Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-casd-3_05-cv-02298/USCOURTS-casd-3_05-cv-02298-1/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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1 05cv2298

UNITED STATES DISTRICT COURT

SOUTHERN DISTRICT OF CALIFORNIA

THOMAS STAFFELD,

Plaintiff,

CASE NO. 05cv2298 BTM (WMc)

ORDER DENYING DEFENDANTS’

MOTION FOR SUMMARY

JUDGMENT [Doc. #21]

vs.

THE PRUDENTIAL INSURANCE

COMPANY OF AMERICA; LEAP

WIRELESS INTERNATIONAL

DISABILITY PLAN #502,

Defendants.

On December 16, 2005, Plaintiff Thomas Staffeld filed a complaint against Defendants

The Prudential Insurance Company of America (hereinafter “Prudential”) and the Leap

Wireless International Disability Plan #502 (the “Plan”) under the Employee Retirement

Income Security Act of 1974, 29 U.S.C. § 1101, et seq. (“ERISA”) for failure to pay Short

Term Disability (“STD”) and Long Term Disability (“LTD”) benefits per the terms of the Plan.

On March 16, 2006, a Stipulation and Order was filed, stipulating that the court shall apply

a de novo standard of review for assessing Plaintiff’s disability claims, unless required by law

to do otherwise. On October 11, 2006, Defendants filed a motion for summary judgment.

For the reasons discussed below, the Court DENIES Defendants’ motion.

//

//

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2 05cv2298

I. FACTUAL BACKGROUND

A. The Disability Plan

At the time of Plaintiff’s alleged disability, he was an employee of Leap Wireless

International (“Leap”), which had obtained an employer-sponsored benefit program for short

and long-term disability from Prudential (the “Plan”; Group Policy G-40946-CA). (See

Prudential’s Claim File (“Claim File”), PRU1-72.) Under the terms of the Plan, a person is

“disabled” and entitled to STD benefits if, after a 7 day elimination period during which the

person performs no work, he or she is then “unable to perform the material and substantial

duties of [his or her] regular occupation due to [his or her] sickness or injury; . . . [has] a 20%

or more loss in weekly earnings due to the same sickness or injury; and . . . [is] under the

regular care of a doctor.” (Claim File, PRU36.) The Plan contains an exclusion to the STD

clause, whereby injuries “arising out of, or in the course of, any work . . . or a sickness

covered . . . by any workers’ compensation law, occupational disease law or similar law” are

excluded from benefit coverage. (Id. at PRU40.) 

Per the terms of the Plan, a person is entitled to LTD benefits if he or she is “unable

to perform the material and substantial duties of [his or her] regular occupation due to [his

or her] sickness or injury; . . . [has] a 20% or more loss in [his or her] indexed monthly

earnings due to that sickness or injury; and . . . [is] under the regular care of a doctor.” (Id.

at PRU45.) Additionally, after 24 months of payments, a person is entitled to LTD when

“due to the same sickness or injury, [he or she] is unable to perform the duties of any gainful

occupation for which [he or she is] reasonably fitted by education, training, or experience.”

(Id.) For both the short and long term disability benefits, the Plan defines “material and

substantial duties” as those duties which are “normally required for the performance of [the

person’s] regular occupation; and cannot be reasonably omitted or modified.” (Id. at 45; see

also PRU36-37.) 

B. Plaintiff Files a Disability Claim

Over the past twenty years, Plaintiff has reported having chronic, painful headaches

of increasing severity. (Id. at PRU79, 92.) On July 9, 2002, Plaintiff did not go to work, and

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3 05cv2298

on July 11 he saw Dr. Charles Moss complaining of severe headaches. (Id. at PRU110.)

Also on July 11, 2002, Plaintiff submitted a claim for disability benefits with Prudential, citing

“chronic headaches which are exacerbated by work induced stress” as his disability, and

answering yes to the question, “[i]s this condition work related?” (Id. at PRU449.) On this

claim, Plaintiff left blank a box asking if he “intend[ed] to file a Workers’ Compensation claim”

and wrote in a question mark next to the box. (Id.) On the Employer Statement, dated

August 30, 2002, a Leap Representative stated that Plaintiff had not indicated that his

absence from work was work-related, and that a workers’ compensation claim had not been

filed. (Id. at PRU458.) In a September 5, 2002 telephone call, Plaintiff informed Prudential

that he was “stressed out” at work, had lost 20 pounds (down to 145 pounds at 6 feet tall),

and had “severe worsening” headaches. (Id. at PRU512 (quotations from Prudential Call

Log, paraphrasing Plaintiff’s description).) On September 6, 2002, Prudential denied

Plaintiff’s STD claim, citing their belief that his “condition [was] caused by, contributed by, or

resulting from [his] occupational sickness or injury” and thus excluded under the work-related

injury clause of the Plan. (Id. at PRU507-8.) On October 7, 2002, Plaintiff filed a

Reimbursement Agreement, and requested that Prudential honor his claim for STD benefits.

(Id. at PRU446.) He stated that he had not filed for workers’ compensation benefits because

he was unsure if his disability was work-related. (Id.) On October 29, 2002, in light of the

Reimbursement Agreement, Prudential approved STD benefits for the period through July

29, 2002 stating that “the medical information submitted . . . supports a period of disability

. . ..” (Id. at PRU503-4, 543, 545.) At this time, Prudential requested that Plaintiff submit

additional medical records from May 2002 if Plaintiff wished to pursue additional benefits.

(Id. at PRU503.) Plaintiff then submitted additional medical records, and was denied LTD

benefits on December 19, 2002, owing to Prudential’s belief that the “medical information in

file [did] not support that [he] had a significant change in [his] chronic headaches and nor

[did] it support that [he had] impairments severe enough to prevent [him] from performing the

material and substantial duties of [his] regular occupation.” (Id. at PRU498-501.)

On February 12, 2004, October 5, 2004, and March 27, 2005, after submission and

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4 05cv2298

consideration of additional medical records from various doctors regarding the claimed

disability, Prudential denied Plaintiff’s first, second, and third appeals for benefits,

respectively. (Id. at PRU472-494.) On December 16, 2005, having exhausted the appeals

process at Prudential, Plaintiff filed this suit under ERISA, 29 U.S.C. § 1101, et seq.

C. Evidence in Prudential’s Record Pertaining to the Disability

There is no shortage of medical opinions on the issue of Plaintiff’s alleged disability.

Much of the administrative record is summarized as follows:

In the initial Attending Physician’s Statement, dated August 1, 2002, Dr. Charles Moss

indicated a primary diagnosis of Acute Stress Syndrome, with secondary diagnoses of weight

loss and headaches. (Id. at PRU454-56.) The administrative record contains nine patient

intake records from the office of Dr. Moss, between the dates of July 11, 2002 (the date

Plaintiff filed for disability) and November 6, 2002, indicating headaches and fatigue. (Id. at

PRU110-118.) Also found in Prudential’s records are numerous notes from Dr. Moss’s office

indicating Plaintiff’s presence there throughout the years of 2002 and 2003. (Id. at PRU405-

433.) 

The record contains a 1997 X-Ray report from Dr. Van Lom at Scripps Memorial

Hospital, indicating “the height of the C6 vertebrae appears slightly diminished” and opining

that “perhaps this is related to some prior trauma.” (Id. at PRU353.)

On December 31, 2002, Plaintiff saw Dr. Aderholdt at Alvarado Hospital. (Id. at

PRU356.) Prudential’s record contains Dr. Aderholdt’s Radiology Report, which states:

“Ther [sic] is moderate loss of vertebral body height affecting both the C5 and C6 levels. Mild

associated degenerative change is suggestive of old injury.” (Id.)

The record contains a February 4, 2003 letter from Dr. Isaac Bakst indicating that

previous doctors have attributed Plaintiff’s headaches to a 1975 head injury, suffered during

a 30 foot fall, and have suspected that Plaintiff suffered from disc degeneration of the cervical

spine. (Id. at PRU107.) Dr. Bakst observed “tenderness in the left aspect of the neck” and

“superior orbit” of the head, and noted that Plaintiff reported increasing severity of the

headaches and weight loss. (Id.) Dr. Bakst stated that “there is probably an aspect of this

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1

 “Analgesic rebound” has been described as a condition by which an individual’s

headache is at least partially caused by the overuse of analgesic (pain-relieving) medication.

See Family Practice News, “Chronic Headaches Due to Analgesic Overuse Reach Epidemic

Levels” (May 1, 2001), available at http://findarticles.com/p/articles/mi_m0BJI

/is_9_31/ai_75176535 (last visited Feb. 12, 2007). 

5 05cv2298

headache that is related to the continued use of Fiorinal and Codeine” and he suggested

Botox treatment. (Id. at PRU108-109.) 

Dr. Bakst referred Plaintiff to Dr. Jack Schim for neurologic evaluation. On February

21, 2003, Dr. Schim sent a letter to Dr. Bakst indicating his evaluation of previously

administered medical tests, stating: “[Plaintiff] has had extensive imaging work-up in the past,

including MRI of the brain which I have reviewed, which was negative, a PET scan which

appears normal, and cervical spine MRI which shows mild cervical degenerative disk

changes.” (Id. at PRU79-82.) Dr. Schim opined that there might have been an element of

analgesic rebound1 present, stating:

Dr. Staffeld has chronic daily headaches which have predominantly features

of chronic tension-type headache. As he is certainly using daily analgesics,

the possibility that there is a rebound element must be considered though his

history that he went 10+ years experiencing daily headaches not using

analgesics and has tried being off analgesics for up to a month without

improvement in his headache, suggest that he may be simply “chasing his

pain” rather than rebound per se. Nevertheless, the likelihood of response

to another preventive oral agent is very slim, having failed several thus far.

(Id. at PRU81.) Dr. Schim also suggested Botox injections for treatment of Plaintiff’s

headaches. (Id.) 

Between May 8, 2003, and September 24, 2004, Plaintiff saw Dr. Hussein Abdulhadi

at Alvarado Hospital at least 27 times for his headaches. The record contains patient intake

records for each of these visits, in which Plaintiff reported headaches and Dr. Abdulhadi

prescribed numerous pain medications and Botox treatments. (Id. at PRU125-146, 364-390.)

In a May 7, 2004 outpatient visit, Dr. Abdulhadi diagnosed a “bioccipital, bifrontal and

retroorbital” daily headache, and noted that Plaintiff scored the pain between 6 and 8 on a

0 to 10 scale. (Id. at PRU125.) Dr Abdulhadi noted that the pain interfered with Plaintiff’s

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2

 It is unclear from the record if Plaintiff informed Dr. Abdulhadi that the pain interfered

with his ability to work and perform recreational activities, or if the doctor independently

determined these facts.

3

 Merriam Webster’s Medical Dictionary defines “conversion disorder” as: “a

psychoneurosis in which bodily symptoms (as paralysis of the limbs) appear without physical

basis -- called also conversion hysteria, conversion reaction.” Merriam-Webster's Medical

Dictionary, at http://www.merriam-webster.com/cgi-bin/mwmedsamp?book=Medical&va=

sample (last visited Feb. 12, 2007) (internal emphasis omitted).

6 05cv2298

ability to work and perform recreational activities.2 (Id.) In a Consultation Memo dated

November 24, 2003, Dr. Abdulhadi noted that [Plaintiff] “is disabled as he is limited by his

headache and neck pain.” (Id. at PRU339.) The doctor then stated:

Headache and pain in general are a subjective phenomenon. There is no

objective test that can reveal objective data to quantitate the amount of pain

the patient is in; in fact, pathology and pain do not correlate together. Again

the patient’s disability remains as perceived by the patient because of pain

otherwise there is no physical limitation. 

(Id. at PRU340.) 

During this time, Dr. Abdulhadi referred Plaintiff to Dr. Charles Farrow. Between

August 27, 2003 and October 10, 2003, Plaintiff saw Dr. Farrow on eight occasions for

neuropsychological examination. (Id. at PRU322.) The record contains an October 14, 2003

report from Dr. Charles Farrow relating the results of these examinations. (Id.) In this report,

Dr. Farrow suggested the possibility of right hemispheric brain damage, and noted that the

“findings suggest[ed] that Mr. Staffeld indeed is struggling with his head injury and sequelae,

and that he is not a true conversion disorder.”3

 (Id. at PRU333.) Dr. Farrow concluded his

extensive report with the following:

Given the functional problems listed above and the clear statistical significance

of many variables, there is reason to believe that Mr. Staffeld suffered a rather

severe concussion 20 years ago. Historically, this fits with the data of severe

headaches since that time, as many persons who suffered a closed head injury

will suffer post-traumatic headaches for years. Given the poor treatment

results to migraine headache treatments, the diagnosis of post-traumatic

headache seems likely. While he clearly fluctuates in his capacity to cope with

his problem, the very fact that the skills most impaired by his trauma were the

ones he relied on at work suggests that his headaches would have been

exacerbated by his efforts to use his negatively affected resources. In sum, it

is clear that he is struggling with a pain disorder with both medical and

psychological components. 

(Id. (emphasis added).)

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4

 It is unclear from this letter as to whom Dr. Moss is attributing this description.

5

 Merriam Webster’s Medical Dictionary defines “somatoform disorder” as: “any of a

group of psychological disorders (as body dysmorphic disorder or hypochondriasis) marked

by physical complaints for which no organic or physiological explanation is found and for

which there is a strong likelihood that psychological factors are involved.” Merriam-Webster’s

Medical Dictionary , at http://www2.merri am-webster.com/cgibin/mwmednlm?book=Medical&va=somatoform (last visited Feb. 14, 2007).

7 05cv2298

On February 12, 2004, Prudential denied Plaintiff’s first appeal for extended STD and

LTD benefits. (Id. at PRU491.)

On July 26, 2004, Dr. Moss sent a letter to Prudential stating that Plaintiff had been

“disabled by the severity of the headaches during the past year.” (Id. at PRU245-46.) Dr.

Moss also described the variety of treatments that had been applied to Plaintiff - Botox,

various pain medications, acupuncture - and noted that these treatments had provided no

significant improvement in Plaintiff’s condition. (Id. at 245.) Dr. Moss noted that Plaintiff’s

headaches “are described as continual, severe, and disabling”4 and stated that Plaintiff had

been “unable to concentrate, read, or function intellectually.” (Id.) Dr. Moss also noted

Plaintiff’s “significant weight loss in the last six months to one year.” (Id.) Additionally, Dr.

Moss stated that, while a prior PET scan and MRI of Plaintiff’s brain were “normal,” a

previously performed MRI of the cervical spine showed “degenerative changes at C5-6 and

cervical myospasm.” (Id.) Finally, Dr. Moss stated: “With [Plaintiff’s] failure to respond to any

therapeutic intervention at this time, I feel he will maintain a chronic disability state.” (Id. at

PRU246.) 

In late 2004, Prudential hired Dr. Goldschmidt to perform an independent medical

review of Plaintiff’s file. (Id. at PRU306-310.) In Dr. Goldschmidt’s September 23, 2004

report, he indicated that Plaintiff’s headaches were “subjective” and without “any defined

organic basis.” (Id. at PRU308.) Dr. Goldschmidt stated that “[s]ince MRI brain and PET

brain [scans] were normal, it is also unlikely that the claimant is demonstrating the effects of

alleged brain injury without loss of consciousness, thirty years earlier.” (Id.) Dr.

Goldschmidt considered the following diagnoses: “Malingering to get drugs (narcotics,

psychostimulants, and barbiturates); Factitious disorder; Somatoform Disorder;5

 Psychogenic

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6

 “Psychogenic pain” is defined as pain which is “originating in the mind or in mental

or emotional conflict.” Id. at http://www2.merriam-webster.com/cgi-bin/mwmednlm?book=

Medical&va=psychogenic (last visited Feb. 14, 2007).

7

 “Dysthymia” is defined as “a mood disorder characterized by chronic mildly

depressed or irritable mood often accompanied by other symptoms (as eating and sleeping

disturbances, fatigue, and poor self-esteem).” Id. at http://www2.merriam-webster.com/

cgi-bin/mwmednlm (last visited Feb. 14, 2007).

8 05cv2298

pain;6 Polysubstance Abuse; Personality Disorder NOS with Passive-Aggressive, Dependent,

and Antisocial traits; and Dysthymia7

 secondary to personality dynamics.” (Id.) Dr.

Goldschmidt also stated that “[p]otential rebound headaches from his Fiorinal should also be

considered.” (Id.) Dr. Goldschmidt opined that Plaintiff’s “substance abuse represents a

facilitated illness based on his physicians willingness to prescribe high dose narcotics for

subjective complaints of pain,” and that Plaintiff had “apparently . . . decided that it was time

to retire.” (Id. at PRU309.) 

Also found in the record is an October 1, 2004 letter from Dr. Moss to the Department

of Social Services, stating: “[Plaintiff] continues to have chronic fatigue and chronic daily

headaches with no improvement or any response to medications. The neuropsychologist

evaluation showed evidence of posttraumatic headaches. [Plaintiff] is unable to perform any

work because of his pain level. The prognosis is poor for significant improvement.” (Id. at

PRU165.) 

On October 5, 2004, Prudential denied Plaintiff’s second appeal for LTD benefits. (Id.

at PRU479.)

In late 2004, Plaintiff had moved to Oregon and began seeing Dr. Stephen Ireland at

the Neurological Center of Bend. (Id. at PRU91-97.) The administrative record contains a

November 19, 2004 letter from Dr. Ireland stating that Plaintiff’s headaches are “vertex

oriented” and noting that previous MRI scans of the brain and cervical spine “failed to

demonstrate any explanatory abnormalities.” (Id. at PRU92.) Dr. Ireland suggested that “it

is quite likely that [Plaintiff] is in analgesic rebound” which could “provok[e] his headaches

. . . [and] drastically decrease his responsiveness to standard anti-headache therapy.” (Id.

at PRU93.)

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The record also contains a December 10, 2004 letter from Dr. Ireland indicating

Plaintiff’s success in discontinuing use of analgesics, though Plaintiff continued to suffer “very

severe headaches.” (Id. at PRU91.) Dr. Ireland did note that he had never seen Plaintiff

“exhibit any outward evidence of severe pain,” and commented that “[t]his may be the result

of a very stoical nature, but it is distinctly unusual to have such severe headaches and look

so comfortable.” (Id.) 

 Finally, as part of his third appeal, Plaintiff submitted a March 22, 2005 letter from the

Social Security Administration indicating that Plaintiff was found to be disabled, as of July 9,

2002, under the Administration’s requirements for disability. (Id. at PRU176.) The Social

Security Administration defines “disability” as: “inability to engage in any substantial gainful

activity by reason of any medically determinable physical or mental impairment which . . . has

lasted or can be expected to last for a continuous period of not less than 12 months . . ..” (Id.

at PRU178.) 

On March 27, 2005, Prudential denied Plaintiff’s third and final appeal for extended

STD and LTD benefits. (Id. at PRU472.) 

II. Legal Standard

Summary judgment is appropriate if the moving party demonstrates that “the

pleadings, depositions, answers to interrogatories and admissions on file, together with the

affidavits, if any, show that there is no genuine issue as to any material fact.” Fed. R. Civ.

P. 56(c); Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 248 (1986); Celotex Corp. v. Catrett,

477 U.S. 317, 323 (1986). A fact is material when, under the governing substantive law, it

could affect the outcome of the case. See Anderson, 477 U.S. at 248; Freeman v.

Arpaio,125 F.3d 732, 735 (9th Cir. 1997). A dispute is genuine if a reasonable jury could

return a verdict for the nonmoving party. See Anderson, 477 U.S. at 248.

A party seeking summary judgment always bears the initial burden of establishing the

absence of a genuine issue of material fact. See Celotex, 477 U.S. at 323. Although the

nonmoving party bears the burden of proof on a matter at trial, the moving party must

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8

 Because the Plan’s standards for short and long term disability do not differ on

material issues, except in the event LTD is paid for 24 months, the following analysis shall

apply to claims for both STD and LTD benefits. 

10 05cv2298

demonstrate to the Court that there is insufficient evidence to support the nonmoving party’s

case. Id. at 325. The moving party, after allowing adequate time for discovery, can satisfy

this burden in two ways: (1) by presenting evidence that negates an essential element of the

nonmoving party’s case; or (2) by demonstrating that the nonmoving party failed to establish

an essential element of the nonmoving party’s case on which the nonmoving party bears the

burden of proof at trial. See id. at 322-23. “Disputes over irrelevant or unnecessary facts will

not preclude a grant of summary judgment.” T.W. Elec. Serv., Inc. v. Pacific Elec.

Contractors Ass’n, 809 F.2d 626, 630 (9th Cir. 1987).

Once the moving party establishes the absence of genuine issues of material fact, the

burden shifts to the nonmoving party to set forth facts showing that a genuine issue of

disputed fact remains. See Celotex, 477 U.S. at 324. The nonmoving party cannot rest on

the mere allegations or denials of his pleading, but must “go beyond the pleadings and by

his own affidavits, or by the ‘depositions, answers to interrogatories, and admissions on file’

designate ‘specific facts showing that there is a genuine issue for trial.’” Id. (citing Fed. R.

Civ. P. 56)). When making this determination, the court must view all inferences drawn from

the underlying facts in the light most favorable to the nonmoving party. See Matsushita Elec.

Indus. Co., Ltd. v. Zenith Radio Corp., 475 U.S. 574, 587 (1986); Fontana v. Haskin, 262

F.3d 871, 876 (9th Cir. 2001). The court must not weigh the evidence or make credibility

determinations in evaluating a motion for summary judgment. See Anderson, 477 U.S. at

255.

III. Discussion8

The parties to this case stipulate that the standard of review for determining the

propriety of Prudential’s denial of Plaintiff’s claim is de novo. As such, and because the other

requirements of the Plan appear undisputed, the ultimate issue before this court is whether

Plaintiff was “unable to perform the material and substantial duties of [his] regular

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occupation due to [his] sickness or injury” such that Plaintiff should be entitled to recover

STD and LTD benefits during the respective and appropriate time periods. (Id. at PRU36,

PRU45.) Additionally, if the Court finds that Plaintiff met this standard for LTD, it must then

determine if, for the period after 24 months of LTD payments would have been made, Plaintiff

was, and is, “unable to perform the duties of any gainful occupation for which [he is]

reasonably fitted by education, training, or experience.” (Id. at 45 (emphasis added).) 

Under the de novo standard, deference is not accorded to the determination made by

Prudential, and discussion of Prudential’s reasonableness in denying Plaintiff’s claim is

irrelevant. Firestone Tire and Rubber Co. v. Bruch, 489 U.S. 101 (1989); Mongeluzo v.

Baxter Travenol Long Term Disability Benefit Plan, 46 F.3d 938, 942 (9th Cir. 1995).

A. Plaintiff’s Declaration

Defendants object to Plaintiff’s declaration as unwarranted evidence not contained in

the record originally before Prudential. As a general rule, a district court may consider only

the evidence which had been before the Plan administrator at the time of the administrator’s

ruling. Silver v. Executive Car Leasing Long-Term Disability Plan, 466 F.3d 727, 732 (9th Cir.

2006). This exclusionary rule is based upon the underlying principle that courts should not

function as “substitute plan administrators,” and the admission of additional evidence would

“frustrate the goal of prompt resolution of claims by the fiduciary under the ERISA scheme.”

Taft v. Equitable Life Assurance Soc’y, 9 F.3d 1469, 1471-1472 (9th Cir. 1993) (quoting Perry

v. Simplicity Eng’g, 900 F.2d 963, 966 (6th Cir. 1990)). However, when a Court is reviewing

the administrator’s decision de novo, the Court has discretion to consider new evidence

“under certain circumstances to enable the full exercise of informed and independent

judgment.” Mongeluzo, 46 F.3d at 943-44. The Mongeluzo Court noted that this discretion

must be tempered in order to effectuate the purposes behind ERISA, and “[i]n most cases,

where additional evidence is not necessary for adequate review of the benefits decision, the

district court should only look at the evidence that was before the plan administrator . . . at

the time of the determination.” Id. at 944 (quoting Quesinberry v. Life Ins. Co. of N. Am., 987

F.2d 1017, 1025 (4th Cir. 1993)). 

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In this instance the record before the Court is replete with observations and diagnoses

by medical doctors, and the Court finds this record sufficient to facilitate the making of a

proper and informed de novo review of Plaintiff’s benefits claim. The Court therefore declines

to exercise its discretion and has not considered Plaintiff’s declaration.

B. Facts Supporting Summary Judgment

In light of the complexity of Plaintiff’s affliction and alleged disability, there is no

shortage of documented opinions regarding his headaches. Defendants submit some of

these opinions in an effort to negate the essential elements of Plaintiff’s disability claim.

Much of this evidence stands for the proposition that Plaintiff’s pain is exaggerated or the

result of Plaintiff’s well-documented use of prescription pain medications.

In support of their belief that Plaintiff’s pain is entirely subjective, or exaggerated,

Defendants point to statements by Drs. Ireland and Abdulhadi. As noted above, Dr. Ireland

indicated that he had never seen Plaintiff “exhibit any outward evidence of severe pain” and

found this unusual given Plaintiff’s alleged disability. (Claim File, PRU91.) Dr. Abdulhadi

remarked, somewhat cryptically: “[T]he patient’s disability remains as perceived by the

patient because of pain otherwise there is no physical limitation.” (Id. at PRU340.)

Defendants also argue that Plaintiff did have the ability to work despite the headaches, as

evidenced by the fact that he had been doing so for the past 20 years and had shown no

objective evidence of a recent increase in pain. The relevance of this fact is questionable at

best. Judge Posner, in addressing a similar claim, stated:

This [assumption] would be correct were there a logical incompatibility

between working full time and being disabled from working full time, but there

is not. A desperate person might force himself to work despite an illness that

everyone agreed was totally disabling. Yet even a desperate person might

not be able to maintain the necessary level of effort indefinitely. [The plaintiff]

may have forced himself to continue in his job for years despite severe pain

and fatigue and finally have found it too much and given it up even though his

condition had not worsened. A disabled person should not be punished for

heroic efforts to work by being held to have forfeited his entitlement to

disability benefits should he stop working.

Hawkins v. First Union Corp. Long-Term Disability Plan, 326 F.3d 914, 918 (7th Cir. 2003)

(internal citations omitted). 

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 It must be noted that the doctor’s definition of “disabling” is not necessarily that of

the Plan. 

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Defendants cite to Drs. Bakst, Schim, and Ireland for statements suggesting that

Plaintiff was in a state of analgesic rebound stemming from his continuous and prolonged

use of potent analgesic pain medications. (Id. at PRU108; PRU81; PRU93.) Prudential’s

independent specialist, upon review of Plaintiff’s medical records, suggested that Plaintiff’s

only illness was substance abuse, and proffered that Plaintiff might be “malingering to get

drugs.” (Id. at PRU308-9.)

C. Facts Opposing Summary Judgment

Plaintiff’s case rests primarily on statements by doctors suggesting that his headaches

are legitimate, disabling, and perhaps caused by trauma related to a 1975 head injury. 

Regarding the severity of the headaches, Plaintiff cites to Dr. Moss’s statements

reporting that Plaintiff’s headaches are “continual, severe, and disabling”9

 and stating that

Plaintiff had been “unable to concentrate, read, or function intellectually.” (Id. at PRU245.)

Plaintiff also cites to Dr. Abdulhadi’s comments reporting a daily headache, with Plaintiff

scoring the pain between a six and eight on a zero to ten scale, and noting that Plaintiff was

“disabled as he is limited by his headache and neck pain.” (Id. at PRU125.) Plaintiff also

points to the fact that the Social Security Administration declared him disabled per their

definition as of July 9, 2002. (Id. at PRU176.) Additionally, Plaintiff notes the dramatic loss

of weight he experienced beginning in 2002. 

For evidence linking the headaches to the 1975 head injury, Plaintiff cites to a 1997

radiology report stating: “The height of the C6 vertebrae appears slightly diminished . . .

Perhaps this is related to some prior trauma.” (Id. at PRU353.) Plaintiff also cites to a 2002

radiology report indicating that the “[m]ild associated degenerate change [found in his spine]

is suggestive of old injury.” (Id. at PRU356.) Plaintiff also relies upon the report of Dr.

Farrow, which was based on the doctor’s numerous neuropsychological examinations. Dr.

Farrow stated that he had reason to believe that Plaintiff suffered a “rather severe

concussion” twenty years prior, and opined that “the diagnosis of post-traumatic headache

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seems likely.” (Id. at PRU333.) 

In rebuttal to Defendants’ claims of causation by analgesic rebound, Plaintiff cites to

Dr. Ireland’s report, which indicates Plaintiff’s success in discontinuing the use of narcotics

without relief. (Id. at PRU91.)

D. Genuine Issues of Material Fact

Admittedly, the issue of Plaintiff’s alleged disability is complex. Viewed in the light

most favorable to the Plaintiff, the evidence supporting Defendants’ views does not negate

the similarly convincing and valid evidence confirming the severity of Plaintiff’s pain, and

offering some physiological explanation therefor. As such, summary judgment is

inappropriate in this instance.

Genuine issues of material fact remain as to: 1) whether Plaintiff’s pain was in fact

severe enough to render him unable to perform the material and substantial duties of his

occupation; 2) what these material and substantial duties were, and at what level of pain they

could have been performed; 3) the cause of Plaintiff’s pain; 4) whether this pain had

increased beginning in 2002; and 5) whether the Plan required an increase in pain to qualify

Plaintiff as disabled. Furthermore, genuine issues remain regarding whether Plaintiff’s

alleged disability was work-related, thereby excluding him from STD benefits for the

remainder of that clause’s applicable time period.

Resolution of these issues is necessary to determine whether Plaintiff was in fact

disabled per the Plan, such that he was unable to perform the material and substantial duties

of his occupation. These facts are material, in that they are at the heart of Plaintiff’s claim,

and genuine, in that a reasonable trier of fact could find for the Plaintiff based on the

evidence in the record. In light of the amount of evidence on both sides of the case, it is

properly left for the fact-finder, after a full de novo review of the entire record submitted to the

Court at that time, to determine the weight to assign to any piece of relevant evidence. On

the record before the Court, it cannot be concluded that Plaintiff cannot meet his burden of

proof to establish disability under the Plan. Rather, a reasonable trier of fact, on de novo

review, could find that Plaintiff was disabled under the Plan. 

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10 Plaintiff has requested oral argument in opposition to Defendants’ motion for

summary judgment. As the Court finds summary judgment inappropriate in this case, that

request is denied.

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IV. Conclusion

For the foregoing reasons, material issues of fact remain in dispute as to Plaintiff’s

entitlement to short and long term disability benefits per the Plan. Accordingly, Defendants’

motion for summary judgement is DENIED.

10

IT IS SO ORDERED.

DATED: June 11, 2007

Hon. Barry Ted Moskowitz

United States District Judge

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