Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-cand-3_14-cv-02740/USCOURTS-cand-3_14-cv-02740-0/pdf.json

Nature of Suit Code: 791
Nature of Suit: Employee Retirement Income Security Act (ERISA)
Cause of Action: 28:1132 E.R.I.S.A.

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United States District Court

Northern District of California

UNITED STATES DISTRICT COURT

NORTHERN DISTRICT OF CALIFORNIA

MARLON MONTOYA,

Plaintiff,

v.

RELIANCE STANDARD LIFE 

INSURANCE COMPANY, et al.,

Defendants.

Case No. 14-cv-02740-WHO 

ORDER DENYING DEFENDANTS’

MOTION FOR SUMMARY JUDGMENT

Re: Dkt. No. 24

INTRODUCTION

Defendant Reliance Standard Life Insurance Company (“Reliance”) denied plaintiff 

Marlon Montoya’s claim for long term disability benefits under a plan covered by the Employee 

Retirement Income Security Act of 1974 (“ERISA”). The question I must answer on defendants’ 

motion for partial summary judgment is whether Montoya properly exhausted his administrative 

remedies before bringing this civil suit under section 502 of ERISA. Because the plan at issue 

does not require exhaustion, I DENY defendants’ motion. However, I also find that it was 

appropriate for Reliance to require that plaintiff attend to two independent medical examinations, 

while his claim was at the administrative appeal stage. Therefore, at the conclusion of the oral 

argument on February 4, 2015, I directed the parties to proceed with scheduling plaintiff for a 

physical IME. 

BACKGROUND

The following facts are undisputed. Through his employer, Montoya is a beneficiary of a 

long term disability insurance plan held by defendant The RSL Group and Blanket Trust (“RSL”). 

Plaintiff’s Complaint (“Compl.”) (Dkt. No. 1) ¶¶ 1–2; Defendants’ Answer (“Ans.”) ¶ 2; 

Administrative Record (“AR”) 1. The parties agree that the plan is covered by ERISA. Compl. 

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¶ 2; Ans. ¶ 2. Defendant Reliance acts as a fiduciary of the plan, insures the plan, and determines 

disability benefits under the plan. Compl. ¶ 3; Ans. ¶ 3.

On April 20, 2013, Montoya filed a claim for long term disability benefits. AR 195–207. 

Reliance denied the claim on June 18, 2013. AR 168–71. The denial letter stated in part:

You may request a review of this determination by submitting your 

request in writing . . . . [¶] This written request for review must be 

submitted within 180 days of your receipt of this letter or the last 

date to which we have paid, whichever is later . . . . Only one review 

will be allowed. [¶¶] In the event that your claim is subject to the 

Employee Retirement Income Security Act of 1974 (“the Act”), you 

have the right to bring a civil action under section 502(a) of the Act 

following an adverse benefit determination on review. Your failure 

to request a review within 180 days of your receipt of this letter may 

constitute a failure to exhaust the administrative remedies available 

under the Act, and effect [sic] you[r] ability to bring civil action 

under the Act.

AR 169–70.

Montoya appealed Reliance’s decision on December 19, 2013. AR 656–58. As part of its

review of the appeal, Reliance arranged for Montoya to undergo two independent medical 

examinations (“IMEs”), one psychological and one physical. AR 1282–84. However, the 

physicians would not consent to Montoya’s counsel attending the examinations. AR 180–81. 

Unable to find physicians who would agree to that condition, Reliance rescheduled the two IMEs 

for June 10 (the physical exam) and June 13, 2014 (the psychological exam). AR 184, 1403–04.

Montoya did not appear for the June 10 physical IME, but he appeared for the 

psychological IME on June 13. AR 1455; 1458–75. That same day, he filed this lawsuit seeking 

declaratory relief and alleging that Reliance’s request for IMEs during the administrative appeal 

was an abuse of ERISA’s procedural safeguards.1 Compl. ¶¶ 13–15. A few days later on June 16, 

2014, Reliance upheld its initial denial of Montoya’s claim, citing his failure to submit to the 

physical IME as a reason for denial. AR 188–94. This denial letter advised Montoya that he was 

“entitled to an additional appeal review,” but only specifically on the issue of his failure to 

 

1 Montoya filed an amended complaint on September 15, 2014, but voluntarily withdrew that 

amended complaint on September 19, 2014. Dkt. 19, 20. Pursuant to this Court’s order, Montoya 

re-filed a first amended complaint (“FAC”) on February 9, 2015. Dkt. 32.

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cooperate with Reliance’s “right to a physical examination.” AR 193. On July 23, 2014, Reliance 

denied Montoya’s claim as to the psychological component of his asserted disability based on the 

results of the psychological IME. AR 1452–57.

Reliance moves for summary judgment on the ground that Montoya failed to exhaust his 

administrative remedies prior to bringing suit under section 502 of ERISA. Defendants’ Motion 

for Summary Judgment (“Mot.”) (Dkt. No. 24) 1–2. Its argument hinges on a provision in the 

insurance policy which states that Reliance “ha[s] the right to have a Claimant interviewed and/or 

examined . . . to determine the existence of any Total Disability which is the basis for a claim.” 

Mot. 1–2; AR 14. It argues that Montoya’s refusal to submit to the physical IME constituted a 

failure to cooperate with the claims process, and that without completion of the IMEs, the appeal 

process was still pending, rendering Montoya’s lawsuit premature. Mot. 1, 6–8.

Montoya responds that Reliance has not provided any documents that actually describe an 

appeal process to which claimants must reasonably adhere. Plaintiff’s Opposition (“Oppo.”) (Dkt. 

No. 27) 1–3. Montoya also contends that Reliance acted unreasonably by delaying the IMEs until 

after Reliance had initially denied Montoya’s claim, and as a result, he should be considered to 

have exhausted his claims. Oppo. 11–13.

LEGAL STANDARD

Summary judgment is proper “if the movant shows that there is no genuine dispute as to 

any material fact and the movant is entitled to judgment as a matter of law.” Fed. R. Civ. P. 56(a). 

The moving party bears the initial burden of demonstrating the absence of a genuine issue of 

material fact. Celotex Corp. v. Catrett, 477 U.S. 317, 323 (1986). The moving party, however, 

has no burden to disprove matters on which the non-moving party will have the burden of proof at 

trial. The moving party need only demonstrate to the court “that there is an absence of evidence to 

support the nonmoving party’s case.” Id. at 325.

Once the moving party has met its burden, the burden shifts to the non-moving party to 

“designate specific facts showing that there is a genuine issue for trial.” Celotex, 477 U.S. at 324 

(quotation marks omitted). To carry this burden, the non-moving party must “do more than 

simply show that there is some metaphysical doubt as to the material facts.” Matsushita Elec. 

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Indus. Co., Ltd. v. Zenith Radio Corp., 475 U.S. 574, 586 (1986). “The mere existence of a 

scintilla of evidence . . . will be insufficient; there must be evidence on which the jury could 

reasonably find for the [non-moving party].” Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 252 

(1986).

In deciding a summary judgment motion, the court must view the evidence in the light 

most favorable to the non-moving party and draw all justifiable inferences in its favor. Anderson, 

477 U.S. at 255. “Credibility determinations, the weighing of the evidence, and the drawing of 

legitimate inferences from the facts are jury functions, not those of a judge . . . ruling on a motion 

for summary judgment.” Id.

DISCUSSION

Defendants’ main argument in support of summary judgment is that IMEs can be required 

during an administrative appeal of a benefits denial and that failure to comply with an IME 

demand means that a claimant has failed to exhaust his remedies, and therefore, dismissal of 

claimant’s ERISA lawsuit is appropriate. Plaintiff essentially ignores that argument and instead 

argues that because defendants failed to comply with various ERISA procedural requirements,

exhaustion should be found or excused. For the reasons discussed below, I find that exhaustion 

should be excused because the plan at issue — as presented to me — does not require exhaustion 

of administrative remedies prior to filing suit.

I. EXHAUSTION UNDER ERISA GENERALLY

ERISA does not require a participant or beneficiary to exhaust administrative remedies in 

order to bring an action under section 502. However, federal courts, including the Ninth Circuit, 

are in agreement that a claimant must first “avail himself or herself of a plan’s own internal review 

procedures before bringing suit in federal court.” Diaz v. United Agric. Emp. Welfare Benefit Plan 

& Trust, 50 F.3d 1478, 1483 (9th Cir. 1995); see also Barboza v. California Ass’n of Prof’l 

Firefighters, 651 F.3d 1073, 1076 (9th Cir. 2011); Vaught v. Scottsdale Healthcare Corp. Health 

Plan, 546 F.3d 620, 626 (9th Cir. 2008); Amato v. Bernard, 618 F.2d 559, 568 (9th Cir. 1980).

Where a plan fails to establish or follow claims procedures required by ERISA, “a claimant 

shall be deemed to have exhausted the administrative remedies available under the plan and shall 

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be entitled to pursue any available remedies under section 502(a) . . . on the basis that the plan has 

failed to provide a reasonable claims procedure that would yield a decision on the merits of the 

claim.” 29 C.F.R. § 2560.503–1(l).Additionally, where a plan is either ambiguous on the need to 

exhaust administrative remedies or reasonably read to allow a claimant to file a lawsuit without 

exhausting administrative remedies, exhaustion is not required. Spinedex Physical Therapy USA 

Inc. v. United Healthcare of Ariz., Inc., 770 F.3d 1282, 1299 (9th Cir. 2014) (recognizing that 

“[e]xempting from the general exhaustion requirement those plan participants who reasonably 

interpret their ERISA plan not to impose an exhaustion requirement will have the salutary effect 

of encouraging employers and plan administrators to clarify their plan terms and, thereby, of 

leading more employees to pursue their benefits claims through their plan’s claims procedure in 

the first instance.” (citations and internal quotation marks omitted)).

The threshold inquiry, therefore, is whether the plan required exhaustion of administrative 

remedies.

II. THE PLAN DOES NOT REQUIRE EXHAUSTION OF ADMINISTRATIVE 

REMEDIES

A. The insurance policy is a plan document for ERISA purposes.

The parties disagree whether the RSL insurance policy is a plan document for ERISA 

purposes. Montoya argues that Reliance has failed to turn over the actual plan documents and 

there is no evidence to show that the insurance policy is the plan document in this situation. 

Oppo. 4–5. Reliance argues that the policy sufficiently establishes the terms of the plan and can 

be construed as a plan document. Reply 2–3.

An ERISA plan can be established “rather easily” by no more than “arrang[ing] for a 

group-type insurance program.” Credit Managers Ass’n of S. Cal. v. Kennesaw Life and Acc. Ins. 

Co., 809 F.2d 617, 625 (9th Cir. 1987) (quotation marks omitted). ERISA requires that “[e]very 

employee benefit plan . . . be established and maintained pursuant to a written instrument” (29 

U.S.C. § 1102(a)(1)), and a program under which an employer provides medical insurance 

benefits constitutes such a plan (see 29 U.S.C. §§ 1002(1)(A) and (3)). Here, Reliance argues that 

the insurance policy is the “written instrument.” See Cinelli v. Sec. Pac. Corp., 61 F.3d 1437, 

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1441 (9th Cir. 1995) (“[I]t is clear that an insurance policy may constitute the ‘written instrument’ 

of an ERISA plan [citation omitted].”). For purposes of determining this motion, I accept 

Reliance’s argument and find that the insurance policy produced in the Administrative Record is 

the written plan document.

B. The insurance policy does not require exhaustion of administrative remedies prior 

to bringing legal action.

Contrary to Reliance’s contentions, the Ninth Circuit has made it clear that under ERISA, 

“internal review procedures must be included in the plan’s written documents, which include the 

plan instrument, see 29 U.S.C. § 1102(a)(1), and a summary of the plan instrument, called the 

‘summary plan description.’ 29 U.S.C. § 1022.” Vaught, 546 F.3d at 627 (emphasis added). As 

Reliance contends that the only document that is the written plan document in this case is the 

insurance policy, the insurance policy controls on the question of exhaustion.

On its face, the insurance policy does not require exhaustion of remedies as a condition 

precedent to filing suit and, instead, implies that exhaustion is not required. In a section labeled 

“CLAIMS PROVISIONS,” the policy details rules concerning notice of a claim, claim form, 

written proof of total disability, payment of claims, arbitration of claims, physical examinations 

and autopsies, and legal action. AR 14–15. The only requirement for exhaustion of remedies is 

found within the rule for arbitration of claims. AR 14 (“In the case of a claim under [ERISA], the 

Insured’s ERISA claim appeal remedies, if applicable, must be exhausted before the claim may be 

submitted to arbitration.”).

However, in the “LEGAL ACTIONS” section, the policy provides that:

No legal action may be brought against us to recover on this Policy 

within sixty (60) days after written proof of loss has been given as 

required by this Policy. No action may be brought after three (3) 

years . . . from the time written proof of loss is received.

AR 15 (emphasis added).

There is nothing else in the policy that discusses administrative remedies and nothing that 

requires exhaustion of those remedies. Instead, the policy implies that the only requirement a 

claimant must meet before filing suit is to wait at least 60 days after submitting written proof of 

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loss but no longer than three years. As the policy language does not require exhaustion and in fact 

suggests that exhaustion is not required, plaintiff need not have exhausted any administrative 

remedies. See Spinedex, 770 F.3d at 1298; see also Nelson v. EG & G Energy Measurements 

Grp., Inc., 37 F.3d 1384, 1388 (9th Cir. 1994).

C. The denial of benefits letters cannot impose an exhaustion requirement.

Reliance argues that Montoya was clearly given notice of his appeal rights in the June 18, 

2013 letter, and that Montoya in fact undertook the administrative remedies offered by Reliance. 

Reply 4. The letter stated in part:

You may request a review of this determination by submitting your 

request in writing . . . . [¶¶] [Y]ou have the right to bring a civil 

action under section 502(a) of the Act following an adverse benefit 

determination on review. Your failure to request a review within 

180 days of your receipt of this letter may constitute a failure to 

exhaust the administrative remedies available under the Act, and 

effect [sic] you[r] ability to bring civil action under the Act.

AR 169–70. This same boilerplate language was used in the June 16, 2014 letter. AR 193.

However, these denial letters cannot be used to impose an exhaustion requirement where 

the plan itself does not expressly require or otherwise incorporate one. In general, benefits 

determination notices are themselves not plan documents. Explicit incorporation based on general 

rules of contract interpretation is the only way the Ninth Circuit has accepted an extraneous 

description of claims procedures to be incorporated into an ERISA plan document. See Vaught, 

546 F.3d at 622, 627 (plan’s summary plan description stated that a description of the plan’s 

appeal procedures would be included in the Explanation of Benefits (EOB) and the details of a 

plan’s internal review procedures were in fact set forth in an EOB sent to the claimant). 

That is not the situation here. The insurance policy makes no mention of benefit 

determination letters or notices, nor does it advise that appeals procedures are detailed in a 

separate document. Rather, the only extraneous documents the policy mentions are the insurance 

application and any attached amendments to the policy. AR 13 (“The entire contact between you 

and us is this Policy, your application (a copy of which is attached at issue) and any attached 

amendments.”) There do not appear to be any attached amendments. Because the policy does not 

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expressly incorporate claims procedures detailed in the explanation of benefits letters, Reliance 

cannot rely on them to establish that plaintiff was required either to participate in the appeal 

procedures or to exhaust those administrative remedies prior to filing suit.

Even if the denial letters are construed as plan documents, they can still be “fairly read as 

suggesting that exhaustion is not a mandatory prerequisite to bringing suit” in combination with 

the language of the insurance policy. Spinedex, 770 F.3d at 1298. The language in the denial 

letters is, at best, ambiguous as to exhaustion. The letters only permit, but do not require, an 

administrative appeal: “[Claimant] may request a review of this determination . . . .” AR 169, 193 

(emphasis added). The denial letters then go on to state that a “failure to request [an adverse 

benefit determination review] . . . may constitute a failure to exhaust the administrative remedies” 

and affect the ability to bring legal action. AR 170, 194 (emphasis added). This permissive

language does not inform an ordinary plan participant that he must exhaust the available 

administrative remedies prior to filing suit.

D. The administrative remedies are deemed exhausted.

Where a plan fails to establish or follow claims procedures required by ERISA, “a claimant 

shall be deemed to have exhausted the administrative remedies available under the plan and shall 

be entitled to pursue any available remedies under section 502(a) . . . .” 29 C.F.R. § 2560.503–

1(l). In the absence of an established procedure in the written plan document for review of an 

adverse determination of benefits, and without any written requirement in the plan compelling

exhaustion (rather, the language indicates that exhaustion is not required), Montoya is not required 

to have exhausted Reliance’s administrative remedies.2

III. IT WAS APPROPRIATE FOR RELIANCE TO REQIRE PLAINTIFF TO ATTEND 

INDEPENDENT MEDICAL EXAMINATIONS DURING HIS ADMINISTRATIVE 

APPEAL

Finally, the parties dispute whether it was appropriate for Reliance to require plaintiff to 

attend IMEs during the administrative appeal stage. I find that it was.

 

2

 Plaintiff raises a number of issues in his Opposition, including alleged deficiencies in Reliance’s 

denial letter and arguments that Reliance improperly ignored the requirements of Montoya’s job as 

well as symptoms Montoya claimed contributed to his disability. Oppo. 3–6. Those are meritbased arguments that may be raised on a subsequent motion.

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After initially denying Montoya’s claim and during the administrative appeal, Reliance 

invoked its right to request an IME based on the “PHYSICAL EXAMINATION AND 

AUTOPSY” section in the policy, which states:

[Reliance] will, at [its] expense, have the right to have a Claimant 

interviewed and/or examined:

(1) physically;

(2) psychologically; and/or

(3) psychiatrically;

to determine the existence of any Total Disability which is the basis 

for a claim. This right may be used as often as it is reasonably 

required while a claim is pending.

AR 14.

The Ninth Circuit has not yet addressed whether it is procedurally or substantively unfair 

to require IMEs during the administrative appeal stage. However, I am persuaded by the out-ofcircuit cases cited by Reliance that have directly addressed this issue in favor of requiring an IME

during administrative appeal.

In Hall v. United of Omaha Life Ins. Co., the plan requested the claimant to undergo an 

IME during the appeal stage. 741 F. Supp. 2d 1348, 1352 (N.D. Ga. 2010). Like Reliance, the 

plan in Hall invoked its right to obtain an IME from the language in the policy. Id. The court 

found the request for an IME appropriate for several reasons. First, there was no established limit 

in the plan as to when in the claims determination process the plan could require a claimant to 

attend an IME. Id. at 1354; see also Bruce v. Hardford, No. 1:14CV18 JCC/TRJ, 2014 WL 

3443823, at *6 (E.D. Va. July 10, 2014) (holding that plan language stating the plan has the right 

to require examination by a physician of its choice was unambiguous and provided clear authority 

for the plan to request a functional capacity evaluation during the appeal stage).3 Second, because 

the appeal was handled by a separate, independent reviewer, an IME was reasonably necessary to 

provide more medical information about the claimant. Id. Third, the request for an IME was 

 

3 Compare with Neiheisel v. AK Steel Corp., No. 103 CV 868, 2005 WL 1077593, at *3, 9 (S.D. 

Ohio Feb. 17, 2005), where the policy language allowing the plan to “consult with [a] health care 

professional who has appropriate training and experience in the field of medicine” did not clearly 

provide for a right to an IME.

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made in good faith. The court found that the IME was “a legitimate part of [the plan’s] 

investigation of [the] claim” and not an attempt to stall a decision on the claim: after a physician 

recommended the IME, the plan immediately scheduled one and notified the claimant. Id. Fourth, 

the request for an IME was reasonable in light of applicable ERISA regulations, which provide 

that when “‘deciding an appeal of any adverse benefit determination that is based in whole or in 

part on a medical judgment . . . [the plan may] consult with a health care professional who has 

appropriate training and experience.’ 29 C.F.R. § 2560.503–1(h)(3)(iii).” Id. Finally, allowing an 

IME during the appeal process was appropriate and consistent with the purpose of the ERISA 

exhaustion requirement because it “could result in a decision in favor of the claimant and 

eliminate the need for a federal lawsuit.” Id. at 1355.

In Hart v. Reliance Standard Life Ins. Co., the policy also contained language similar to

Reliance’s policy, allowing the plan to have a claimant physically examined, at its own expense, to 

determine the existence of a disability as the basis for the claim. No. 12-CV-02434-MSK-MEH, 

2013 WL 4781623, at *4 (D. Colo. Sept. 6, 2013). The policy further stated that “the right may be 

exercised ‘as often as it is reasonably required while a claim is pending.’” Id. The court held that 

the term “while a claim is pending” applied to the appeals stage, because it was “entirely possible 

that, upon review, the plan administrator could reverse the denial of benefits.” Id. As a result, it 

was reasonable for the plan to order an IME while it was reviewing the claim on appeal. Id.; see 

also Acierno v. First Unum Life Ins. Co., No. 98 CV 3885 SJ, 2002 WL 1208616 (E.D.N.Y. Mar. 

31, 2002) (holding that a plan’s request for an IME during appeals stage was reasonable, noting 

there are many circumstances where an insurance company may reasonably need additional 

physical examinations).4

Those cases are analogous to the situation here. In contrast, Montoya relies on several 

cases that are not. 5 This is not a bad faith insurance case, like Ace v. Aetna Life Ins. Co., where

 

4

See also Hunter v. Metro. Life Ins. Co., 251 F. Supp. 2d 107 (D.D.C. 2003) and Zalka v. Unum 

Life Ins. Co. of Am., 65 F. Supp. 2d 1369 (S.D. Fla. 1998) (in both cases, the courts did not 

address whether an IME request during administrative appeal was appropriate — rather, the courts 

assumed they were, and went on to conclude that claimants had failed to exhaust administrative 

remedies).

5 Montoya’s reliance on Perez v. Cozen & O’Conner Group Long Term Disability Coverage, 459 

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the Ninth Circuit found that the defendant insurer’s request for an IME “[at] the last minute” after 

twice denying plaintiff’s claim was sufficient evidence not only of the insurer’s bad faith but also 

reckless indifference to support an award of punitive damages. 139 F.3d 1241, 1246–47 (9th Cir. 

1998). Here, Montoya cites no facts other than the request for IMEs on administrative appeal to 

attempt to show that Reliance was acting in bad faith (much less with reckless disregard to the 

insured’s rights), as the defendant insurer was in Ace.

Nor is this a case where there has been an unreasonable delay in requesting IMEs, as in 

Cherry v. Digital Equip. Corp., No. CIVS05-2165 WBS JFM, 2006 WL 2594465 (E.D. Cal. Sept. 

11, 2006). There, the court held that the plan’s request for an IME at the appeals stage was 

unreasonable where the plan delayed the request until late into the already-extended time period to 

complete its review of the appeal, a practice that could be interpreted as “stalling.” Id. at *7–8 

(internal quotation marks omitted) (also citing favorably Gilbertson v. Allied Signal, Inc., 328 F.3d 

625, 636 (10th Cir. 2003) which noted that the costs from insurers’ delays are generally much 

higher for claimants — who need the benefits — than for plan administrators). 

Montoya also relies on Kowalski v. Farella, Braun & Martel, LLP, No. C-06-3341 MMC, 

2007 WL 1342475 (N.D. Cal. May 7, 2007), for the proposition that “it is ‘simply unreasonable’ 

to request [an IME] following denial.’” Oppo. 1, fn. 1; FAC 8. That is an incorrect and 

incomplete statement from the court’s order in that case. In Kowalski, the court followed the 

holding in Sidou v. Unumprovident Corp. 245 F. Supp. 2d 207, 216 (D. Me. 2003) that “it is 

simply unreasonable to request that a claimant submit to medical examinations after the 

applicable deadline for ruling on her appeal.” Kowalski, 2007 WL 1342475, at *4 (emphasis 

added); see also Sidou, 245 F. Supp. at 216 (“it is clear in this case that the only purpose of the 

requested examinations was to develop a factual record for purposes of determining an appeal 

after the applicable deadline for reviewing the appeal had expired.” (emphasis added)). Again, a 

request for an IME past the deadline for ruling on the appeal is not at issue in this case.

 

F. Supp. 2d 1018 (S.D. Cal. 2006) is misplaced. That case did not directly address whether an 

IME at the appeals stage was reasonable or appropriate. Instead, the court in Perez concluded that 

the appeals process established by the plan at issue did not discuss and did not require plaintiff to 

submit to an IME to exhaust her administrative remedies.

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Finally, Kosiba v. Merck involved a situation where the plan administrator (rather than the 

claims administrator) intervened in the appeals process and requested the claimant to undergo an 

IME on appeal in an apparent effort to counter the consistent evidence from plaintiff’s physicians 

as to her disability. 384 F.3d 58, 61, 67–68 (3d Cir. 2005). The issue under consideration in 

Kosiba was not whether an IME during an administrative appeal was appropriate, but what 

standard of review was appropriate for the District Court to apply in reviewing the denial of 

benefits. Id.6 Although the court found that the circumstantial evidence suggested that the plan 

administrator had a desire to use the IME to generate evidence to counter the claimant’s 

physicians’ diagnoses, it also emphasized that “[i]ndependent medical examinations are not 

uncommon in the claims administration world, and this is responsible plan administration [the 

court] would not wish to deter.” Id. at 68.

In sum, Montoya’s cases are inapposite while Reliance’s cases speak directly to the 

question at hand and support my conclusion that absent bad faith or other extenuating 

circumstances, a plan administrator’s request for an IME during the administrative appeal stage 

does not violate ERISA. Because there is no argument that Reliance’s request for an IME was 

made in bad faith or unreasonably delayed, I conclude that plaintiff is required to submit to a 

physical IME in order to complete the record in this case. As I indicated at oral argument, the 

parties are to proceed with the IME, and the IME shall be conducted as soon as practicable. Given 

Montoya’s request, every reasonable effort should be made to find a physician who will agree to 

conduct the IME with Montoya’s counsel present. If the parties have been unable to find a 

physician who will agree to this condition, the parties shall submit a joint letter describing their 

efforts on this matter within seven days of the date of this Order.

CONCLUSION

For the reasons described above, defendants’ motion for partial summary judgment on the 

issue of exhaustion of remedies is DENIED. The parties shall proceed with the physical IME and 

 

6 Because the court found that the defendant was not acting as a disinterested fiduciary, the court 

applied the more searching “heightened arbitrary and capricious standard of review” to its review 

of the claims denial. Kosiba, 384 F.3d at 68.

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that IME shall be conducted within 60 days of the date of this Order.

Additionally, in supplemental briefing submitted after the oral argument, the parties raised 

the new issue of whether Montoya is entitled under ERISA to review the findings of an IME 

before a final decision on administrative appeal is rendered by Reliance. That issue will be 

addressed in a separate order.

IT IS SO ORDERED.

Dated: March 2, 2015

______________________________________

WILLIAM H. ORRICK

United States District Judge

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