Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-cand-3_07-cv-01001/USCOURTS-cand-3_07-cv-01001-1/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

IN THE UNITED STATES DISTRICT COURT

FOR THE NORTHERN DISTRICT OF CALIFORNIA

SARA WONG,

Plaintiff,

 v.

AUTODESK, INC. LONG TERM

DISABILITY PLAN, and AETNA LIFE

INSURANCE COMPANY,

Defendants.

 /

No. C-07-1001 MMC

ORDER DENYING PLAINTIFF’S MOTION

TO DETERMINE SCOPE OF

ADMINISTRATIVE RECORD; VACATING

HEARING

(Docket No. 16)

Before the Court is plaintiff Sara Wong’s Motion to Determine the Scope of the

Administrative Record, filed July 20, 2007. Defendant Aetna Life Insurance Company

(“Aetna”) has filed opposition to the motion; plaintiff has filed a reply. Having considered

the papers filed in support of and in opposition to the motion, the Court finds the matter

appropriate for resolution without oral argument, hereby VACATES the August 24, 2007

hearing on the matter, and rules as follows.

BACKGROUND

Plaintiff asserts a claim against defendants Autodesk, Inc. Long Term Disability Plan

and Aetna, pursuant to the Employee Retirement Income Security Act of 1974 (“ERISA”),

for long-term disability benefits. (See Compl. ¶¶ 27-29.) Plaintiff alleges her most recent

appeal of Aetna’s denial of benefits was submitted to Aetna on November 6, 2006, that

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Aetna informed her that she would receive a written response to her appeal prior to

February 4, 2007, and that no decision on her appeal was received by that date. (See id.

¶¶ 21-24.) Plaintiff filed the instant action February 16, 2007.

In a letter dated February 15, 2007, Aetna denied plaintiff’s appeal. (See Roboostoff

Decl. ¶ 2 and Ex. A.) Plaintiff received the denial on February 20, 2007, after she filed the

instant action. (See id. ¶ 2.)

DISCUSSION

Plaintiff now seeks a ruling that the scope of the administrative record does not

include Aetna’s February 15, 2007 denial of plaintiff’s appeal, or the “peer review report” of

R. David Bauer, M.D. (“Bauer report”), referenced therein and dated February 12, 2007. 

Plaintiff argues that the denial was untimely and that the Bauer report was obtained by

Aetna after the deadline for Aetna to respond to plaintiff’s appeal, and that, consequently,

the Court should not consider those documents as part of the administrative record.

Where a disability benefits claimant seeks review of an adverse benefit

determination, the applicable federal regulations require the plan administrator to notify the

claimant of the plan’s decision “within a reasonable period of time, but not later than [45

days] after receipt of the claimant’s request for review by the plan, unless the plan

administrator determines that special circumstances . . . require an extension of time for

processing the claim.” See 29 C.F.R. §§ 2560.503-1(i)(1)(i) and (i)(3)(i). “If the plan

administrator determines that an extension of time for processing is required, written notice

of the extension shall be furnished to the claimant prior to the termination of the initial [45-

day] period,” and such notice “shall indicate the special circumstances requiring an

extension of time and the date by which the plan expects to render the determination on

review.” See 29 C.F.R. § 2560.503-1(i)(1)(i). “In no event shall such extension exceed a

period of [45 days] from the end of the initial period.” See 29 C.F.R. §§ 2560.503-1(i)(1)(i)

and (i)(3)(i). Here, plaintiff alleges Aetna notified her that it was extending the appeal

period by 45 days, to February 4, 2007, (see Compl. ¶ 23), a date 90 days after November

6, 2006, the date on which plaintiff submitted her most recent appeal. Because Aetna did

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not decide the appeal until February 15, 2007, Aetna failed to determine plaintiff’s appeal

within the 90-day time limit set forth in the above-referenced federal regulations.

Plaintiff has cited no authority, however, requiring the Court, in deciding plaintiff’s

claim, to disregard Aetna’s untimely denial of benefits or any evidence Aetna relied upon in

reaching such decision. Under some circumstances, a plan’s failure to comply with

applicable time limits may result in the Court’s applying de novo review to a plaintiff’s claim

for benefits under ERISA. See Jebian v. Hewlett-Packard Co. Employee Benefits

Organization Income Protection Plan, 349 F.3d 1098, 1103 (9th Cir. 2003); but see Gatti v.

Reliance Standard Life Ins. Co., 415 F.3d 978, 982 (9th Cir. 2005) (holding “violations of

the time limits established in [prior version of] 29 C.F.R. § 2560.503-1(h) are insufficient to

alter the standard of review”). The Court need not decide whether such circumstances

exist here, however, because the parties agree that de novo review is the appropriate

standard of review. (See Motion at 5:1-5; Opp. at 5:24-26.) 

Where the Court conducts a de novo review, the administrative record consists of

the evidence that was before the plan administrator, as well as any additional evidence that

is “necessary to conduct an adequate de novo review of the benefit decision.” See

Kearney v. Standard Ins. Co., 175 F.3d 1084, 1090 (9th Cir. 1999) (en banc) (internal

quotation and citation omitted); see also Abatie v. Alta Health & Life Ins. Co., 458 F.3d 955,

972-73 (9th Cir. 2006) (en banc) (“When a plan has failed to follow a procedural

requirement of ERISA, the court may have to consider evidence outside the administrative

record.”). Plaintiff cites no authority, and the Court is aware of none, authorizing the Court

to strike from the administrative record, as a result of a plan’s failure to decide an appeal

within applicable time limits, any evidence the plan had before it and relied upon in denying

a claim for benefits. Moreover, contrary to plaintiff’s argument, the Court finds no lack of

fairness as a result of the Court’s considering the reasons and evidence upon which Aetna

ultimately relied in Aetna’s decision to deny plaintiff’s claim.

Accordingly, plaintiff’s motion will be DENIED. 

/ /

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CONCLUSION

For the reasons set forth above, plaintiff’s motion is hereby DENIED.

This order terminates Docket No. 16.

IT IS SO ORDERED.

Dated: August 15, 2007 MAXINE M. CHESNEY

United States District Judge

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