Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-casd-3_16-cv-02448/USCOURTS-casd-3_16-cv-02448-0/pdf.json

Nature of Suit Code: 791
Nature of Suit: Employee Retirement Income Security Act (ERISA)
Cause of Action: 29:1001 E.R.I.S.A.: Employee Retirement

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UNITED STATES DISTRICT COURT 

SOUTHERN DISTRICT OF CALIFORNIA 

JOHN R. FRITCH, 

Plaintiff,

v. 

UNITED OF OMAHA LIFE 

INSURANCE COMPANY, 

Defendant.

 Case No.: 16cv02448 JAH - BGS 

FINDINGS OF FACT, 

CONCLUSIONS OF LAW AND 

ORDER 

INTRODUCTION 

 Plaintiff, John R. Fritch, filed a complaint for relief under the Employee Retirement 

Income Security Act of 1974 (“ERISA”). Plaintiff seeks a review of Defendant United of 

Omaha Life Insurance Company’s termination of long term disability (“LTD”) payments. 

Defendant filed an answer on October 21, 2016. See Doc. No. 4. 

 The parties filed separate trial briefs and Defendant filed a motion in limine on July 

24, 2017. Plaintiff filed a reply to Defendant’s trial brief and an opposition to the motion 

in limine on August 21, 2017. Defendant filed a reply to Plaintiff’s trial brief and a second 

motion in limine on August 21, 2017. The parties filed separate memorandum of 

contentions of fact and law on October 9, 2017. They parties appeared before this Court 

for hearing the motions in limine and trial on October 17, 2017. Having heard oral 

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argument presented at trial and having considered the record as a whole, this Court makes 

the following findings of fact and conclusions of law. 

FINDINGS OF FACT

1. Plaintiff was employed by Arena Pharmaceuticals, Inc. as an Associate Fellow 

performing research and development work beginning April 1, 2002. 

2. During his employment, Plaintiff was a participant in Arena’s employee benefit plan 

which included long term disability benefits funded by a group insurance policy issued by 

Defendant. 

3. The plan provides for long term disability benefits equal to 60% of month earnings 

in the event of total disability. 

4. Plaintiff suffered a herniated disc on March 15, 2013, and underwent back surgery. 

5. Plaintiff underwent surgery again on January 12, 2015, after being diagnosed with 

spinal stenosis. 

6. Plaintiff submitted a claim for short term disability benefits just prior to his surgery 

which Defendant approved effective January 12, 2015 through March 15, 2015. Benefits 

terminated when Plaintiff returned to work on March 8, 2015. 

7. At a follow-up visit with surgeon Dr. Scott Leary in April 2015, Plaintiff complained 

of returned pain and Dr. Leary determined Plaintiff suffered from spinal instability and 

recommended another surgery. 

8. Plaintiff underwent another surgery on May 11, 2015. 

9. Defendant approved an extension of short term disability benefits through June 14, 

2015. 

10. Defendant approved long term disability payments beginning June 15, 2015. 

11. On June 30, 2015, Plaintiff saw Dr. Leary for a follow-up consultation. Dr. Leary 

noted Plaintiff was doing well overall and reported continued improvement of his lower 

back pain but did complain of bilateral leg pain which was made worse with prolonged 

sitting. 

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12. On August 7, 2015, Plaintiff was seen by Dr. Janine Kasch for dizziness, 

palpitations, back pain, neck pain, tremor and thyroid problems. Plaintiff reported his 

lower back pain was moderate to severe and was relieved by lying down and pain 

medication. Dr. Kasch noted Plaintiff was 3 months post-op from back surgery and he 

could not sit for more than 20 minutes. 

13. On August 18, 2015, Plaintiff returned to Dr. Leary for a follow up and reported 

decreased back pain, increased flexibility and the ability to tolerate more activity but also 

reported he was still limited to a sitting tolerance of 15-30 minutes. Dr. Leary noted good 

postoperative recovery and instructed Plaintiff to gradually increase activity levels and 

remain off work for additional 3 months. 

14. On September 21, 2015, Plaintiff saw Dr. Kasch for hypertension, heartburn, anxiety 

and back pain. Plaintiff reported slow progress with his back pain and taking oxycodone 

and lyrica for the pain. Dr. Kasch counseled Plaintiff to start tapering off the lyrica and 

use the oxycodone sparingly. 

15. On September 24, 2015, Plaintiff went to urgent care complaining of insomnia. The 

doctor opined that Plaintiff was likely withdrawing from lyrica and valium and advised 

Plaintiff to go back to his usual doses. 

16. On November 4, 2015, Plaintiff saw Dr. Kasch for a medical check, bp check and 

back pain. Plaintiff reported worsening back pain which is relieved by lying down, 

movement and changing positions. Plaintiff also reported he could sit up for 2 hours a day 

but in a lot of pain which reduced his concentration and that he could sit, stand or walk a 

total of 8 hours a day, maximum 2 hours at a time. Dr. Kasch directed Plaintiff to continue 

his lyrica dose for 2 weeks and then start tapering off. 

17. On November 17, 2015, Plaintiff saw Dr. Leary for a follow up and reported his 

back felt strong and stable and his flexibility increased with physical therapy. Plaintiff also 

reported his back pain was still present but better than prior to the surgery. Dr. Leary 

instructed Plaintiff to continue physical therapy, use of growth stimulator and a gradually 

increase in activity levels. 

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18. On November 20, 2015, Plaintiff submitted a “Declaration of Disability” 

maintaining he was unable to drive more than 15-25 miles at one time; sit more than 15-20 

minutes at one time; sit more than 2 hours in a workday; stand with pacing more than 1 

hour at a one time; stand with pacing more than 3 hours in a workday with 1 hour of sitting 

or more than 2 hours in a workday with 2 hours of sitting; lift more than 10 pounds on an 

occasional basis; lift anything on a frequent basis; and bend, stoop or twist on a regular 

basis due to pain in his back or legs or a feeling of weakness in his legs. 

19. Nurse Denise Theisen issued a report opining that Plaintiff should be able to lift, 

push, pull and carry up to 25 pounds occasionally, and less than that more frequently; sit, 

stand and/or walk up to 6 hours each or combination thereof in an 8 hour workday from 

November 18, 2015, but should continue to limit constant twisting and bending. 

20. In a letter dated January 6, 2016, Defendant wrote to Dr. Leary explaining it 

believed, despite his ongoing restrictions and limitations, Plaintiff could return to his prior 

occupation as an associate fellow on a full-time basis and asking Dr. Leary to sign the letter 

if he agreed with the assessment. 

21. Dr. Leary signed the letter on January 12, 2016. 

22. Defendant denied Plaintiff’s claim for long term disability benefits on January 22, 

2016. 

23. Plaintiff participated in a functional capacity evaluation on April 11, 2016. The 

evaluator, Barbara Tourtellot, opined Plaintiff demonstrated the following functional 

capacity: (1) maximum sitting tolerance of approximately 27 minutes and an average 

sitting tolerance of 10 minutes; (2) stationary standing tolerance of approximately 2 to 10 

minutes maximum and an average standing capacity of 6 minutes; (3) a capacity for short 

periods of repetitive reaching; (4) the ability to walk for short periods of time; (5) above 

average grip strength. 

24. Plaintiff appealed Defendant’s denial of benefits through counsel on May 2, 2016. 

25. Dr. Alan Neuren, MD, performed a medical review and opined there was lack of 

support for impairment beyond November 17, 2015. 

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26. Defendant notified Plaintiff’s counsel of its decision upholding its prior denial on 

July 27, 2016. 

27. Plaintiff submitted additional medical records from Dr. Kasch, Dr. Andrew Chen, a 

cardiologist, and Dr. Christiana Silva of SD Psychological Services, on August 23, 2016. 

28. Defendant notified Plaintiff the records did not alter its decision and it upheld the 

denial of benefits by letter dated September 13, 2016. 

29. Plaintiff filed this action seeking review of the denial on September 29, 2016. 

CONCLUSIONS OF LAW

1. This Court has jurisdiction over the proceedings under 29 U.S.C. section 1132(e). 

2. The parties agree the Court must conduct a de novo review of Defendant’s denial of 

benefits. A court conducting a de novo review of a challenge to a denial of benefits 

evaluates whether the plan administrator correctly or incorrectly denied benefits. Abatie 

v. Alta Health & Life Ins. Co., 458 F.3d 955, 948 (9th Cir. 2006). This determination is 

made based upon the evidence in the administrative record. See Opeta v. Northwest 

Airlines Pension Plan for Contract Employees, 484 F.3d 1211 (9th Cir. 2007). However, 

a court may consider, in its discretion, extrinsic evidence when it is necessary to conduct 

an adequate de novo review. Mongeluzo v. Baxter Travenol Long Term Disability Benefit 

Plan, 46 F.3d 938, 943-44 (9th Cir. 1995). 

3. The Court finds Plaintiff’s medical records from 2014, 2015 and 2017, and the July 

2017 letter from Dr. Leary are necessary to conduct an adequate de novo review due to the 

existence of complex medical issues and lack of clarity. In the July 2017 letter, Dr. Leary 

explains he did not have specific details regarding the physical requirements of Plaintiff’s 

job nor had the opportunity to review the functional capacity evaluation when he signed 

the January 6, 2016 letter, and he defers to the functional capacity evaluation findings 

which he describes as “thorough in its testing and evaluation of [Plaintiff’s] functionality.” 

4. The Court finds Plaintiff’s June 20, 2017 declaration which seeks to modify his job 

description is irrelevant and inadmissible. 

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5. Plaintiff has the burden to demonstrate he is disabled under the terms of the plan. 

See Muniz v. Amec Construction Mgmt., Inc., 326 F.3d 1290, 1294 (9th Cir. 2010). 

6. The Court finds the medical evidence supports the functional capacity evaluation 

findings as to Plaintiff’s functional limitations. 

7. The Court finds Dr. Neuren’s and Nurse Theisen’s paper review reports which 

included no examination, observation or discussion with Plaintiff are not supported by the 

evidence of record and are less persuasive than the information provided by Plaintiff’s 

treating physicians and the function capacity evaluation. 

8. The Court finds Plaintiff meets his burden of demonstrating by a preponderance of 

the evidence he is disabled under the terms of the plan. 

ORDER

 Based on the foregoing, IT IS HEREBY ORDERED: 

 1. Judgment is entered in favor of Plaintiff. Defendant’s denial of benefits is 

reversed. Defendant shall pay long term disability benefits in the amount of $9,012.50 a 

month as provided under the applicable plan from January 22, 2016 through December 15, 

2018. 

 2. The parties shall file briefs on the applicable prejudgment interest rate on or 

before December 29, 2017. The parties shall file responsive briefs on or before January 

12, 2018. 

DATED: December 6, 2017 

 

 _________________________________ 

 JOHN A. HOUSTON 

 United States District Judge 

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