Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-casd-3_06-cv-00486/USCOURTS-casd-3_06-cv-00486-2/pdf.json

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

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1 Defendant provided the Administrative Record (“AR”) with its motion for

summary judgment. Defendant numbered the pages in the AR as “MET-ORD ____”. The Court

will use the MET-ORD page numbers in providing citations to the AR. 

06cv486 

 

UNITED STATES DISTRICT COURT

SOUTHERN DISTRICT OF CALIFORNIA

DAVID ORDWAY,

Plaintiff,

v.

METROPOLITAN LIFE INSURANCE

COMPANY, 

Defendant.

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Civil No. 06-CV-486-L(WMc)

ORDER DENYING DEFENDANT’S

MOTION FOR SUMMARY

JUDGMENT and GRANTING IN

PART MOTION FOR SUMMARY

ADJUDICATION [doc. #18]

Defendant Metropolitan Life Insurance Company (“MetLife” or “defendant”) moves for

summary judgment or in the alternative, for partial summary judgment [doc. #18]. The motion is

fully briefed and has been submitted without oral argument. Having carefully considered the

matters presented, the Court enters the following decision. 

Factual and Procedural Background

David Ordway (“Ordway” or “plaintiff”) was the general manager of an automobile

dealership, MiraMar Volkswagen Audi. On February 19, 2004, plaintiff underwent total knee

replacement surgery. (Administrative Record1

 (“AR”) 24) Because of post-operative

arthrofibrosis, plaintiff had a second surgery for total knee replacement revision arthroplasty on

June 7, 2004 (AR 89, 104) Plaintiff claims a disability as of September 30, 2004, as a result of

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2 Defendant indicates that the review on appeal “included but was not limited to the

following information:” Dr. Swenson’s progress notes from June 17, 2004 to April 27, 2005; 

Dr. Paul Pollice progress note dated May 6, 2005; physical therapy notes dated October 7, 2004

to February 20, 2005; MRI dated December 31, 2003; Marty-Meador letter dated July 12, 2005

from Fuller Ford; and the video surveillance and report. Defendant also states that the

information was reviewed by an Independent Physician Consultant, Board Certified in

Orthopedic Surgery. (AR at 71-72)

2 06cv486 

right knee arthrofibrosis. Ordway was notified on September 24, 2004, that he was terminated

from his employment effective October 1, 2004. (AR 79) Plaintiff last worked on September 23,

2004. (AR 180) 

Plaintiff had a disability policy issued by MetLife through his employer. On September

29, 2004, Ordway notified MetLife of his disability benefits claim. (AR 27) Dr. F. Craig

Swenson (“Dr. Swenson”), plaintiff’s treating orthopedic physician, provided an Attending

Physician’s Statement certifying plaintiff’s disability as of September 30, 2004 as a result of

knee pain and limited movement. (AR 186-188) Dr. Swenson’s statement noted that plaintiff

could sit four hours per day intermittently; could lift/carry 11-20 pounds occasionally; and could

not stand and walk for more than 1-2 hours per day. (AR 188)

MetLife originally denied plaintiff’s claim on March 5, 2005 after reviewing Dr.

Swenson’s statement and progress reports and a surveillance report initiated by defendant. (AR

124-125) Plaintiff was notified of the reasons for the denial and of his right to file an appeal. 

(Id.) On July 18, 2005, plaintiff filed an appeal and defendant subsequently conducted another

review. MetLife sent a letter dated August 19, 2005, indicating that it was upholding its original

determination and the reasons for its decision.2

 (AR 83-87) 

One of MetLife’s Financial Services Representatives, Frank Meram, contacted MetLife

about plaintiff’s concerns over the denial of long-term disability benefits. (AR 74-75) In

response to Meram’s contact, defendant sent plaintiff a letter dated December 21, 2005, offering

clarification of its decision to deny plaintiff’s claim and setting forth the information that was

reviewed on appeal. (AR 71-72) 

Plaintiff also sent a letter dated February 28, 2006, that advised defendant that the Social

Security Administration had approved disability benefits for plaintiff commencing in March

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3 It is the usual practice in cases seeking review of Plan Administrator’s decisions

in ERISA cases for the parties to file cross motions for summary judgment. Here, plaintiff has

not filed a motion for summary judgment.

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2005. (AR 34)

On April 10, 2006, in response to the submission of additional information from plaintiff,

MetLife again reviewed the newly provided information and indicated that the information

would not change its decision to deny plaintiff’s claim. (AR 31).

Plaintiff filed a Complaint in this Court on March 3, 2006 seeking damages for

defendant’s failure to approve plaintiff’s disability benefits claim. On January 17, 2007,

defendant filed a motion for summary judgment, or in the alternative, for partial summary

judgment. Defendant’s motion has been fully briefed and is considered below.

Standard of Review

1. In General

Defendant moves for summary judgment;3

 however, the usual legal standard for summary

judgment motions generally does not apply where the Court is asked to review an ERISA plan

administrator’s decision. Bendixen v. Standard Ins. Co., 185 F.3d 939, 942 (9th Cir. 1999); FED.

R. CIV. P. 56(c). In ERISA actions, where the plaintiff is challenging the Plan administrator's

denial of benefits, "a motion for summary judgment is merely the conduit to bring the legal

question before the district court and the usual tests of summary judgment, such as whether a

genuine dispute of material fact exists, do not apply." Bendixen v. Standard Ins. Co., 185 F.3d

939, 942 (9th Cir.1999). Thus, a summary judgment motion resting on the administrative

record is not a typical summary judgment, but rather, is a procedural vehicle for determining

whether benefits were properly granted or denied. 

A threshold question, therefore, is the standard of review the court must apply in these

types of cases. A denial of benefits under an ERISA plan "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." Firestone Tire & Rubber Co. v.

Bruch, 489 U.S. 101, 115 (1989); Kearney v. Standard Ins. Co, 175 F.3d 1084, 1090 (9th Cir.

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1999)(“the district courts must review claims de novo unless the discretion to grant or deny

claims is ‘unambiguously retained’ by a plan administrator or fiduciary”). “De novo is the

default standard of review.” Abatie v. Alta Health & Life Insur. Co., 458 F.3d 955, 963 (9th

Cir. 2006). But where a Plan document gives an administrator discretionary authority, a court

must apply the "abuse of discretion" or "arbitrary and capricious" standard of review to its

decision to deny benefits. Firestone, 489 U.S. at 111; see also, Abatie 458 F.3d at 963;

Bendixen, 185 F.3d at 942. 

Under the abuse of discretion standard, the Court reviews the administrative record to

determine whether substantial evidence supports the administrator's decision. Clark v.

Washington Teamsters Welfare Trust, 8 F.3d 1429, 1432 (9th Cir. 1993). If so, then the

administrator's decision will be upheld, even though the record may contain evidence that could

support a contrary conclusion. Snow v. Standard Ins. Co., 87 F.3d 327, 332 (9th Cir. 1996),

overruled on other grounds by Kearney v. Standard Ins. Co., 175 F.3d 1084 (9th Cir. 1999)(en

banc); Taft v. Equitable Life Assur. Soc., 9 F.3d 1469, 1473 (9th Cir. 1993); Eley v. Boeing Co.,

945 F.2d 276, 279 (9th Cir. 1991); 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."); Mizzell v. Paul Revere Life Ins. Co.,

118 F. Supp. 2d 1016, 1019-20 (C.D. Cal. 2000). Under this deferential standard, it is an abuse

of discretion for an ERISA plan administrator to make a decision without any explanation, or in

a way that conflicts with the plain language of the plan, or that is based on clearly erroneous

findings of fact. But the fact that the plan administrator's decision is directly contrary to some

evidence in the record does not show that the decision is clearly erroneous. Rather, review under

the “clearly erroneous” standard is significantly deferential, requiring a definite and firm

conviction that a mistake has been committed. Snow, 87 F.3d at 331.

In Abatie, the Ninth Circuit recently considered the question of whether the standard of

review changes to de novo review when a plan confers discretion but its administrator operates

under a conflict of interest or the process is irregular. Abatie, 458 F.3d at 962. The Abatie court

noted that the Firestone case requires an “abuse of discretion review whenever an ERISA plan

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28 4 The court may admit additional evidence on de novo review. Abatie, 458 F.3d at

970.

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grants discretion to the plan administrator, but a review informed by the nature, extent, and

effect on the decision-making process of any conflict of interest that may appear in the record.” 

Id. at 967. In other words, a court is required to weigh a conflict of interest as a factor in abuse

of discretion review and to consider a case-by-case balancing. Id. at 968. 

Under the abuse of discretion standard, a court generally limits its review to the record

before the plan administrator.4

 Id. at 970 (“Today, we continue to recognize that, in general, a

district court may review only the administrative record when considering whether the plan

administrator abused its discretion . . .). But, as the Abatie court also noted, “[a] subtler

question arises when a court must decide how much weight to give a conflict of interest under

the abuse of discretion standard.” Id. at 970. The Ninth Circuit now holds that:

The district court may, in its discretion, consider evidence outside the

administrative record to decide the nature, extent, and effect on the decisionmaking process of any conflict of interest; the decision on the merits, though, must

rest on the administrative record once the conflict (if any) has been established by

extrinsic evidence or otherwise.

Id. Thus, the abuse of discretion standard of review does not change to a de novo review when

the plan confers discretionary authority and the administrator has a conflict of interest. Rather,

the abuse of discretion standard remains applicable but is informed by weighing the conflict of

interest. 

A finding of a conflict of interest may be based on whether the Plan administrator:

provides inconsistent reasons for denial (citation omitted); fails to adequately

investigate a claim or ask the plaintiff for necessary evidence (citation omitted);

fails to credit a claimant’s reliable evidence (citation omitted); or has repeatedly

denied benefits to deserving participants by interpreting plan terms incorrectly or

by making decisions against the weight of the evidence.

Id. at 968-69. 

2. Supplementing the Administrative Record

The assigned magistrate judge held a telephonic status conference on February 8, 2007, at

which time plaintiff sought to have discovery reopened with respect to the single issue of

conflict of interest. The magistrate judge set briefing on the issue of reopening discovery by

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5 The surveillance report of Michael Reddy indicates that he observed plaintiff for

approximately 28 minutes on January 25, 2005 and obtained three minutes and 28 seconds of

video tape documenting plaintiff’s movements on a golf course. (AR 105-106)

6 Based on the applicable law, the Court does not consider the Collins’ letter in

determining whether defendant abuse its discretion in denying plaintiff’s claim but only insofar

as plaintiff has alleged a conflict of interest.

6 06cv486 

requiring the simultaneous filing of letter briefs. (Order filed February 9, 2007 [doc. #22]). The

parties were also permitted to file responses to the letter briefs. The Court notes that on

February 16, 2007, plaintiff filed an ex parte application before the district court seeking to

delay the March 5, 2007 hearing and ruling on defendant’s present motion for summary

judgment until the magistrate judge had entered a decision with respect to reopening discovery

(Ex parte application [doc. #23]). Defendant opposed the ex parte application but the Court

stayed consideration of the summary judgment motion until the magistrate judge had an

opportunity to consider reopening discovery on the issue of conflict of interest. (Order filed

February 26, 2007 [doc. #27])

On June 6, 2007, the magistrate judge entered a decision concerning discovery and

related issues. (Order filed June 6, 2007 [doc. #36]). First, the magistrate judge, relying on

Abatie, denied plaintiff’s request to conduct additional discovery with respect to the conflict of

interest issue. (Id. at 1-2)

Plaintiff also sought the introduction of the videotape that defendant made that purports to

show that plaintiff could walk for extended periods of time.5

 Plaintiff alleged that the videotape

itself was not a part of the Administrative Record but instead only investigator Michael Reddy’s

Report (AR 129), based upon the videotape, was included in the Administrative Record. 

Plaintiff also argued that a letter from Jack Collins, a witness to the events on the videotape,

should be included for the Court’s consideration in determining the level of conflict of interest. 

The magistrate judge permitted the introduction of both the surveillance videotape and witness

letter.6

 (June 7, 2007 Order at 2-3 [doc. #36]) 

In its “motion to correct two factual statements in Magistrate Judge McCurine’s June 7,

2007 Order, defendant states that “the surveillance videotape (actually a compact disk) was

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always part of the Administrative Record that its personnel thoroughly reviewed and analyzed in

connection with Plaintiff David Ordway’s . . . claim for long-term disability benefits” but “it

(the surveillance videotape on compact disk) was simply omitted inadvertently from the copy

provided to Ordway’s counsel and filed with the Court.” (Motion at 1 [doc. #37]) 

Finally, plaintiff sought to include the full deposition testimony of plaintiff’s employer,

Craig Joyner. Excerpts of Joyner’s deposition had been made part of the Administrative Record. 

The magistrate judge, concluding there was no prejudice to defendant, granted plaintiff’s request

to supplement the AR with the complete Joyner deposition. (June 7, 2007 Order at 3 [doc. #36]) 

Defendant points out in its motion to correct factual statements that the Joyner deposition was

not taken in this litigation, but instead was taken in a separate lawsuit entitled David Ordway v.

Richard C. Richley, M.D., that is pending in the Superior Court in San Diego. Nevertheless, the

entire Joyner deposition has been provided to this Court for review with respect to the issue of

conflict of interest.

Because the magistrate judge has entered his decision, the Court will now consider

defendant’s motion for summary judgment.

3. Appropriate Standard of Review in this Action

The Firestone Court noted that if a Plan grants an administrator the right to determine

eligibility for benefits or to construe the terms of the plan, it has discretionary authority. 489

U.S. at 111. In the present case, the Plan provides, in relevant part:

MetLife in its discretion has authority to interpret the terms, conditions, and

provisions of the entire contract. This includes the Group Policy, Certificate and

any Amendments.

(AR 189). The Court finds that this languages confers discretion on the plan administrator. 

The Court must then consider whether there is any showing of conflict of interest or

procedural irregularities. Defendant acknowledges an inherent structural conflict of interest

because it is both the claim decision maker and payor of benefits. 

Plaintiff argues, however, that the conflict of interest goes beyond the structural conflict

noted by defendant. Plaintiff rightly contends that defendant initially erred in denying benefits

by misinterpreting the medical file. Instead of the two total knee replacement surgeries that

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formed the basis for plaintiff’s disability claim, defendant denied the claim based on deep vein

thrombosis and a meniscal tear. (AR 124) This misdiagnosis is clearly erroneous but defendant

appears to have corrected this fact with respect to subsequent reviews of plaintiff’s claim. 

Plaintiff also argues that defendant denied benefits because it erroneously relied on the

incorrect belief that plaintiff was employed in a sedentary position and had an executive

assistant. Plaintiff presented excerpts from Joyner’s deposition to show that plaintiff’s activity

level as the general manager were not sedentary, notwithstanding Joyner’s prior statement that

plaintiff’s position was sedentary. (AR 36-38) I t is also undisputed that plaintiff did not have an

executive assistant. The continuing use of and reliance on flawed evidence suggests some

conflict of interest on the part of the Plan administrator.

Plaintiff also faults defendant for failing to have him physically examined by an

independent physician. Although under the policy, defendant has the right to have such an exam

taken, it is not a requirement. Nevertheless, defendant’s decision to not have plaintiff submit to

an independent medical exam under the circumstances of this case raises a slight inference of

conflict of interest.

Finally, plaintiff contends that defendant failed to properly credit plaintiff’s reliable

evidence, and in particular, plaintiff’s attending physician’s opinion that plaintiff was disabled. 

Defendant did not set forth a rational basis for discounting plaintiff’s physician’s opinion in

favor of the opinion of a non-treating, non-examining physician’s review of the medical records. 

Again, this suggests some level of conflict of interest. 

The Court also notes that defendant’s stalwart reliance on a three minute, 28 second

videotape and surveillance report to demonstrate plaintiff’s level of physical activity with respect

to his employment is suspect in the absence of any other evidence of activity level.

Here, the Court finds that an abuse of discretion standard is applicable to a review of the

decision to deny plaintiff benefits. In its review, the Court also weighs the fact that there is a

structural conflict of interest and as discussed above, other aspects of the record and

supplemented materials that suggest the Plan administrator had a conflict of interest that

influenced defendant’s decision to deny plaintiff’s claim. 

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DISCUSSION

1. Plan Language

Disability is defined in the Plan as:

“Disabled” or “Disability” means that, due to sickness, pregnancy or accidental

injury, you are receiving Appropriate Care and Treatment from a Doctor on a

continuing basis; and

1. during your Elimination Period and the next 24 month period, you are unable to

earn more than 80% of your Predisability Earnings or Indexed Predisability

Earnings at your Own Occupation for any employer in your Local Economy; or 

2. after the 24 month period, you are unable to earn more than 80% of your

Indexed Predisability Earnings from any employer in your Local Economy at any

gainful occupation for which you are reasonably qualified taking into account your

training, education, experience and Predisability Earnings.

. . .

“Own Occupation” means the activity that you regularly perform and that serves as

your source of income. It is not limited to the specific position you held with your

Employer. It may be a similar activity that could be performed with your

Employer or any other employer.

(AR at 206-07).

2. Reviewing Defendant’s Determination

a. Medical Reports

On September 30, 2004, plaintiff’s treating orthopedic surgeon, Dr. Swenson, advised

plaintiff to discontinue working because of knee pain and difficulty with range of motion (AR at

169). On January 31, 2005, defendant requested all information Dr. Swenson had regarding

plaintiff’s disability. (AR 144) Dr. Swenson provided monthly progress reports including

reports dated October 14, 2004; November 12, 2004; December 10, 2004; and January 14, 2005. 

The January 14, 2004 report states, in part, “Mr. Ordway is now 7 months postop. He is

continuing to have pain. His walking tolerance is 3-4 blocks. . . . All we can do is wait and

continue to work on his range of motion. . . . He will return in three months.” (AP 137)

Defendant’s nurse consultant reviewed this medical information, which defendant

misinterpreted, along with the surveillance report and videotape. The nurse consultant

concluded that the medical information and defendant’s activity level suggested by the

surveillance did not support a severity of impairment level that would prevent plaintiff from

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returning to work. (AR 12-13)

The above statements from Dr. Swenson comprise the medical evidence presented to

defendant prior to making its March 3, 2005 determination to deny plaintiff benefits. (AR 124-

125)

Subsequent to its initial determination to deny plaintiff benefits, plaintiff provided the 

April 27, 2005 statement of Dr. Swenson that provided in relevant part: 

[Plaintiff] is continuing to have significant disability as a result of arthrofibrosis in

his revision right total knee arthroplasty. . . . Mr. Ordway would be able to return

to employment with restriction limited to light work. He can work standing or

walking with minimal demands for physical effort. He is to do no heaving lifting,

no prolonged weight bearing, no climbing, walking over uneven ground, squatting,

kneeling, crouching, crawling, or bending. These restrictions will exist

indefinitely.

(AR 104-107 at 107). Dr. Swenson also indicated that by September 30, 2004, plaintiff’s

condition had significantly deteriorated. Finally, Dr. Swenson noted that plaintiff could work

but with accommodations. 

Paul F. Pollice, M.D. performed an orthopaedic evaluation and his report, dated May 5,

2005, states that “even with aggressive physical therapy, I would not expect that to positively

impact his range of motiion and perceived stiffness.” (AR 109)

Dr. Richard Silver, a board-certified orthopedic surgeon, served as an independent

physician consultant for defendant’s review of plaintiff’s long-term disability claim. On August

3, 2005, after reviewing the entire claim file, including all medical records submitted initially

and on appeal, Dr. Silver opined:

Mr. Ordway is capable of working full time in his normal capacity as a general

manager, with frequent position changes, ambulation, sitting, standing, bending,

and occasional stooping. He has been capable of doing so for quite some time. . . .

Mr. Ordway does have some functional limitations. These functional limitations

are not precluding his employment, . . . Although he has a loss of range of motion

of the left knee, his left knee is still functional and is capable of being utilized in

his normal activities of daily living as well as in his form of employment as a

general manager, standing, walking, sitting, talking, and getting in and out of

chairs, up and down areas, attending meetings, etc. There is nothing in the range

of motion of his left knee that precludes his employment . . . 

(AR 89-94 at 91). 

On August 19, 2005, defendant upheld its denial of plaintiff’s claim on the basis of the

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7 As noted above, the entire Joyner deposition has been provided to this Court rather

than just the excerpts presented to MetLife in its decision-making process. As noted above, the

Joyner deposition was taken in the case of David Ordway v. Richard C. Richley, M.D., that is

pending in the state court.

11 06cv486 

above cited medical records.

b. Other Considerations

Craig Joyner, owner and president of Miramar Volkswagon Audi, plaintiff’s employer,

provided MetLife with a statement that as a general manager, an executive position, plaintiff was

in a sedentary job. (AR 180-82) Plaintiff disputed this classification. Nine months after

defendant denied plaintiff’s claim, plaintiff provided MetLife with excerpts from Joyner’s

deposition which indicated that the general manager position involved non-sedentary duties and

activities.7

 (AR 35-44) Defendant reconsidered its determination after receiving this

information but again denied plaintiff’s claim concluding that the medical and other records did

not support a disability finding. (AR 31).

Plaintiff also provided defendant with a July 12, 2005 letter from the general manager at

Fuller Ford, a dealership where plaintiff did not work, who stated that the general manager job is

not sedentary work. (AR 108)

Defendant authorized a surveillance report and videotape of plaintiff’s physical activity

level. The investigator’s report and the videotape upon which the report was based, was

included as part of the Administrative Record because defendant considered both in denying

plaintiff benefits. As noted above, the report was based on a three minute and 28-second

surveillance videotape taken by defendant’s investigator that allegedly shows plaintiff engaging

in a round of golf, plaintiff lifting and carrying a bag of golf clubs, and swinging a golf club. 

There is nothing else in the AR to support defendant’s conclusion that plaintiff was able to return

to a similar employment position based on his physical activity level. 

Defendant contends that its decision to deny plaintiff’s disability claim was also based, in

part, on the timing of plaintiff’s claim. (Reply memo. at 2) Specifically, plaintiff continued to

work as the general manager of the automobile dealership after his second knee surgery until he

was notified on September 24, 2004 that his employment was terminated as of October 1, 2004. 

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8 The March 5, 2005 letter denying plaintiff long-term disability benefits states: 

“Lacking from the medical information is any doppler studies to indicate you were ever positive

for a DVT to your leg or an MRI indicating a meniscus tear.” Plaintiff never contended he

suffered from DVT or a meniscus tear in seeking disability benefits. (AR at 105)

12 06cv486 

Five days after receiving the notification of his termination, plaintiff submitted his claim for

disability benefits (AR 86-87) and on September 30, 2004, plaintiff’s treating physician ordered

plaintiff to stop working because of his alleged disability. According to defendant, this sequence

of events raises the issue that plaintiff’s request for disability benefits was tied to his termination. 

3. Assessment of Defendant’s Review

The Court initially notes that plaintiff concedes that defendant offered reasons for its

decision denying disability benefits but argues defendant’s decision is based on clearly

erroneous findings of fact and “is made under the cloud of [its] conflict of interest. (Opp. at 9) 

Thus, the Court must determine whether, under an abuse of discretion standard of review and

considering the AR without the inclusion of extrinsic evidence but informed by the weighing of

any conflict of interest shown, the decision to deny plaintiff’s claim is based on clearly

erroneous findings of fact or was made in a way that conflicts with the plain language of the

Plan.

The first denial of benefits to plaintiff was based on a clearly erroneous diagnosis.8

Nevertheless, defendant appears to have corrected its diagnosis in later documents. 

It also appears that defendant reviewed all the medical and other evidence presented by

plaintiff for consideration including other relevant factors that plaintiff brought to the attention

of defendant. Defendant reopened its process and determination when plaintiff requested the

opportunity to introduce additional supporting materials. With the subsequent reviews of

additional information submitted by plaintiff, the Plan administrator’s decision denying benefits

was not based on an incomplete record. 

But as noted above, although defendant offered reasons for its denial of benefits,

defendant has not provided any rationale for discounting plaintiff’s treating physician’s opinion

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9 The Court is not attempting to apply the same standard of review that is

undertaken in the context of a Social Security appeal in this case. In reviewing a Social Security

decision, “more weight is given to a treating physician’s opinion than to the opinion of a

nontreating physician because a treating physician is employed to cure and has a greater

opportunity to know and observe the patient as an individual. Likewise, greater weight is

accorded to the opinion of an examining physician than a non-examining physician.” Andrews

v. Shalala, 53 F.3d 1035, 1040-41 (9th Cir. 1995) (internal quotation marks and citations

omitted). “A treating physician’s opinion on disability, even if controverted, can be rejected

only with specific and legitimate reasons supported by substantial evidence in the record.” 

Reddick v. Chater, 157 F.3d 715, 725 (9th Cir. 1998). “This can be done by setting out a

detailed and thorough summary of the facts and conflicting clinical evidence, stating [the ALJ’s]

interpretation thereof, and making findings. The ALJ must do more than offer his conclusions. 

He must set forth his own interpretations and explain why they, rather than the doctor’s are

correct.” Id. 

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of disability.9 Instead, defendant appears to rely exclusively on the opinion of a non-treating,

non-examining physician in finding no disability on the part of plaintiff. 

Moreover, defendant relied heavily on a three minute, 28 second surveillance videotape. 

Defendant’s “snapshot” approach to determining plaintiff’s activity level is far from substantial

evidence with which to determine benefits. Hitting one golf ball does not provide a view of

physical capability particularly in the context of the work environment. 

Having carefully reviewed the entire AR and relying solely on the AR, the Court finds

and concludes that although defendant’s finding of non-disability is supported by some

evidence, the taint of conflict of interest seriously undermines defendant’s decision, and the

evidence, when taken as a whole, is not substantial. The Court is not substituting its own

judgment in making this finding. The Court is cognizant that an administrator’s decision should

be upheld even though the record may contain evidence that could support a contrary conclusion

but only if the administrator’s decision is supported by substantial evidence and the conflict of

interest is not significant. Here, applying the abuse of discretion standard, and weighing the

conflict of interest as a factor in an abuse of discretion review, the Court has a definite and firm

conviction that a mistake has been committed. Snow, 87 F.3d at 331. Accordingly, defendant is

not entitled to summary judgment. 

Conclusion

Based on the foregoing, to the extent defendant bases its alternative motion for summary

adjudication on whether the abuse of discretion standard of review is applicable, the motion for

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summary adjudication is GRANTED. Similarly, to the extent that defendant contends the Court

must rely solely on the Administrative Record in reviewing the Plan administrator’s decision

under the abuse of discretion standard, the motion for summary adjudication is also GRANTED

in accordance with the Abatie decision. In all other respects, defendant’s motion for summary

judgment is DENIED. 

The parties shall jointly contact the assigned magistrate judge for further proceedings

including but not limited to a settlement conference within ten days of the filing of this Order.

IT IS SO ORDERED.

DATED: August 21, 2007

M. James Lorenz

United States District Court Judge

COPY TO: 

HON. WILLIAM McCURINE, JR.

UNITED STATES MAGISTRATE JUDGE

ALL PARTIES/COUNSEL

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