Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-cand-3_05-cv-02716/USCOURTS-cand-3_05-cv-02716-2/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

For the Northern District of California

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UNITED STATES DISTRICT COURT

NORTHERN DISTRICT OF CALIFORNIA

ANTONIO PRADO,

Plaintiff,

 v.

ALLIED DOMECQ SPIRITS AND WINE

GROUP DISABILITY INCOME POLICY,

Defendant. 

LIBERTY MUTUAL INSURANCE, LIBERTY

LIFE ASSURANCE COMPANY OF BOSTON

Real Party In Interest. ___________________________________

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No. C-05-2716 SC

ORDER GRANTING

PLAINTIFF'S MOTION

FOR SUMMARY JUDGMENT

AND DENYING

DEFENDANT'S MOTION

FOR SUMMARY JUDGMENT

I. INTRODUCTION

Plaintiff Antonio Prado ("Plaintiff" or "Prado") filed a

complaint against the Allied Domecq Spirits and Wine Group

Disability Income Policy ("Defendant" or "the Plan") alleging a

failure to extend disability benefits in accordance with the Plan

and the Employee Retirement Income Security Act of 1974 ("ERISA"),

28 U.S.C. § 1132. See Docket No. 1. The Real Party in Interest,

Liberty Mutual Insurance ("Liberty"), is the Plan administrator. 

Presently before the Court are cross-motions for summary judgment. 

See Docket Nos. 41, 44. Both parties have filed oppositions and

replies. See Docket Nos. 47, 48, 49, 50. 

For the following reasons, the Court GRANTS Plaintiff's

motion and DENIES Defendant's motion.

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II. BACKGROUND

Plaintiff worked as a production manager for Mumm Napa Valley

("Mumm"), a subsidiary of Allied Domecq Spirits and Wine, from

February, 1987 until September 2003. McGee Decl. Ex. B Claim File

("CF") at 299. Plaintiff was a beneficiary of his employer's

sponsored long-term disability plan and this plan was insured by a

group disability income policy issued by Liberty. Id.; Def.'s

Mot. at 2. On September 1, 2003, Plaintiff informed Liberty that

pain from a work-related injury had escalated to the point that he

could no longer continue working. CF at 8, 299. He then filed a

disability benefits claim, which Liberty received on March 25,

2004. Id. at 299. According to the benefits plan, "disability"

is defined as the inability of the plan participant "during the

Elimination Period and the next 24 months . . . to perform all of

the material and substantial duties of his occupation . . . ." 

McGee Decl. Ex. A., Group Disability Income Policy, at 4.

After reviewing his claim, Liberty, on June 2, 2004, denied

long-term benefits. CF at 243-46. Liberty provided the following

reason for the denial: "There is insufficient evidence to show

that you were disabled from the date you stopped working

throughout the Elimination Period. There is insufficient evidence

on file to support restrictions and limitations that preclude you

from preforming your occupation from September, 2003, to the

present." Id. at 245. Plaintiff appealed the decision and, on

August 4, 2004, after further review, Liberty upheld its initial

denial. Id. at 190-93.

Plaintiff then requested that Liberty Mutual reconsider its

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denial in light of new medical information. Id. at 18. 

Specifically, Plaintiff sought to introduce the results of an MRI

that was performed on September 17, 2004, and the medical records

from a back surgery that was performed on January 26, 2005. Id. 

Liberty informed Plaintiff on May 6, 2005, that it would not

reconsider the claim because Plaintiff had already exhausted his

administrative remedies under ERISA. Id. at 17. Plaintiff filed

the present action on July 1, 2005.

 

III. DISCUSSION

Entry of summary judgment is proper "if the pleadings, the

discovery and disclosure materials on file, and any affidavits

show that there is no genuine issue as to any material fact and

that the movant is entitled to judgment as a matter of law." Fed.

R. Civ. P. 56(c). "Summary judgment should be granted where the

evidence is such that it would require a directed verdict for the

moving party.” Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 250

(1986). Thus, "Rule 56(c) mandates the entry of summary judgment

. . . against a party who fails to make a showing sufficient to

establish the existence of an element essential to that party's

case, and on which that party will bear the burden of proof at

trial." Celotex Corp. v. Catrett, 477 U.S. 317, 322 (1986). 

"Where the decision to grant or deny benefits is reviewed for

abuse of discretion, 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.

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Standard Ins. Co., 185 F.3d 939, 942 (9th Cir. 1999).

In the present case, Liberty argues that summary judgment is

proper because Liberty's decision to deny benefits is entitled to

substantial deference by the Court and the decision was

reasonable. Liberty also argues that even if the Court affords

Liberty's decision little deference, the record supports Liberty's

decision. Plaintiff argues that Liberty's denial of benefits was

an abuse of discretion. 

A. Liberty's Conflict of Interest

As a preliminary matter, the Court addresses the issue of

Liberty's conflict of interest. Where a plan administrator "both

decides who gets benefits and pays for them, . . . it has a direct

financial incentive to deny claims," and therefore "labors under .

. . a conflict of interest." Saffon v. Wells Fargo & Co. Long

Term Disability Plan, No. 05-56824, 2008 WL 80704, at * 2 (9th

Cir. 2008). The Ninth Circuit has explained:

On the one hand, such an administrator is

responsible for administering the plan so

that those who deserve benefits receive

them. On the other hand, such an

administrator has an incentive to pay as

little in benefits as possible to plan

participants because the less money the

insurer pays out, the more money it

retains in its own coffers. 

Abatie v. Alta Health & Life Ins. Co., 458 F.3d 955, 965-66 (9th

Cir. 2006). 

Although courts "nominally review [a denial of benefits] for

abuse of discretion, the degree of deference [courts] accord to a

claim's administrator's decision can vary significantly" depending

on the conflict. Saffon, 2008 WL 80704, at * 2. Courts "'weigh'

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such a conflict more or less 'heavily' depending on what other

evidence is available." Id. (citing Abatie, 458 F.3d at 968).

We "view[]" the conflict with a "low"

"level of skepticism" if there's no

evidence "of malice, of self-dealing, or

of a parsimonious claims-granting

history." But we may "weigh" the

conflict "more heavily" if there's

evidence that the administrator has given

"inconsistent reasons for denial," has

failed "adequately to investigate a claim

or ask the plaintiff for necessary

evidence," or has "repeatedly denied

benefits to deserving participants by

interpreting plan terms incorrectly."

Id. (citing Abatie, 458 F.3d at 968) (internal citations omitted,

alteration in original). Accordingly, "when reviewing a

discretionary denial of benefits by a plan administrator who is

subject to a conflict of interest, [a court] must determine the

extent to which the conflict influenced the administrator's

decision and discount to that extent the deference we accord the

administrator's decision." Id.

In the present case, Defendant concedes that a conflict of

interest exists. See Def.'s Mot. at 2 (stating "Liberty's

structural conflict of interest is a factor to be considered by

the Court in determining the weight to be given to Liberty's

decision . . ."). In reviewing Liberty's decision to deny

benefits, the Court must determine the extent, if any, to which

this conflict influenced Liberty's decision. 

Several instances stand out from the record. To begin,

Liberty's justification for denying benefits is worth noting. The

Ninth Circuit has held that a plan administrator must give a

claimant a "'description of any additional material or

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information' that [is] 'necessary' for [him or] her to 'perfect

the claim,' and to do so 'in a manner calculated to be understood

by the claimant.'" Saffon, 2008 WL 80704, at * 5 (citing 29

C.F.R. § 2560.503-1(g)). In the present case, Liberty made

repeated requests for general medical information, including

"complete medical information," CF at 244, and "all medical

records from August, 2003 through the present, including any test

results." Id. at 244, 255. 

Other than Liberty's request for Plaintiff's MRI, however,

its repeated requests for general medical information provided no

guidance to Plaintiff for what, specifically, Liberty needed in

order to make an informed decision on Plaintiff's claim. For

example, it is unclear what Liberty was seeking when it repeatedly

requested Plaintiff's "treatment notes" and "clinical evidence." 

By Liberty's own admission, Plaintiff had submitted various

"notes" from Dr. Levy detailing Plaintiff's pain and symptoms,

including his chart note stating that he had reviewed Plaintiff's

August 28, 2003, lumbar scan and MRI. Furthermore, Dr. Levy's

notes, beginning on October 15, 2003, all recommend that Plaintiff

remain off of work. This recommendation was in effect through at

least July 1, 2004. CF at 227. 

In another example of potential evidence of Liberty's

conflict of interest, Liberty requested that Plaintiff provide a

phone number for Kaiser Hospital so that Liberty could request

certain of Plaintiff's files. Liberty, however, was unable to get

in touch with Kaiser because, according to Liberty, Plaintiff "had

listed an incorrect 800 number on the Claimant Information Form." 

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Def.'s Mot. to Dismiss at 6. Liberty then requested that

Plaintiff provide another number for Kaiser. Id. Plaintiff

provided a local number which, according to Liberty, was also

incorrect. Id. Instead of looking up Kaiser's number in a phone

book, however, Liberty apparently made no further efforts to

contact Kaiser in order to obtain Plaintiff's medical records.

Liberty's failure to contact Kaiser is worth noting. It is

hard to see how this satisfies Liberty's "duty--outlined . . . in

Booton[ v. Lockheed Med. Benefit Plan, 110 F.3d 1461 (9th Cir.

1997)]--to have a meaningful dialogue with its beneficiary in

deciding whether to grant or deny benefits." Saffon, 2008 WL

80704, at * 8. A claimant's failure to provide the correct number

for a large, well-known hospital, and a claim provider's

subsequent failure to obtain, on its own, what is surely a

readily-available number, is simply not a valid justification for

a later denial of a claim due to incomplete medical records.

Evidence of Liberty's conflict is even manifest in the briefs

it submitted to this Court. In Liberty's Opposition to

Plaintiff's Motion for Summary Judgment, Liberty states that

Plaintiff did not establish that he was disabled from the period

beginning immediately after he stopped working because "the

earliest certification of alleged disability by a doctor is the

conclusory statement of Dr. Levy on a prescription note dated

October 13, 2003--more than a month after [Plaintiff's] last day

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1 That Dr. Levy's statements are conclusory is not

surprising. Doctors, in diagnosing patients' ailments, generally

do make conclusions based on their observations. 

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of work."1 Def.'s Opp'n at 1. In Liberty's own Motion for

Summary Judgment, however, Liberty acknowledges that Plaintiff

submitted records from doctors' visits on August 5, 2003, while he

was still working, and September 4, 2003, three days after his

last day of work. Def.'s Mot. at 9. 

The August 5 visit produced a medical report indicating that

Plaintiff was complaining of neck and back pain, was not improving

with physical therapy and medication, was unable to sit or work

for prolonged periods of time due to pain that radiated from his

left shoulder into his fingers, and a diagnosis of radiculopathy

and lumbar disc disease. Def.'s Mot. at 9; CF at 237-38. The

September 4 visit was a neurology consultation in which the doctor

noted Plaintiff's pain in his back and neck and numbness in his

nose, upper lip, and fingers. CF at 240. Whether these records,

in and of themselves, establish disability is not clear; what is

clear, however, is that Liberty had medical records in support of

Plaintiff's claim that predated Dr. Levy's October 13 report. 

Thus, Liberty's statement that "the earliest certification of

alleged disability by a doctor is the conclusory statement of Dr.

Levy on a prescription note dated October 13, 2003--more than a

month afer [Plaintiff's] last day of work," is simply wrong.

The Court must also note that Liberty, in its moving papers,

characterizes the report from the September 4 neurological

examination as "essentially benign." Def.'s Mot. at 10. The

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Court, however, is hard-pressed to understand how a medical report

that concludes that a person is experiencing burning pain in their

back, neck and head and experiencing numbness in their face and

hands can be "benign." 

From this evidence and the additional evidence discussed

below, the Court finds that Liberty's conflict of interest did in

fact influence its decisions in denying Plaintiff's claim. The

Court therefore "weigh[s] such a conflict more . . . heavily,"

Saffon, 2008 WL 80704, at * 3, and "discount[s] to that extent the

deference [the Court] accord[s] the administrator's decision." 

Id.

This conclusion is buttressed by Liberty's failure to present

any evidence that the conflict did not affect its decision to deny

Plaintiff's claim. "[A] conflicted administrator, facing closer

scrutiny, may find it advisable to bring forth affirmative

evidence that any conflict did not influence its decisionmaking

process, evidence that would be helpful to determining whether or

not it had abused its discretion." Abaties, 458 F.3d at 969. 

Examples of this type of evidence include evidence of independent

medical examiners, a neutral review process, or a lack of

incentives for plan-administrator employees to deny claims. See

id. at 969 n.7. Liberty has presented no such evidence.

B. Liberty's Decision to Deny Benefits

This Court previously held that Liberty's decision to deny

benefits is to be reviewed under an abuse of discretion standard. 

See November 22, 2006, Order, Docket No. 37. As noted above, this

deference is tempered by evidence of Liberty's conflict of

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interest.

At the outset, Plaintiff's argument that Liberty abused its

discretion by not reopening his claim after it had been denied on

appeal is without merit. Liberty denied Plaintiff's claim in June

2004. Plaintiff then appealed this denial and submitted

additional medical records in support of his appeal. This appeal,

however, was rejected in August 2004. Five months later,

Plaintiff had disc replacement surgery. Eight months after the

appeal was denied, Plaintiff submitted approximately 200 pages of

new medical records related to the disc replacement surgery. 

Liberty refused to reopen Plaintiff's claim or consider this new

evidence. Plaintiff offers no authority in support of his

argument that this refusal to reopen the claim was an abuse of

discretion. Accordingly, the Court finds that Liberty did not

abuse its discretion by not reopening Plaintiff's claim. The

Court therefore will not consider any evidence outside of the

administrative record in determining the merits of the issue of

whether Liberty abused its discretion in denying benefits. See

Bendixen, 185 F.3d at 944 (stating "[b]ecause the report was not

before the plan administrator at the time of the denial, the

district court was limited to that record and could not consider

that report in its review"). The Court therefore reviews the

evidence contained within the administrative record to determine

whether Liberty, in light of its conflict of interest, abused its

discretion.

In support of Plaintiff's initial claim for disability,

Plaintiff's primary physician, Dr. Levy, submitted three separate

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2 Liberty makes much of the fact that Plaintiff's treating

physician sent "only three pages of information." Def.'s Mot. at

4; see also id. at 6 (stating "[b]ecause Liberty had received only

three pages of medical information from Dr. Levy, . . . Liberty

left Plaintiff a phone message . . . advising it did not have

enough information"). The Court, however, is mindful that it is

the content of the pages, rather than the number of pages, that

matters.

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documents relating to Plaintiff's medical condition.2 The first

was a hand-written note from October 15, 2003, stating that

Plaintiff was feeling a little better after physical therapy but

was still complaining of numbness in his left arm. In addition,

the note stated that Plaintiff had recently had an MRI that Dr.

Levy had not yet reviewed and that Dr. Levy was considering

whether to refer Plaintiff for disc replacement surgery. CF at

279. 

The second was a letter from Dr. Levy, also from October 15,

stating: "Mr. Prado continues to be symptomatic with headaches and

symptoms of numbness down his left arm along with his continuing

low back condition. I would like for him to remain off work until

November 15, 2003." Id. at 281. Finally, Dr. Levy faxed Liberty

his chart notes from October 22 that detail his review of

Plaintiff's August 28, 2003, MRI. These notes indicate, in part,

that Plaintiff had suffered a "complete collapse of the bottom

disc space with a minimal bulge"; there was no disc herniation;

surgery was not required; and Plaintiff was suffering from

headaches and numbness in his scalp. Id. at 280.

Liberty reviewed these documents from Dr. Levy but determined

that more information was needed before a decision could be

reached on Plaintiff's disability claim. Liberty then sent Dr.

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Levy a letter requesting "updated information," including

"treatment notes from April, 2004" and "any current restrictions

and the proposed treatment plan." CF at 259.

In response to this request, Dr. Levy faxed Liberty a copy of

a letter stating that Plaintiff "has had almost complete collapse

of his disc space." Id. at 260. The letter also proposed various

treatments. Id. In addition, Dr. Levy noted that he had seen

Plaintiff on April 28 for severe back and leg pain and felt

Plaintiff may benefit from either a complete disc replacement or

an interbody fusion. Id. 

Nonetheless, citing insufficient proof of disability, Liberty

denied Plaintiff's claim. Plaintiff then appealed and submitted

additional information. Included in the additional information

were the following:

 -- A note from Dr. Levy from November 17, 2003, stating

that Plaintiff continued to be symptomatic with

headaches, numbness down his left arm, and lower back

pain. Dr. Levy recommended that Plaintiff remain off

work until December 31, 2003. CF at 230.

-- A note from Dr. Levy from January 15, 2004, stating

that Plaintiff was to remain off of work until at least

March 1, 2004. Id. at 229. 

-- A note from Dr. Levy from May 10, 2004, stating that

Plaintiff should continue to remain off of work until at

least July 1, 2004. Id. at 227. 

 -- Records from a doctor's visit from August 5, 2003,

almost a month before Plaintiff stopped working. The

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records indicate that Plaintiff was suffering from neck

and back pain, was unable to sit or work for long

periods of time, and a diagnosis of cervical

radiculopathy and lumbar disc disease. Plaintiff was

also referred to a spine clinic. Id. at 237-38.

-- Records from a neurology consultation from September 

4, 2003, three days after Plaintiff stopped working. 

The records indicate that Plaintiff was suffering from

pain in his back and neck and numbness in his nose,

upper lip, and fingers. The doctor also found no muscle

atrophy, no sensory abnormalities, and opined that

Plaintiff probably did not need surgery. Id. at 239-40.

-- Records from a June 13, 2004, doctor's appointment

noting that Plaintiff continued to experience radiating

neck pain. Id. at 241.

After reviewing these records, Liberty concluded that

Plaintiff was still capable of performing light occupational

duties, including lifting up to 25 pounds. Id. at 4, 221. 

Although Plaintiff's employer Mumm had submitted a description of

Plaintiff's job that included a "medium" physical requirement of

lifting 50 pounds, Liberty nonetheless obtained a vocational

analysis report and concluded that Plaintiff's job was classified

as "light." Liberty thus decided that Plaintiff could perform his

occupation and it upheld its denial of Plaintiff's disability

claim.

This sequence of events is worth noting. Although Liberty

stated several times that Plaintiff's claim was denied because of

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insufficient medical information, Liberty nonetheless was able to

determine, from Plaintiff's records, that Plaintiff could lift up

to 25 pounds, and therefore perform a job classified as "light." 

See CF at 220. After Liberty received this information from its

medical reviewer, Liberty then submitted Plaintiff's occupational

information for a vocational analysis report by a Liberty

employee. CF at 4, 209. Even though Liberty recognized that

Plaintiff's occupation was classified as "medium" because

Plaintiff was required to lift up to 50 pounds, Liberty instead

made a determination that Plaintiff's occupation should be

classified as "light," notwithstanding Plaintiff's employer's own

description of the job. With this new "light" classification, and

with Liberty's prior medical conclusion that Plaintiff could

perform "light" occupational duties, Liberty was able to deny

Plaintiff's claim for disability. From these facts, Liberty's

reclassification of Plaintiff's occupation from "medium" to

"light" is suspect, as it appears that the reclassification was

made in order to conform Plaintiff's occupational description with

Plaintiff's physical limitations as determined by Liberty's

medical reviewer. The Court therefore examines Liberty's

reclassification of Plaintiff's occupation in further detail. 

C. Plaintiff's Job Classification

According to the benefits plan issued to Plaintiff by

Liberty, "disability" is defined as the inability of the plan

participant "during the Elimination Period and the next 24 months

. . . to perform all of the material and substantial duties of his

occupation . . . ." McGee Decl. Ex. A., Group Disability Income

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Policy at 4 (emphasis added).

Plaintiff's employer Mumm classified Plaintiff's job as that

of production manager. CF at 293. The only physical requirement

for this position according to Mumm is the "ability to lift heavy

boxes up to 50 lbs." Id. Nonetheless, Liberty obtained a

vocational analysis and review as to the physical requirements of

Plaintiff's occupation as it exists in the national economy and

decided to adopt, as a description of Plaintiff's occupation, the

Department of Labor's description for "Wine Maker." Def.'s Mot.

at 4. Significantly, this occupational description classified the

physical requirements of Plaintiff's occupation as light strength,

meaning the most Plaintiff had to lift was 20 pounds. Id. at 5. 

This directly contradicts Plaintiff's own employer's description

of the physical requirements. Furthermore, Liberty's doctor who

reviewed Plaintiff's claim on appeal concluded that Plaintiff's

medical condition enabled him to perform only light duty

occupations. Thus, had Liberty not reclassified Plaintiff's

physical requirements from medium duty (lifting 50 pounds) to

light duty (lifting 20 pounds), Plaintiff would have been unable

to perform a material requirement of his job and would have been

disabled, according to Liberty's own doctor.

Liberty provides no justification for reclassifying

Plaintiff's job description from medium to light activity. 

Instead, Liberty argues that it was not unreasonable to look to

the Department of Labor's Dictionary of Occupational Titles

("DOT"), for a description of Plaintiff's occupation. Liberty,

however, already had a detailed description from Mumm setting

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forth the requirements for Plaintiff's occupation. The collection

of district court cases, many from other circuits, cited by

Liberty do not provide justification for ignoring the physical

requirement provided by Plaintiff's employer and instead

substituting a lesser physical requirement based on a national

database. Most deal with the situation, which is plainly not the

case here, where the claimant's occupation was not defined. See,

e.g., Richards v. Hartford Life & Accident Ins., 356 F. Supp. 2d

1278 (S.D. Fla. 2004) (stating "[w]hen the term 'occupation' is

undefined, courts properly defer to the Department of Labor's

Dictionary of Occupational Titles's . . .") (emphasis added);

Tsoulas v. Liberty Life Assurance Co., 397 F. Supp. 2d 79, 96 n.

17 (D. Me. 2005) (stating the same).

Liberty's reliance on a Sixth Circuit decision in which the

court found that a plan administrator's reliance on the DOT was

reasonable is misplaced. In Osborne v. Hartford Life & Accident

Ins. Co., 465 F.3d 296 (6th Cir. 2007), a claimant appealed

Hartford's denial of disability benefits. The claimant, an

executive at an insurance company, submitted a description of his

job as entailing, among other duties, significant travel. Id. at

297. In reviewing whether the claimant could perform all of the

material and substantial duties of his job, Hartford referred to

the DOT. Id. at 298. Hartford concluded that the claimant's job

was classifiable as "President, Financial Institution," and that

this position did not require travel. Id. The claimant, who

conceded that he played golf at least once a week after he claimed

disability, filed suit, claiming that Hartford's reliance on the

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DOT was arbitrary and capricious, and thus an abuse of discretion,

given that it conflicted with the job description that the

claimant actually provided. Id. The Sixth Circuit affirmed

Hartford's use of the DOT, stating:

The word "occupation" is sufficiently

general and flexible to justify

determining a particular employee's

"occupation" in light of the position

descriptions in the [DOT] rather than

examining in detail the specific duties

the employee performed.

Id. at 299.

Such reasoning is understandable in situations where the

claimant's actual occupation might contain duties that are outside

the scope of the requirements typically associated with such an

occupation. In situations, however, where the only difference

between the DOT description and the claimant's actual job

description is, for example, a reduction in the amount of weight

an employee must be able to lift, the claim provider's

justification for using the DOT becomes far less compelling. This

is especially true when the plan administrator subsequently denies

disability benefits based specifically on the lessened physical

requirement. 

Liberty concedes the similarity of the DOT description and

Mumm's description, stating "the DOT occupational description . .

. matched [Plaintiff's] job description." Def.'s Reply at 6. The

only significant difference, as far as the Court can see, is that

the DOT physical requirement is "light," and requires lifting of

only 20 pounds, while Plaintiff's actual occupational requirement

requires lifting of "heavy boxes up to 50 pounds." Id. at 283,

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293.

In denying Plaintiff's disability claim because Plaintiff

could perform the physical activity listed in the DOT but not the

physical activity in the claimant's employer's job description,

Liberty invited skepticism. In such a situation a court is

entitled to question whether this is not "evidence . . . of selfdealing . . . ." Saffon, 2008 WL 80704 at * 3.

The DOT's relevance to the present case is questionable for

other reasons as well. According to Liberty's own Vocational Case

Manager, the description for Plaintiff's occupation in the DOT was

last updated in 1977, making its relevancy today questionable. 

See CF at 282. Even Liberty's own Vocational Case Manager

expressed some doubt regarding the utility of the DOT description,

stating, "It should be noted that the claim file and industry in

which this employee works has not been reviewed by a Liberty

Mutual Vocational Case Manager. This is a basic description

without input from a vocational professional." CF at 282.

Liberty also argues that this reclassification was

appropriate because Plaintiff himself told Liberty "that his job

only required him to work on the computer, use a telephone, and

stand." Def.'s Reply at 2. This, however, mischaracterizes

Plaintiff's statement. Liberty's own notes from the call state

that Plaintiff told Liberty that his job "mostly entailed

computer, phone work, and standing 3-4HRS/Day." CF at 8. The

Court is troubled by Liberty's substitution in its brief of the

word "mostly" with "only." This switch is particularly vexing

given that Liberty's definition of "disability" requires that

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Plaintiff be unable to perform "all of the material and

substantial duties of his occupation." McGee Decl. Ex. A., Group

Disability Income Policy at 4. The fact that Plaintiff's work

mostly entailed computer and phone work by no means indicates that

Plaintiff was not also required to perform heavy lifting. Mumm's

own job description clearly states that lifting up to 50 pounds is

a requirement of the occupation.

D. Relevance of Plaintiff's Subjective Pain

Finally, Plaintiff argues that the Social Security paradigm

for demonstrating "excess pain" is helpful to the present case as

Plaintiff was in significant pain and this pain was not always

easily demonstrable with objective proof. Liberty asserts that

the Social Security standards regarding pain are irrelevant and

inapplicable to an ERISA action. 

The Ninth Circuit recently addressed this issue. In Saffon,

2008 WL 80704, at * 7, the court recognized that "in Social

Security disability cases, . . . we have noted that individual

reactions to pain are subjective and not easily determined by

reference to objective measurements." The court further held: 

While the rules and presumptions of our

Social Security case law do not apply to

ERISA benefits determinations, see Black

& Decker Disability Plan v. Nord, 538

U.S. 822 (2003), our Social Security

precedents are relevant for the factual

observation that disabling pain cannot

always be measured objectively--which is

as true for ERISA beneficiaries as it is

for Social Security claimants.

Id. at *7 n.2. Thus, if a provider "is turning down [an]

application for benefits based on [a] failure to produce evidence

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[of pain] that simply is not available, that . . . may bear on the

degree of deference the district court shall accord [the

provider's] decision and on its ultimate determination as to

whether [the claimant] is disabled." Id. at * 7.

In the present case, Liberty repeatedly asserts that

Plaintiff's complaints of pain are not sufficiently documented

with objective evidence. For example, Liberty states that "[i]t

is not an abuse of discretion or evidence of a conflict of

interest for Liberty to evaluate whether objective evidence, as

opposed to plaintiff's subjective complaints of pain, supported

his claim for disability." Def.'s Mot. at 17. Such a statement,

however, is undermined by Saffon. Liberty may not ignore

Plaintiff's subjective pain complaints and instead rely solely on

objective evidence if evidence of Plaintiff's pain is not

available. Given the not-insubstantial evidence of how Liberty's

conflict of interest affected its decisions and the substantial

evidence of Plaintiff's disability, the Court hereby finds that

Liberty abused its discretion in denying Plaintiff disability

benefits. 

IV. BENEFITS DUE

Plaintiff is entitled to benefits for the period in which he

was prevented from working in "his occupation." This period, as

defined by the Plan, is 24 months. See McGee Decl. Ex. A at 5. 

The parties disagree about the amount of benefits due under this

period. The Court therefore orders the parties to meet and confer

regarding the amount of benefits due under this period and submit

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a stipulation no later than 12:00 p.m. on Friday, February 29,

2008. 

After this initial 24-month period, a claimant, to prove

continuing disability, must show that he is "unable to perform,

with reasonable continuity, all of the material and substantial

duties of his own or any other occupation for which he is or

becomes reasonably fitted by training, education . . . ." Id.

(emphasis added). There is insufficient evidence in the record,

and the parties have not briefed the issue, of whether Plaintiff

is entitled to benefits after the 24-month period. The Court

therefore remands the case to the Plan Administrator for

determination of benefits, if any, during this period.

V. PRE-JUDGMENT INTEREST AND ATTORNEYS' FEES

Plaintiff has moved the Court for pre-judgment interest and

attorneys' fees. For the following reasons, the Court awards

both. "A district court may award prejudgment interest on an

award of ERISA benefits at its discretion." Blankenship v.

Liberty Life Assurance Co. of Boston, 486 F.3d 620, 627 (9th Cir.

2007). Among the factors to be considered in determining whether

pre-judgment interest should be awarded are bad faith and whether

the defendant would suffer any financial interest. See Landwehr

v. DuPree, 72 F.3d 726, 739 (9th Cir. 1995); Dishman v. UNUM Life

Ins. Co. of America, 269 F.3d 974, 988 (9th Cir. 2001). Although

the Court has not found that Liberty acted in bad faith, there is

also no evidence that Liberty would suffer any financial hardship

by paying prejudgment interest. Therefore, Plaintiff is awarded

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pre-judgment interest.

For these reasons the Court also awards Plaintiff attorneys'

fees. See Smith v. CMTA-IAM Pension Trust, 746 F.2d 587, 590 (9th

Cir. 1984) (stating "absent special circumstances, a prevailing

ERISA employee should ordinarily receive attorney's fees from the

defendant"). In the present case, the Court finds no such special

circumstances. See also id. at 589 (holding "[a]s a general rule,

ERISA employee plaintiffs should be entitled to a reasonable

attorney's fee if they succeed on any significant issue in

litigation which achieves some of the benefit the parties sought

in bringing suit"). 

VI. CONCLUSION

For the reasons stated above, the Court GRANTS Plaintiff's

Motion for Summary Judgment and DENIES Defendant's Motion for

Summary Judgment. 

IT IS SO ORDERED.

Dated: January 22, 2008

 

UNITED STATES DISTRICT JUDGE

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