day of July, 2010.

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