Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-caed-2_05-cv-01331/USCOURTS-caed-2_05-cv-01331-3/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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1 Because oral argument will not be of material

assistance, the court orders these matters submitted on the

briefs. See E.D. Cal. L.R. 78-230(h).

1

UNITED STATES DISTRICT COURT

EASTERN DISTRICT OF CALIFORNIA

----oo0oo----

PATRICIA RIFFEY,

NO. CIV. S-05-1331 FCD/JFM

Plaintiff,

v. MEMORANDUM AND ORDER

HEWLETT-PACKARD COMPANY

DISABILITY PLAN,

Defendant.

----oo0oo----

This matter is before the court on the parties’ crossmotions for summary judgment in this case arising out of

defendant Hewlett-Packard Company Disability Plan’s (“defendant”

or the “Plan”) denial of plaintiff Patricia Riffey’s

(“plaintiff”) claim for long-term disability (“LTD”) benefits.1

 

For the reasons set forth below, the court finds that the

proper standard of review of this matter is abuse of discretion,

as opposed to de novo, and thereunder, the court cannot find that

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2 The following statement of the facts is primarily drawn

from defendant’s motion for summary judgment (Docket #25), as the

facts stated therein derive from the underlying administrative

record and Plan documents. Moreover, plaintiff does not dispute

the essential facts as stated by defendant. Indeed, plaintiff

did not recount a full description of the underlying facts in her

cross-motion or opposition papers; instead, plaintiff largely

relied on the facts as stated by defendant but argued different

legal ramifications of those facts when reviewed under what

plaintiff contends is the correct standard of review (de novo or

“low deference”--abuse of discretion).

3 The Plan is attached as Exhibit B to the Declaration of

Janet Curry, filed in support of defendant’s motion for summary

judgment (Docket #s 26-39 [Curry Decl. and exhibits thereto])

("Curry Decl."). The Plan bears the production number range of

HP564-619. All further references to the Plan will be to “Ex. B”

and where appropriate, to the applicable section and production

number. The Summary Plan Description ("SPD") for the Plan is

attached as Exhibit C to the Curry Decl. and bears the production

number range of HP620-35. References to the SPD herein will be

to “Ex. C” and where appropriate, to the applicable section and

production number. The Administrative Services Agreement (“ASA”)

is attached to the Curry Decl. as Exhibit D and bears the

production number range of HP636-92. Further references to the

ASA will be to “Ex. D” and where appropriate, to the applicable

section and production number.

2

defendant acted arbitrarily or capriciously in denying

plaintiff’s LTD benefits claim. As such, the court GRANTS

defendant’s motion for summary judgment and DENIES plaintiff’s

motion.

BACKGROUND2

A. VPA Determines Benefits Claims Under the Plan

Hewlett-Packard Company (“HP” or the “Company”) adopted the

Plan3 to provide its employees with income in the event of

certain disabilities. The Plan is entirely self-funded by HP and

not insured through any insurance company. (Ex. B, § 4,

HP580-81, HP609.) Voluntary Plan Administrators, Inc. (“VPA”) is

the Plan's claims administrator under the ASA between HP and VPA. 

(Ex. B, § 2(a), HP570; Ex. D.) For VPA to approve a claim for

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LTD benefits, a “Member” must establish that he or she is

"Totally Disabled" as defined under the Plan. (Ex. B.) VPA must

make the determination of “Total Disability” on the basis of

"objective medical evidence." (Id.) The Plan defines "objective

medical evidence" as "evidence establishing facts or conditions

as perceived without distortion by personal feelings, prejudices

or interpretations." (Ex. B, § 2(o), HP574.) The Member is

"solely responsible for submitting . . . any other information or

evidence on which the claimant intends the Claim Administrator to

consider in order to render its decision on review." (Ex. B, §

8(b), HP615.)

Benefits are not paid from VPA's assets. (Ex. B, 

§ 4(e)-(f), HP581; Ex. D, § VII.A-B, HP641.) VPA is compensated

based upon a flat quarterly fee, not on the number of claims

processed, the dollar amount paid out, or the number of claims

denied. (Ex. D, § VII.A-B, HP641.)

B. VPA’s Discretion

Numerous Plan provisions grant VPA discretionary power to

determine eligibility for benefits both in the Plan as enacted in

1998 and in the amendments effective January 1, 2002. 

Specifically, the Plan, as amended, provides that:

The Company is the named fiduciary which has the

discretionary authority to act with respect to any appeal

from a denial of benefits. The Company’s discretionary

authority includes the authority to determine eligibility

for benefits and to construe the terms of the Plan. The

Claims Administrator [VPA] shall administer the review of

denied claims on the Company’s behalf and make the decision

on review.

(Ex. B, § 8(a), HP614.) The original 1998 version of the Plan

contained the same language; the 2002 amendment simply

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substituted the word “Company” for the word “Organization,”

referencing the Hewlett-Packard Company Employee Benefits

Organization. (Ex. B, compare HP614 with HP594.) In addition,

Section 8(c) of the 1998 Plan states:

The Claims Administrator [VPA] will make the decision on

review in conformance with procedures it has developed in

the normal course of its business, and the claimant will 

be notified promptly and in writing of the decision. The

Claims Administrator shall have the discretionary power to

construe the language of the Plan and make the decision on

review on behalf of the Organization. To the extent the 

Plan language does not address a claim or to the extent the

Claims Administrator is unable to construe the Plan

language, the Claims Administrator shall consult with the

Organization prior to making a decision on review.

(Ex B, HP596 [emphasis added].) Likewise, the 2002 amendment now

separates that provision into a new Section 8(e), but with no

change in the operative language. (Ex. B, § 8(e), HP617.) The

Plan also vests discretionary authority in VPA, as claims

administrator, to determine “Total Disability” on the “basis of

objective medical evidence” and to “process[] claims.” (Ex. B,

§§ 2(a), (o), 4(f), 7(b).)

C. “Total Disability” Under the Terms of the Plan

For VPA to approve a claim for benefits, a Member must

establish that he or she is "Totally Disabled" as defined under

the Plan. "Total Disability" is defined differently depending

upon whether a claimant is seeking short-term disability or LTD

benefits. (Ex. B, § 2(o), HP573.) A Member applying for

short-term disability benefits must show that "following the

onset of the injury or sickness, the Member is continuously

unable to perform each and every duty of his or her Usual

Occupation . . . ." (Id. at § 2(o)(I).) A Member's "Usual

Occupation" is defined as the normal work assigned to the Member

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by HP. (Ex. B, § 2(t), HP576-77.) If a Member qualifies, he or

she is entitled to receive up to a maximum of 52 weeks of short

term disability benefits. (Ex. B, §§ 2(o)(I) and 2(t).)

In contrast, a Member, such as plaintiff, who is applying for LTD

benefits, must show that after the initial 52-week period of

receiving short term disability benefits, "the Member is

continuously unable to perform any occupation for which he or she

is or may become qualified by reason of his or her education,

training or experience." (Ex. B, § 2(o)(ii), HP573.) The Plan's

claims administrator must make the determination of “Total

Disability” on the basis of “objective medical evidence,” as said

terms are defined above. (Id. at § 2(o), HP574.)

The Plan also contains explicit limitations on LTD benefits.

In evaluating “Total Disability” for LTD benefits purposes, the

Plan imposes the following limitations on benefits for mental

illness:

With respect to any Total Disability caused or contributed

to by mental illness . . . the following limitations shall

apply:

(A) Mental Illness

During the period described in (ii) above [setting forth 

the definition of ‘Total Disability’ after the initial

fifty-two-week period], in the case of a disability

resulting from a nervous or mental disorder, the Member

shall be considered Totally Disabled only if he or she is

confined to a hospital or other licensed long term care

facility for the treatment of such disability or has been 

so confined for fourteen (14) or more consecutive days

during the preceding three (3) months. An illness shall be

considered a nervous or mental disorder if:

(Ex. B, § 2(o), HP574-75.) Under the limitation above, absent a

Member's confinement to a hospital or long term care facility

meeting the Plan's requirements, a Member with a disability

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4 The administrative record is attached as Exhibit A to

the Curry Decl. and bears the production range HP1-563. All

further references to the administrative record will be to “Ex.

A” and where applicable, the production number. 

6

resulting from a nervous or mental disorder is not considered

“Totally Disabled” under the explicit terms of the Plan. (Id.)

D. VPA’s Denial of Plaintiff’s Claim for LTD Benefits

1. Claims History

Plaintiff was employed with HP as an Account Representative

in Customer Support until July 15, 2002, when she began shortterm disability. (Curry Decl., Ex. A, HP433.)4 As part of her

claim for short-term disability benefits, her chiropractor,

Thomas Pesko, submitted a "Physician's Certificate for

Self-Insured Disability Benefits" dated July 30, 2002. (Ex. A,

HP506.) That form indicated that her diagnosis was cervical

segmental dysfunction and cervical myalgia and noted that she was

not fully disabled but could be on light duty with specified

physical limitations for four hours per day with five minute

breaks each hour to "stretch and move." Her approximate return

to full-time work date was listed as August 30, 2002. (Id.)

Plaintiff filed a claim for LTD benefits on April 15, 2003,

indicating that she was disabled due to neck pain, back pain,

shoulder pain and headaches. (Ex. A, HP433, HP1.) She stated

that these were caused by a previous surgery. (Id.) An

Attending Physician's Statement of Disability, dated April

19, 2003, submitted by Dr. Pesko listed her diagnosis as

"Cervical Seg. Dysfunction, Cervical Myalgia, Thoracic Seg.

Dysfunction." (Ex. A, HP430.)

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In order to review plaintiff's claim, on May 27, 2003, VPA

requested medical records from her doctors. (Ex. A, HP1.) 

Disability Benefits Specialist Linda Kennedy reviewed the medical

records submitted by plaintiff's doctors in June and July of

2003. (Ex. A, HP1-2.) In late July, on the basis of the

submitted evidence, Ms. Kennedy concluded plaintiff was "unable

to return to her past work" and sent her file to CorVel for a

transferable skills assessment, an evaluation of plaintiff's

ability to perform other types of work. (Ex. A, HP2.) The

CorVel report stated that plaintiff would be able to perform work

"within her education level, benefits level, wage level and

physical work capacity" with accommodations. (Ex. A, HP2,

HP275-77.) Based on the report, on September 4, 2003, Ms.

Kennedy recommended approval of plaintiff’s LTD claim, as the

Plan provided plaintiff benefits if she could not perform any

occupation without accommodations. (Ex. A, HP2.)

On September 6, 2003, a VPA manager reviewed plaintiff's

claim and noted that additional medical records were needed to

evaluate her claim, since there were no “really” current records

in the file. The VPA manager directed that plaintiff be sent to

a functional capacity evaluation (“FCE”) so that VPA could

determine her current restrictions and limitations. Plaintiff

had been participating in physical therapy and the VPA manager

noted that such therapy should have “produced improvements in her

systems.” (Ex. A, HP3.) Subsequently, Ms. Kennedy requested

additional medical records from plaintiff’s doctors and asked

plaintiff to undergo a FCE at Healthsouth. That evaluation

indicated plaintiff was capable of sedentary work without

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accommodation. (Id.)

On October 27, 2003, VPA wrote to plaintiff, denying her

initial claim. (Ex. A, HP209-13.) The letter reviewed the

medical records in her file along with the report of her FCE,

which indicated that she was capable of performing a sedentary

job, such as her former position. (Id.; Ex. A, HP438.)

On April 22, 2004, plaintiff appealed the denial of her

claim and requested additional time to provide VPA with more

information. (Ex. A, HP99-102.) Plaintiff's attorney sent an

additional letter on May 4, 2004, enclosing additional medical

records and stating:

As can be seen, the claimant deals with borderline high

blood pressure and hyperlipidemia. The more pertinent

diagnoses for disability purposes are: reactive

airway disease, dysphagia, headaches, arm numbness problems,

and depression. The headaches are essentially daily. No

clear cause for the arm numbness has been found, but there

are myofascial tenderness in the neck and trigger points in

the shoulders. Medication tried for the depression had

untenable side-effects. Obviously my appeal focused on

addressing the errors in the exertionally based analysis

used to deny this claim, but it should be obvious that

nonexertional factors of pain, including daily headache pain

and neck pain, and fatigue and mental fogginess associated

with the combination of impairments, depression, and

medications, are more serious impediments to performance of

any kind of work.

(Ex. A, HP57.) On May 17, May 19 and July 23, 2004, counsel for

plaintiff submitted additional documentation regarding her

condition to VPA. (Ex. A, HP23, HP25, HP29-30.)

On October 28, 2004, plaintiff's counsel submitted

additional documentation to support plaintiff's disability claim

to VPA. (Ex. A, HP16.) On November 4, 2004, VPA sent

plaintiff's counsel a letter indicating that VPA had called his

office in August (see HP4) to ask if additional information on

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plaintiff's appeal was forthcoming and inquiring into the status

of her Social Security Disability claim but did not receive a

response. (Ex. A, HP20.) That letter also indicated that VPA

had received another extension request from his office on

November 1, 2004. (Id.)

On January 20, 2005, plaintiff's counsel sent a letter to

VPA stating:

I just came across your 11/4/04 letter inquiring about 

the status of Plaintiff's Social Security disability claim,

misfiled in an unrelated file. [¶ ] That claim is still

ongoing. Of note, an appeal was greatly delayed because of

Ms. Riffey's psychological inability to complete a simple

form. Her psychiatrist had to write a note explaining this,

in order to help excuse the delay.

(Ex. A, HP13.) On January 30, her counsel submitted additional

information and noted:

I believe you may think I continue to request additional

time. I did request additional time back when I made the

formal appeal of 4/22/04. However, I was able to provide

additional medical information over the following month or

so. [¶ ] At this point, though, it appears that Ms. Riffey

has significantly increased psychiatric symptoms,

resulting from her original problems. I am not sure how you

want to handle this, but I could probably provide some

specialized medical information in this regard within a

limited time frame – so if you want to agree to hold this

record open yet longer, it may be a good idea all the way

around.

(Ex. A, HP14.)

On March 2, 2005, VPA sent a letter to Plaintiff's attorney

advising of its decision to deny her appeal. (Ex. A, HP10-12.)

The denial letter stated that, although plaintiff underwent

extensive testing, "the objective test results . . . do not

provide a clear condition that would be considered disabling for

Plaintiff. Other than some documented changes of early

degenerative disc disease, plaintiff's test results were all

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within normal limits." (Ex. A, HP11.) VPA also discussed the

more recent doctors' notes, which indicated that plaintiff's

symptoms had improved and a FCE which documented that "Ms. Riffey

was capable of performing work full-time at the sedentary level."

(Ex. A, HP12.) VPA also noted that plaintiff claimed disability

for depression and mental and nervous conditions cannot be taken

into account for LTD purposes unless she were confined to a

hospital or long term care facility. (Ex. A, HP11.)

2. Plaintiff’s Medical History Concerning Her

Reported Neck Pain, Headaches, Fatigue, and

Depression Following Surgery to Remove a

Zenker’s Diverticulum

Plaintiff underwent surgery to remove a Zenker's

diverticulum on November 7, 2001. (Ex. A, HP365, HP75.) In his

first examination of plaintiff following surgery, on November 28,

2001, her doctor, Keith Boston, indicated that plaintiff reported

fatigue, but wrote that she should "[r]echeck next August for

physical." (Ex. A, HP127.) On December 4, 2001, Dr. Boston saw

plaintiff and stated that she reported "persistent back pain,"

and he noted "[m]ild reactive depression." (Ex. A, HP126.) He

indicated that he "would concur with non-paid leave of absence

for the patient to recover." (Id.) His notes from an

examination two weeks later, on December 20, 2001, noted that

plaintiff is "noticeably better after chiropractic therapy." 

(Ex. A, HP125.) He stated that her neck is "supple without

nodes," but that there is "significant myofascial tenderness in

the trapezius." He also stated that "[i]n general, patient's

affect is much brighter and she appears much more engaged and

less tearful today." He further noted that her "[m]ild reactive

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depression" was "improving." (Id.) Similarly, on January 21,

2002, Dr. Boston indicated that "headaches and neck pain are

improving. Depression is improving." (Ex. A, HP124.)

From this time through March 2004, the administrative record

reflects Dr. Boston's reports that plaintiff continued to present

with myofascial tenderness in the left trapezius and headaches.

(Ex. A, HP87, HP89, HP95, HP97-98, HP114-15, HP118, HP356,

HP527.) At times, he believed her symptoms to be

improving. (Ex. A, HP118, HP120-21, HP525.) He also reported

that she felt fatigued and depressed and prescribed her

antidepressants, although her depression appeared to improve in

March of 2004. (Ex. A, HP87, HP95, HP97, HP115-16, HP356.)

Dr. Boston's notes from August 19, 2003, indicate that

plaintiff had reported that her "[h]eadaches persist on a daily

basis." (Ex. A, HP91.) Although he stated that plaintiff has a

history of depression, he did not note neck and back pain. (Ex.

A, HP91-92.) He indicated that on examination her neck is

"Supple without adenopathy, JVD or thyromegaly." (Ex. A, HP91.)

Dr. Boston's February 20, 2004 notes state:

She continues to feel poorly. She continues to hurt all the

time. She is frustrated that no one is finding objective

evidence of her problems. She now notes tingling in both

hands and both feet though the left arm appears to be more

pronounced than the right arm. She got approximately 50%

transient reduction after her trigger point injection.

She does note increasing depression and fatigue.

(Ex. A, HP88.) Dr. Boston prescribed pain medication and an

anti-depressant and ordered an MRI to rule out a herniated

cervical disc. (Id.)

During the relevant period, plaintiff was also under the

care of the chiropractor, Dr. Pesko, who submitted her statements

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of disability. On August 29, 2002, he indicated that he believed

"6 more weeks of care should do her well, she may need periodic

follow up care." (Ex. A, HP416-17.) He stated that:

[Ms. Riffey] was getting some counseling and her counselor

suggested some time off work for healing she asked me 

if I would write her a disability slip, I wrote on 

August 12 for 3 months.

(Ex. A, HP417.) He also noted decreased movement, "positive

right shoulder depression," and "Vertebral fixation noted at

C1-2, C4, T3-6 and right 2-3 rib heads." (Ex. A, HP416.) On

October 14, 2002, Dr. Pesko reported that plaintiff's pain and

headaches were improving. (Ex. A, HP490.) He found that "if she

continues to stretch and strengthen all cervical muscles along

with mid Thoracic muscle she should do better." (Id.) Dr. Pesko

recommended a decreased schedule of therapy. (Id.)

Dr. Pesko continued to report that plaintiff complained of

headaches and "C/T discomfort and pain" through March 2003. (Ex.

A, HP234-35, HP499.) On March 18, 2003, he noted plaintiff's

continued complaints of "frequent C/T pain, moderate mostly with

associated posterior and suboccipital headaches," but indicated

that she had some improvement in her limitations on her range of

motion. (Ex. A, HP235.) Under "Objective Findings," Dr. Pesko

stated:

Finding about the same as last report with some increase 

in C/T AROM mostly in B/L rotation. Anterior cervical

muscles weak doing with right SCM muscle. Foraminal

compression and left lateral compression positive C/T pain.

Frequent fixations at C1, T4-5, and right third rib.

(Id.)

Plaintiff's physical therapist, Katie Thorne, submitted

records to VPA dated from August 2002 to May 21, 2003, noting

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plaintiff's complaints of "cervical, thoracic and upper extremity

symptoms of pain and rapid fatigue," and noting "significant

postural fatigue with a significantly collapsed posture, severe

forward head position, thoracic kyphosis, upper cervical

extension, and protracted scapulae bilaterally." (Ex. A,

HP320-21, HP333, HP483-86.) On January 8, 2003, her report

stated:

Joint mobility testing of the cervical spine revealed a

prominent C2 spinous process with C3 rotated to the right

mildly and C3 tenderness. The C5-C6 is anteriorly oriented,

though mobility is within normal limits.

(Ex. A, HP321.) Ms. Thorne also noted that plaintiff had "left

anterior cervical restrictions" and "suboccipital muscular

spasms" that were "more significant on the right vs. the left and

appear to be the source of her headache symptoms." (Ex. A,

HP321, HP322-24, HP326-38.) However, by May 21, 2003, Ms. Thorne

noted some improvement, including that plaintiff's range of

motion was within normal limits, and she was discharged from

physical therapy to a home exercise program. (Ex. A, HP333.)

A report from Dr. Aditi Mandpe, an otolaryngologist, on

November 4, 2002, reported "vague complaints of headaches and

neck and shoulder pain," but focused on plaintiff's complaints of

dysphagia and skin changes from the incision from her surgery to

correct a Zenker's diverticulum. (Ex. A, HP367.) Dr. Mandpe

suggested a barium swallow to rule out a recurrence of the

diverticulum. (Id.) A subsequent esophagram noted a "[m]inimal

small Zenker's diverticulum extending from the posterior

aspect of the distal cervical esophagus. This demonstrated

momentary filling with spontaneous emptying. There is no

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evidence of pooling of contrast within this diverticula." (Ex.

A, HP69.) A January 8, 2003 report from Dr. Mandpe indicated

that plaintiff "has dysphagia . . . maybe related to more of a

pharyngeal source." (Ex. A, HP399.) Dr. Mandpe saw plaintiff on

July 7, 2003, but could not confirm her complaints of dysphagia,

and noted a benign oral cavity on exam and recommended some

follow-up testing. (Ex. A, HP166.)

On April 21, 2003, Dr. Rajiv Pathak, a neurologist, noted

that plaintiff indicated that she has headache pain "at the

center of the back" which is there "24 hours a day. Some days are

bad; some days are not so bad," but that her "vision gets

blurred," and "she gets disoriented and her focus is poor."

(Ex. A, HP377.) His assessment was that she had muscle tension

headaches. (Ex. A, HP379.) On June 2, 2003, Dr. Pathak indicated

that plaintiff complained that she "still gets daily [headaches]"

and complained of side effects from her medication. (Ex. A,

HP376.) On September 29, 2003, he reported that plaintiff's neck

pain and headaches were "muscular in nature" and their "treatment

. . . mainly symptomatic." (Ex. A, HP31.) He adjusted her

medication and suggested the use of a TENS unit, an electrical

nerve stimulation device. (Id.)

On March 10, 2004, John Schroeder, PhD, a psychotherapist,

noted plaintiff was "feeling depression, severe[,] and anxiety,

moderate" and had "low levels of energy." (Ex. A, HP55.)

3. VPA Commissioned Independent Medical Examination

of Plaintiff

As part of its determination of plaintiff's qualification

for short-term disability benefits, VPA directed her to Dr.

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Dennis Chu for an independent medical examination. On January

21, 2003, Dr. Chu wrote a report in which he discussed his

examination of plaintiff and review of her medical records.

(Ex. A, HP300-04.) He noted that she had a "negative MRI scan of

cervical spine, splondylosis on thoracic spine X-Rays," but that

she was somewhat functionally limited in that she was unable to

do any climbing, repetitive stooping or bending, lifting over ten

pounds. (Ex. A, HP303.) He also indicated that she could stand

for 30-60 minutes and sit or walk for one hour. (Id.) He found

her mental status to be "competent." (Id.) Dr. Chu indicated

that he did not "feel she can return to her usual and customary

work at this point." (Ex. A, HP454.) He recommended that "she

have a regular cervical MRI to assess for cervical disc

herniation," and noted that "[t]he prognosis for her neck and

upper back pain is fair." (Id.)

Dr. Chu was asked to supplement his report to indicate

whether plaintiff could return to work in a light duty

environment. (Ex. A, HP455.) He responded:

I recommend before the patient return to work, she should

have a cervical MRI scan to assess the cervical disc

herniation. If the MRI scan is negative, I feel she can

return to work part time, 4 hours a day for 2 weeks, then 6

hours a day for 2 weeks then full time afterward. [¶ ]

However, if the cervical MRI scan reveals cervical disc

herniation, she should have a neurosurgical consultation for

possible cervical discectomy and fusion before she can

resume working.

(Ex. A, HP456.) No subsequent MRI revealed any cervical disc

herniation. (Ex. A, HP58.)

4. The Objective Evidence of Plaintiff’s Ailments

As stated above, while plaintiff’s physical therapist and

chiropractor observed a decreased range of movement and a

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collapsed posture (Ex. A, HP416, HP483-86), an MRI of plaintiff’s

cervical soft tissue dated July 3, 2002, indicated

that: "Normal cervical soft tissues. No evidence of cystic or

solid abnormalities at the operative level where the Zenker's

diverticulum has been resected." (Ex. A, HP72.) 

She also had a normal brain MRI. (Ex. A, HP72-73.) On

August 19, 2002, Dr. Boston indicated that her "[n]eurological

exam [was] intact." (Ex. A, HP118.)

On October 15, 2002, plaintiff had a "Cervical Spine Series"

indicating a "normal cervical spine," but a "Thoracic Spine

Series" indicated "[e]arly degenerative disc changes and

spondylosis in the mid thoracic spine [but] no acute changes are

identified." (Ex. A, HP71.) On August 25, 2003, plaintiff had

a "[n]egative CT scan of the abdomen and pelvis." (Ex. A, HP64.)

On March 4, 2004, plaintiff had an additional MRI of the cervical

spine which found "Early degenertive disk changes at C3-4 and

C6-7. No disk herniation, central canal or neural foraminal

stenosis is demonstrated." (Ex. A, HP58.)

A Speech Pathology Consultation Report was completed by Dr.

Susan Langmore on March 10, 2003 (Ex. A, HP307-08), which

indicated: “ Normal pharyngeal swallow. Probable esophageal

dysphagia and likely GERD. Possible hypersensitivity in the

pharynx secondary to surgical trauma and residual

irritability.” (Ex. A, HP307.) An esophagogram done on May 1,

2003, indicated "slight irregularity of the upper cervical

esophagus consistent with previous resection of a Zenker

diverticulum," "mild tertiary peristalsis of the distal third of

the thoracic esophagus but with subsequent clearance," "no

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evidence of reflux with Valsalva," "otherwise negative

esophagram," "no evidence of Zenker diverticulum, mucosal or

mural lesions, intraluminal filling defects, or extrinsic

compression." (Ex. A, HP38-39; HP360.) On September 11,

2003, plaintiff had a "[n]egative gastrointestinal series. No

evidence of esophageal lesions including diverticula, reflux,

mucosal or mural lesions, or intraluminal filling defects." (Ex.

A, HP61.) On February 27, 2004, plaintiff had a normal cervical

esophagogram and normal thoracic esophagogram. (Ex. A, HP36-37.)

5. Vocational Assessments of Plaintiff

In addition to Dr. Chu's analysis, the administrative record

contains several reports on plaintiff’s claimed vocational

limitations. An "Employee's Work Limitation Slip" dated July 25,

2002, signed by Dr. Pesko indicated that she could work part time

for four hours a day so long as she was "allowed to get up and

stretch every hour for 3-4 minutes," but she was precluded from

"excessive or repeated" climbing, pulling, pushing, and reaching

above shoulder. (Ex. A, HP498.) Plaintiff was also precluded

from lifting over twenty pounds. (Id.) Dr. Pesko did not,

however, explain how her medical condition imposed these

limitations.

On February 10, 2003, Ms. Thorne, plaintiff’s physical

therapist, sent a letter to the State of California Department of

Social Services, stating, among other things, that plaintiff

continues to have significant complaints of pain and fatigue with

any activities in a sustained position; she cannot tolerate

sitting for more than thirty minutes, standing approximately

forty five minutes, or walking approximately forty five minutes;

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and she complains of disorientation symptoms and shakiness making

handling small objects and focused concentration very difficult,

particularly with computer work, her primary responsibility at

work. (Ex. A, HP338.) Ms. Thorne specifically noted that her

assessment relied on plaintiff’s "subjective reports."

Soon thereafter, on February 14, 2003, Dr. Pesko sent a

"Progress Report" to the State of California Department of Social

Services, noting that plaintiff's updated diagnosis was "cervical

segmental & thoracic segmental dysfunction, cervical myalgia,

tension headaches." (Ex. A, HP233.) He wrote: "Patient not able

to work, in process of seeing other doctors for opinions on

throat & past surgery." (Id.) He did not provide, however, any

basis for his conclusion that plaintiff’s medical condition

prevented her from working.

On July 25, 2003, Dr. Pesko sent a "Physician's

Supplementary Certificate" indicating that "headaches &

cervico-thoracic pain" continued to disable plaintiff and that

she might return to work by November 1, 2003. (Ex. A, HP238.)

Plaintiff’s file contains several "Disability Slip"

documents. The earliest is dated August 12, 2002, and is signed

by Dr. Pesko. He indicated that plaintiff would be on disability

from August 16, 2002, through November 16, 2002, due to "neck

pain & headaches." (Ex. A, HP505.) Dr. Pesko signed similar

slips on November 6, 2002, January 9, 2003, July 15, 2003,

October 20, 2003, July 19, 2004, October 18, 2004, and January

24, 2005. (Ex. A, HP15, HP17, HP24, HP172, HP298, HP325, HP476,

HP487.) A note from Dr. Boston dated November 26, 2002, stated

"Pt unable to work. Will reevaluate ~12/20/02." (Ex. A, HP503.)

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Although, these slips did not offer documentation of plaintiff’s

functional capacity.

On September 4, 2003, as noted above, a Vocational

Rehabilitation Consultant at CorVel did an "Employability

Assessment" based on her review of plaintiff’s file, but without

examining plaintiff personally. (Ex. A, HP275-77.) On the basis

of notes in plaintiff’s file that indicate that "her headaches

and cervical pain are intensified with computer work and she

cannot tolerate more than 30 minutes to one hour of computer

work," the assessment determined that "Plaintiff appears to be

vocationally limited due to her restrictions with computer work,

because it is difficult for her to maintain cervical positioning

at the computer." (Ex. A, HP276.) The report determined that

with accommodations, however, plaintiff "has the skills to

perform within her educational level, benefit wage level and

physical work capacity." (Ex. A, HP277.)

On October 21, 2003, Healthsouth Physical Therapist Steven

Nader performed the FCE of plaintiff in person. (Ex. A,

HP173-87.) That evaluation found that plaintiff was "capable of

performing work in the sedentary classification according to the

U.S. Department of Labor Standards on an 8 hour day basis.” (Ex.

A, HP173.)

///

///

///

///

///

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5 In an ERISA benefits case, the "traditional" summary

judgment standards are not necessarily appropriate. Fed. R. Civ.

P. 56. Where, as here, the administrator's decision 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. Standard Ins. Co., 185 F.3d 939, 942 (9th Cir. 1999) (finding

that "[a]lthough there may be contradictory evidence in the

record, we hold that, as a matter of law, the plan administrator

did not abuse its discretion"). 

20

ANALYSIS

A. Applicable Standard of Review – Abuse of Discretion5

Before reaching the merits of the parties’ motions, the

court must determine the appropriate standard of review to apply

to VPA’s denial of benefits determination. 

The Plan at issue here is an employee welfare benefit plan

governed by ERISA. In Firestone Tire & Rubber Co. v. Bruch, the

United States Supreme Court held that a challenge to the denial

of benefits under an ERISA plan is reviewed de novo "unless the

benefit plan gives the administrator or fiduciary discretionary

authority to determine eligibility for benefits or to construe

the terms of the plan." 489 U.S. 101, 115 (1989). Where a plan

document gives an administrator such discretionary authority, a

court must apply the "abuse of discretion" or "arbitrary and

capricious" standard of review to its decision to deny benefits. 

Id. at 111; see also Abatie v. Alta Health & Life Insur. Co., 458

F.3d 955, 963 (9th Cir. 2006). 

In this case, numerous Plan provisions, as set forth above,

vest sufficient discretionary power in VPA to invoke the

abuse of discretion standard as defined in Firestone and Abatie. 

Plaintiff argues notwithstanding these provisions, that certain

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6 Moreover, even if delegation were required, plaintiff’s

argument is based on a misreading of the Plan. Since Section 9

was not amended, the Organization remains the “plan

administrator” and “plan sponsor” and retains “the discretionary

authority to control and manage the operation and administration

of the Plan.” (Ex. B, § 9, HP597.) The 5th Amendment to the

Plan at Section 8 gives to the Company only “the discretionary

authority to act with respect to any appeal from a denial of

benefits,” and “the authority to determine eligibility for

benefits and to construe the terms of the Plan.” (Ex. B, § 8(a),

HP614 (as amended December 2002).) In other words, the 5th

Amendment to the Plan does not strip the Organization of all of

its rights and responsibilities under the Plan, but transfers

only specific duties from the Organization to the Company. It is

not contrary to ERISA for there to be more than one named

fiduciary, as ERISA provides that a plan “shall provide for one

or more named fiduciaries who jointly or severally shall have

authority to control and manage the operation and administration

of the plan.” 29 U.S.C. § 1102(a); see also 29 U.S.C. 

§ 1105(c)(1)(B); Madden v. ITT Long Term Disability

Plan for Salaried Employees, 914 F.2d 1279, 1283 (9th Cir. 1990).

As such, the 5th Amendment to the Plan creates no barrier to the

21

Plan amendments deprived the “Company” of the ability to delegate

plan rights and responsibilities to VPA, and thus, discretionary

authority is not properly vested in VPA. This “failure to

properly delegate” argument is irrelevant, however, given the

Plan’s direct assignment of duties to the claims administrator. 

In other words, the Plan grants discretion to VP directly, not

through delegation. (Ex. B, § 8(a), HP614 [providing that “The

Claims Administrator shall administer the review of denied claims

on the Company’s behalf and make the decision on review.”]; 

Ex. B, § 8(e), HP617 [providing “The Claims Administrator shall

have the discretionary power to construe the language of the Plan

and make the decision on review on behalf of the Company.”]; 

Ex. B, § 2(a), (o), 4(f), 7(b) [vesting discretionary authority

in VPA, as claims administrator, to determine “Total Disability”

on the “basis of objective medical evidence” and to “process[]

claims.”].)6

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delegation of duties to VPA under the Plan, although none is

required because the claims administrator was assigned its

responsibilities and discretion directly.

22

Indeed, plaintiff’s argument ignores that the language in

Section 8(e) of the Plan is precisely the language courts have

construed as unambiguously granting sufficient discretion to VPA

to warrant abuse of discretion review under Firestone. In

LaMantia v. Voluntary Plan Administrators, Inc., the Ninth

Circuit held that the Plan gave “VPA the discretionary power to

construe the language of the Plan and to make the

decision on review so the abuse of discretion standard would

normally apply.” 401 F.3d 1114, 1123 (9th Cir. 2005) (internal

quotation marks omitted). Numerous other courts have found

similarly--that this Plan, both originally and as amended,

sufficiently grants discretion to VPA. Carter v.

Hewlett-Packard Co., 2007 U.S. Dist. LEXIS 3249, at *1 (N.D. Cal.

Jan. 1, 2007) (holding this Plan “unambiguously grants

discretionary authority to VPA and, therefore, the abuse of

discretion standard applied”); accord Tabatabai v.

Hewlett-Packard Co. Disability Plan, 2006 U.S. Dist. LEXIS 66110,

at *6 (N.D. Cal. Sept. 1, 2006); Moore v. Hewlett-Packard Co.,

2000 WL 361680 (D. Pa. Apr. 6, 2000); Guthrie v. Hewlett-Packard

Co. Employee Benefits Organization, 773 F. Supp. 1414, 1415 (D.

Colo. 1991).

Plaintiff alternatively argues that because VPA is the

“Organization’s” agent, pursuant to the ASA, VPA must share the

Organization’s conflict of interest. Such a conflict, plaintiff

contends, mandates application of de novo review pursuant to

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7 Plaintiff makes this argument in support of her

position that de novo review is the correct standard of review in

this case; however, under Abatie, a conflict of interest finding

would not dictate application of de novo review but rather

require a less deferential review under abuse of discretion

(sometimes referred to as “heightened” abuse of discretion

review). Abatie, 458 F.3d at 972.

23

Abatie.7

 Plaintiff is incorrect. The conflict of

interest to which Abatie refers, is one where an insurer both

funds and administers the Plan. Abatie, 458 F.3d at 958, 965-66;

see also Coleman-Lea v. Metropolitan Life Ins. Co., 2006 U.S.

Dist. LEXIS 89352, *11-12 (N.D. Cal. Dec. 11, 2006) (“no evidence

of a conflict of interest beyond the apparent conflict which

exists when the insurer both funds and administers the plan”);

Shemano-Krup v. Mutual of Omaha Ins., 2006 U.S. Dist. LEXIS

84352, *29-31 (N.D. Cal. Nov. 20, 2006) (denying

discovery where there was no evidence of a conflict of interest

beyond the “apparent conflict which exists when the insurer both

funds and administers the plan”). Plaintiff cannot argue that

such a funding mechanism exists here as benefits are not paid

from VPA’s assets; rather, HP makes contributions to the Plan

that are held in a trust, out of which the Organization pays

benefits. (Ex. B, § 4(e), HP581.)

While certainly the doctrine of respondeat superior applies

(plaintiff is suing the Plan for VPA’s allegedly improper denial

of benefits), plaintiff cites no authority for the proposition

that a structural conflict of interest is transferred from the

funding source of a Plan to the claims administrator, where the

administrator is not paid on the basis of claims denied. Courts

have recognized that steps can be taken to prevent a claims

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administrator from laboring under a conflict of

interest. See, e.g., Sin v. Metropolitan Life Ins., 2006 U.S.

Dist. LEXIS 90885, at *8 (D. Or. Dec. 13, 2006) (“Since [the

claims administrator] has no economic interest in the outcome of

plaintiff’s claim, no conflict of interest arises.”); see also

Sandoval v. Aetna Life and Casualty Ins. Co., 967 F.2d 377,

378 (10th Cir. 1992) (claims administrator “received flat fees

for processing claims and thus had no direct financial incentive

to deny or to terminate benefits to plan participants”).

Plaintiff’s argument ignores the specific steps taken by

defendant to prevent VPA from having an economic incentive in the

outcome of claims decisions, namely, VPA’s compensation through a

flat fee and the payment of benefits out of the Plan’s trust, not

VPA’s assets. (Ex. B, § 4(e)-(f), HP581; Ex. D, § VII.A-B,

HP641.) Here, VPA has no conflict of interest because it has no

economic interest in the denial of claims. Indeed, if an agency

theory defeated the discretion granted to VPA, then no

administrator could ever be shielded from the funding source’s

conflict of interest. Plaintiff’s “agency theory” does not

provide a basis for de novo review in this case.

As a final argument in favor of application of de novo

review, plaintiff contends that under Abatie, this court must

apply de novo review due to “procedural irregularities” in this

case, specifically, VPA’s untimely issuance of its denials of

plaintiff’s benefits claim. Plaintiff’s argument is unavailing

for several reasons. First, plaintiff reads Abatie too broadly. 

In Abatie, the Ninth Circuit held that “[w]hen an administrator

engages in wholesale and flagrant violations of the procedural

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requirements of ERISA, and thus acts in utter disregard of the

underlying purpose of the plan as well, we review de novo the

administrator’s decision to deny benefits.” 458 F.3d at 971

(emphasis added). The court recognized that such instances are

“rare,” and “in the more ordinary situation in which a plan

administrator has exercised discretion, but in doing so, has made

procedural errors,” de novo review is not mandated. Id. at 972.

The court further held that “[w]hen an administrator can show

that it has engaged in an ongoing, good faith exchange of

information between the administrator and the claimant, the court

should give the administrator’s decision broad deference

notwithstanding a minor irregularity.” Id. (internal quotation

marks omitted).

As an example of what constitutes “wholesale and flagrant

violations of the procedural requirements of ERISA,” the Ninth

Circuit cited the facts in Blau v. Del Monte Corp., 748 F.2d 1348

(9th Cir. 1984), noting that in Blau, “the administrator had kept

the policy details secret from the employees, offered them no

claims procedure, and did not provide them in writing the

relevant plan information.” Abatie, 458 F.3d at 971. Obviously,

no such failure “to comply with virtually every applicable

mandate of ERISA” is at issue here, and an abuse of discretion

standard remains appropriate. Id.

Indeed, even before Abatie, under two recent Ninth Circuit

decisions (Jebian and Gatti) the violations of time limits like

the ones plaintiff claims here would not result in application of

the de novo standard of review. See Jebian v. Hewlett-Packard

Co. Employee Benefits Org. Income Protection Plan, 349 F.3d 1098

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8 Following Jebian, HP amended its Plan to eliminate the

“deemed denied” language discussed in that case. Subsequently,

courts in this circuit have determined that, where the applicable

ERISA regulations do not contain the “deemed denied” language,

a technical violation of the ERISA time limits offers no basis

for a finding that the claims administrator did not exercise its

discretion, the predicate for applying a de novo standard of

review. See, e.g., Freitas v. Delta Family-Care Disability &

Survivor, 2006 U.S. Dist. LEXIS 29902, at *6-8 & n.1 (E.D. Cal.

May 15, 2006) (noting that because ERISA no longer deemed an

appeal denied on the expiration of a time limit, plaintiff’s

argument for de novo review after the plan failed to issue a

timely appeal decision was even less persuasive); Peterson v.

Fed. Express Corp. Long Term Disability Plan, 2006 U.S. Dist.

LEXIS 34343, at *17-18 (D. Ariz. May 24, 2006) (in analyzing

whether the Gatti court’s analysis should be extended to cases

arising under the amended regulations, found that the court would

not require “de novo review every time a plan administrator

violates ERISA, no matter how inconsequential the violation”);

Oman v. Intel Corp. Long Term Disability Benefit Plan, 2004 U.S.

Dist. LEXIS 21909, *10-11 (D. Ore. Oct. 21, 2004) (pre-Gatti case

contrasting the regulations at issue in Jebian with the current

regulations in which “all references to claims being ‘deemed

denied’ due to expiration of time

limits has been removed.”).

26

(9th Cir. 2003) (applying de novo review only because the plan

explicitly provided that a claim is “deemed to have been denied

on review” if the administrator neither responded to the appeal

within sixty days nor informed the claimant of the need for a

sixty day extension [no such “deemed denied” provision exists in

this Plan]”);8 Gatti v. Reliance Standard Life Insur. Co., 415

F.3d 978, 982, 985 (9th Cir. 2005) (reversing district court’s

application of de novo review, finding, despite the fact that the

claims administrator issued its decision 279 days after the

claimant submitted her request for administrative review, that

“violations of time limits established in [the previous version

of the regulations] are insufficient to alter the standard of

review,” rather violations must be so “flagrant as to alter the

substantive relationship between the employer and employee,

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9 Defendant does not dispute that VPA overran the

applicable time limits; generally, the Plan requires that VPA

make its initial determination within 45 days, and if additional

time for processing is required, the determination period may be

extended to up to 105 days if certain procedures are met. (Ex.

B, § 7(b), HP612.)

27

thereby causing the beneficiary substantive harm”). 

Here, the delay in deciding plaintiff’s claim was minor9 and

largely due to plaintiff’s counsel’s requests for additional time

to provide supporting evidence of plaintiff’s aliments. Once

plaintiff completed her submission of records, VPA responded

promptly with its final denial of her claim. A brief overview of

the pertinent facts establishes these points:

VPA received plaintiff’s claim for LTD benefits and her

Attending Physician’s Statement of Disability on April 22, 2003.

(Ex. A, HP1, HP430, HP433.) Plaintiff submitted additional

information on June 18, 2003, and spoke with Ms. Kennedy at VPA

on September 4, 2003, about her application for Social Security

benefits. (Ex. A, HP1-3, HP6.) On September 12, 2003, plaintiff

sent in verification of her appointment with Social Security, and

VPA called her to set up a functional capacity evaluation. (Ex.

A, HP6.) VPA received additional medical records from

plaintiff’s doctors up through September 23, 2003. (Ex. A, HP6.)

Plaintiff communicated with VPA again regarding her Social

Security application on September 25 and 26. (Ex. A, HP6,

HP267.) Although VPA had set up a functional capacity evaluation

for plaintiff on September 12, when plaintiff arrived for that

evaluation on October 3 she expressed concerns about undergoing

the testing because of the limitations her care providers had

placed on her activities. (Ex. A, HP7.) After procuring

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permission from her healthcare providers, that examination

finally took place on October 21. (Ex. A, HP7, HP263-66.)

After reviewing the FCE, VPA initially denied her claim on

October 27, 2003. (Ex. A, HP209-13.) At that time, plaintiff

was told that she would have until April 23, 2004, to appeal the

denial of her claim. (Id.) On April 22, 2004, plaintiff

appealed the denial of her claim and requested additional time to

provide VPA with more information. (Ex. A, HP99-102.) The

letter requested an open-ended extension: “I request additional

time to provide further information that could help this claim be

more properly and favorably resolved.” (Ex. A, HP102.) 

Plaintiff’s attorney sent an additional letter on May 4, 2004,

enclosing additional medical records and indicating that he

expected “to provide further information besides the enclosed.” 

(Ex. A, HP57.) On May 17, May 19 and July 23, 2004, counsel for

plaintiff submitted additional documentation regarding her

condition to VPA. (Ex. A, HP23, HP25, HP29-30.)

On August 2, 2004, VPA called plaintiff’s counsel and left a

message inquiring as to whether additional information was

forthcoming. (Ex. A, HP4, 20.) Plaintiff’s counsel did not

return that call, but on September 19, 2004, he sent a letter to

VPA stating that “[i]t would seem that the time frame for

determining this claim is being significantly overrun.” (Ex. A,

HP22.) However, on October 28, 2004, plaintiff’s counsel

submitted additional documentation to support plaintiff’s

disability claim to VPA. (Ex. A, HP16.) On November 4, 2004,

VPA sent plaintiff’s counsel a letter indicating that VPA had

called his office in August (see HP4) to ask if additional

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information on plaintiff’s appeal was forthcoming and

inquiring into the status of her Social Security Disability

claim. (Ex. A, HP20.) That letter also indicated that

VPA had received another extension request from plaintiff’s

counsel’s office on November 1, 2004. (Id.)

Plaintiff’s counsel did not respond until January 20, 2005.

(Ex. A, HP13.) On January 30, her counsel submitted additional

information and noted:

I believe you may think I continue to request additional

time. I did request additional time back when I made the

formal appeal of 4/22/04. However, I was able to provide

additional medical information over the following month or

so. [¶ ] At this point, though, it appears that Ms. Riffey

has significantly increased psychiatric symptoms,

resulting from her original problems. I am not sure how you

want to handle this, but I could probably provide some

specialized medical information in this regard within a

limited time frame – so if you want to agree to hold this

record open yet longer, it may be a good idea all the way

around.

(Ex. A, HP14.)

On March 2, 2005, VPA sent a letter to plaintiff’s attorney

advising of its decision to deny plaintiff’s appeal. (Ex. A,

HP10-12.)

Under these facts, the court cannot find that the procedural

violations of the Plan’s time limits are sufficient to require

application of de novo review pursuant to Abatie. While VPA

overran the applicable time limits, it was regularly in contact

with plaintiff during all relevant times and can only be

described as engaging “in an ongoing, good faith exchange of

information between [administrator] and [claimant].” Abatie, 458

F.3d at 972. As such, “the court should give the [VPA’s] 

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10 Plaintiff argues alternatively that if the court does

not apply de novo review, it should nonetheless apply a more

“searching” or “heightened” review under the abuse of discretion

standard, citing Abatie. In Abatie, the Ninth Circuit recognized

that a heightened review under abuse of discretion is appropriate

where there are procedural errors which may not rise to the level

of requiring application of de novo review (i.e., they are not so

“wholesale” or “flagrant”) but nonetheless are matters that

should be “weighed in deciding whether an administrator’s

decision was an abuse of discretion” (i.e., a “conflict of

interest”). 458 F.3d at 972 (emphasis added). Here, plaintiff

claims VPA’s request for additional information before

determining plaintiff’s initial LTD claim warrants more searching

review, and that VPA’s reading of the FCE and other portions of

the record constituted “procedural errors” that should affect the

court’s application of abuse of discretion review. The court

disagrees. Plaintiff’s latter argument is not procedural. 

Abatie’s holding does apply when the claimant simply disagrees

with the administrator’s interpretation of the record. 458 F.3d

at 971 (distinguishing the case where a claimant challenges

procedural errors in an administrator’s review from the more

common situation “when a plan participant disagrees with an

administrator’s interpretation of the record or with its

application of the plan’s terms to the facts” [only the former

can possibly impact the standard of review]). As to plaintiff’s

first argument, VPA did not commit a procedural error in

obtaining all relevant medical records. Procurement of the

records was required by the Plan in order for VPA to make an

informed decision on plaintiff’s claim.

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decision broad deference notwithstanding [m]inor irregularities.” 

Id.

Therefore, because the Plan clearly delegates discretion to

VPA to render claims decisions and because there were no

procedural irregularities sufficient to alter the standard of

review, the court finds that abuse of discretion is the

appropriate standard of review in this case.10

B. VPA’s Decision to Deny LTD Benefits

Applying the abuse of discretion standard of review, the

sole issue before the court is whether VPA abused its discretion,

or in other words, acted arbitrarily and capriciously, in denying

plaintiff’s disability claim. An administrator's decision is an

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abuse of discretion only where it is "without reason, unsupported

by substantial evidence or erroneous as a matter of law." 

Abnathya v. Hoffman-LaRoche, Inc., 2 F.3d 40, 45 (3rd Cir. 1993)

(citations omitted); Taft v. Equitable Life Insur. Co., 9 F.3d

1469, 1472 (9th Cir. 1998). So long as the administrator's

decision has a rational basis, the court is not free to

substitute its own judgment for that of the administrator in

determining the eligibility for plan benefits even if the court

disagrees with that decision. Id. Under the abuse of discretion

standard, the only issue is whether, on the evidence considered,

the administrator's determination was "reasonable." Horan v.

Kaiser Steel Retirement Plan, 947 F.2d 1412, 1417 (9th Cir.

1991); see also Clark v. Wash. Teamsters Welfare Trust, 8 F.3d

1429, 1432 (9th Cir. 1993) ("Our inquiry is not into whose

interpretation of plan documents is most persuasive, but whether

the plan administrator's interpretation is unreasonable."). 

Moreover, the scope of review under the arbitrary and capricious

standard is very limited. The focus of an abuse of discretion

inquiry is the administrator's analysis of the administrative

record--it is not an inquiry into the underlying facts. Alford

v. DCH Found Group Long-Term Disability Plan, 311 F.3d 955, 957

(9th Cir. 2002).

Here, the Plan provides that an individual qualifies for LTD

benefits only if, based upon “objective medical evidence,” that

individual is “continuously unable to perform any occupation for

which he or she is or may become qualified by reason of his or

her education, training or experience.” (Ex. B, § 2(o)(ii),

HP573.) In this case, the court finds that VPA’s decision was

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11 Moore, 2000 WL 361680 at *7 (describing “objective

medical evidence” as for example, “lab test results, X-rays,

consulting physician’s reports, or physical therapy results” or

“any other data that could be considered objective evidence

perceived without distortion of personal feelings, prejudices or

interpretations”) (emphasis added).

12 Plaintiff tries to distinguish Jordan, arguing that

this case is not a “finding-less case of fibromyalgia” but rather

a case involving a “serious” Zenker’s diverticulum. However,

plaintiff is not claiming that an esophageal diverticulum

disabled her; instead, she is claiming disability on the basis of

“pain” she claims resulted from surgery to remove that

diverticulum. For the reasons set forth below, she has not

demonstrated by objective medical evidence that her pain totally

disables her, and in that regard, this case is analogous to

Jordan. 

32

compelled by the terms of the Plan and as such, it was neither

arbitrary nor capricious.

Although plaintiff complained to numerous doctors of

headaches and neck and back pain, there is little objective11

medical evidence in the record of those subjective reports. See

e.g. Jordan v. Northrup Grumman Co. Welfare Benefit Plan, 370

F.3d 869, 878 (9th Cir. 2004) (recognizing that an administrator

may ultimately reject physicians’ diagnoses that rely on the

patient’s subjective reports of pain).12 Indeed, plaintiff’s lab

tests and other screenings were all essentially normal, except

for an MRI of the cervical spine which found “[e]arly degenertive

disk changes at C3-4 and C6-7,” but, significantly, revealed

“[n]o disk herniation, central canal or neural foraminal

stenosis” (Ex. A, HP58 [emphasis added]), and a “Thoracic Spine

Series” that indicated “[e]arly degenerative disc changes and

spondylosis in the mid thoracic spine” but identified “[n]o acute

changes.” (Ex. A, HP71; compare HP64, HP72-73, HP118 [emphasis

added].) 

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Likewise, there is no objective medical evidence of

plaintiff’s “memory and concentration deficits” beyond her own

subjective complaints. 

In addition, while her physical therapist and chiropractor

observed a decreased range of movement and a collapsed posture

(Ex. A, HP416, HP483-86), they never explained how those

limitations, which had improved by the time she left

physical therapy in May 2003 (Ex. A, HP333), prevented her from

performing in a sedentary position.

In that latter regard, there is also little evidence of how

plaintiff's claimed medical issues prevented her from performing

any occupation for which she was qualified or could become

qualified based on her education, training or experience. There

is substantial evidence in the record that plaintiff's

conditions did not prevent her from working at a sedentary job.

(Ex. A, HP 211-12.) The independent examiner who performed

plaintiff’s FCE, which occurred closest to the date at which she

was required to demonstrate total disability, stated that she was

"capable of performing work in the sedentary classification

according to the U.S. Department of Labor Standards

on an 8 hour day basis." (Ex. A, HP173.) Even the previous

functional capacity file review by CorVel determined that with

accommodations plaintiff "has the skills to perform within her

educational level, benefit wage level and physical work

capacity." (Ex. A, HP277.) Moreover, the notes from her doctors

are largely conclusory statements that she was not able to work,

without discussion of how any conditions affected her functional

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capacity. (Ex. A, HP15, HP17, HP24, HP172, HP233, HP238, HP298,

HP325, HP476, HP487, HP505.)

Plaintiff argues, to the contrary, that VPA either

misrepresented the evidence or omitted to discuss items that she

views as crucial to her claim in its denials, and that this was

an abuse of discretion. First, plaintiff argues VPA

misrepresented and misinterpreted the FCE performed by

Healthsouth. Plaintiff concedes that the examiner concluded that

she was capable of performing work in the sedentary

classification according to U.S. Department of Labor Standards on

an 8 hour daily basis. (Ex. A, HP173.) However, she argues that

VPA should have interpreted the examiner’s report as

contradicting its conclusion, because plaintiff reported pain

during, and increased pain following, the examination. Likewise,

plaintiff argues that her reports to the examiner regarding her

own perceived abilities should have been considered in the

conclusion. Id. Plaintiff’s reports of subjective feelings are

not “objective medical evidence” required by the Plan--such

reports of pain are not “evidence establishing facts or

conditions as perceived without distortion by personal feelings,

prejudices or interpretations,” as the Plan defines “objective

medical evidence.” (Ex. B, § 2(o), HP574.) The Plan mandates

that VPA’s review focus on objectively measurable criteria, and

thus, plaintiff’s argument is unavailing. 

Plaintiff also argues that her posture and muscular

tenderness should have affected the FCE examiner’s conclusion;

yet, plaintiff does not explain how that aliment rendered her

disabled from any occupation. Nor does she explain why a

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need “to sit frequently to rest from testing in a standing

position” or the inability to “lift 10 lbs. safely on a

frequent basis” would prevent her from performing in a sedentary

occupation. She also places great emphasis on the examiner’s

observation that she “was observed to lose her balance

momentarily on a frequent basis due to reports of dizziness and

back spasms.” (Pl.’s MSJ at 10, 14 [citing HP175].) However,

she does not indicate how that precluded her from working in a

sedentary position. 

In addition, plaintiff relies on Dr. Chu’s assessment, but

ignores his finding in January of 2003 that she could “return to

work part time, 4 hours a day for 2 weeks, then 6 hours a day for

2 weeks then full time afterward.” (Ex. A, HP425.) Clearly, 

Dr. Chu did not determine that she was disabled from a sedentary

position. (Id.)

Plaintiff also cites to her physical therapist’s initial

evaluation of her in January 2003 and the February 10, 2003

report to the California Disability agency as evidence of her

claim. However, she does not explain how those reports remain

relevant when the same physical therapist reported improvement

and a normal range of motion in her report discharging

plaintiff from physical therapy in May 2003. (Ex. A, HP333.)

Moreover, as the physical therapist stated in her letter to the

California disability agency, her findings were based “solely on

clinical findings and patients [sic] subjective reports.” (Ex A,

HP338.) Like the above, nothing in these records evidences

“total disability” on the basis of objective medical evidence.

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13 To the extent plaintiff alternatively argues that this

court should find error in VPA’s failure to consider her claims

of depression as a basis for an award of benefits, the court

finds plaintiff’s arguments wholly unpersuasive. By the express

terms of the Plan, plaintiff did not meet the hospitalization

requirement of the mental illness limitations of the Plan, and

thus, any claimed depression was properly excluded from

consideration by VPA. (Ex. B, § 2(o), HP574.) Furthermore, even

if plaintiff’s depression was caused by her physical pain and

disability, such depression is nonetheless included in the Plan’s

definition of mental illness and specifically excluded from

coverage after the first 52 weeks. (Ex. B, § 2(o)(A)(1), HP575.) 

As such, VPA, properly, did not consider any claim of disability

“caused or contributed to” by plaintiff’s depression and anxiety. 

(Ex. B, § 2(o)(A), HP574-75.)

36

Plaintiff further contends that Healthsouth’s FCE

contradicted the review of her file by CorVel. However, it

cannot be considered an abuse of discretion for VPA to give

greater weight to an in-person examination over a review of

records that were not completely up to date. Indeed, the

restrictions and limitations provided to CorVel for its

assessment derived from Dr. Chu’s examination in January 2003,

but plaintiff’s caregivers observed improvements over the

following months (Ex. A, HP333), which improvements were

reflected in the most-current assessment by Healthsouth. 

Plaintiff also claims, more generally, that VPA did not

properly address various medical records in its letters denying

her claim (Pl.’s MSJ at 15-16). While it is true that VPA did

not mention every medical record in plaintiff’s extensive file of

over 500 pages (HP 10-12, HP209-13) in issuing its denials of

plaintiff’s benefits claim, what is relevant is that plaintiff

has not pointed to any objective medical evidence of her claimed

disability that VPA should have addressed but did not.13

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In sum, plaintiff continues to rely on her subjective

complaints of pain to support her claim for long-term disability

benefits, and she still has not identified any objective medical

evidence that she is totally disabled as defined by the Plan. 

The burden of production rests with plaintiff (Ex. B, § 8(b),

HP615), and her failure to support her claim then, and even now,

with objective medical evidence is fatal to her claim herein.

See e.g. Mitchell v. Aetna Life Insur. Co., 359 F. Supp. 2d 880,

890 (C.D. Cal. 2005) (granting summary judgment in favor of

defendants on the grounds the plan administrator did not abuse

its discretion in denying employee’s LTD benefits claim based on

the employee’s “subjective reports of pain and her doctors’

unexplained conclusory opinions that she was disabled from

performing any job”).

CONCLUSION

For the foregoing reasons, the court GRANTS defendant’s

motion for summary judgment and DENIES plaintiff’s motion for

summary judgment. The Clerk of the Court is directed to close

this file.

IT IS SO ORDERED.

 DATED: March 26, 2007

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