Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-cand-3_05-cv-03294/USCOURTS-cand-3_05-cv-03294-6/pdf.json

Nature of Suit Code: 791
Nature of Suit: Employee Retirement Income Security Act (ERISA)
Cause of Action: 29:1132 E.R.I.S.A.: Employee Benefits

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IN THE UNITED STATES DISTRICT COURT

FOR THE NORTHERN DISTRICT OF CALIFORNIA

SANDRA BREBER,

Plaintiff,

 v.

ARTHUR ANDERSEN LLP GROUP

ACCIDENT AND HEALTH INSURANCE

PLAN,

Defendant.

 /

No. C 05-03294 JSW

ORDER DENYING CROSSMOTIONS FOR SUMMARY

JUDGMENT

Now before the Court are the cross-motions for summary judgment filed by plaintiff

Sandra Breber (“Plaintiff”) and defendant Arthur Andersen LLP Group Accident and Health

Insurance Plan (“Defendant” or “the Plan”). Having carefully reviewed the parties’ papers,

considered their arguments and the relevant legal authority, the Court hereby denies both

parties’ motions.

BACKGROUND

This action arises from the denial of Plaintiff’s claim for benefits under the Plan. 

Plaintiff brought this action to challenge the denial of her claim for disability benefits under

Section 502(a)(1)(B) of the Employee Retirement Income Security Act of 1974 (“ERISA”), 29

U.S.C. § 1132(a)(1)(B). 

Plaintiff worked for Arthur Anderson LLP for approximately 22 years. The parties

dispute whether Plaintiff became disabled while she was covered by the Plan, and if so, what

position Plaintiff held at Arthur Anderson at that time. 

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On April 1, 2002, Plaintiff hit her head in a skiing accident. Immediately after the

accident, Plaintiff was stunned, but not overtly confused or unconscious. (Aetna 450.) Soon

thereafter, she felt “woozy” and nauseated and had headaches. She eventually developed fatigue

and slowed information processing. Plaintiff also suffered from vertigo. (Id.; see also Aetna

453.) She was “quite ill” for the first couple of weeks after the accident and stayed in bed. (Id.) 

During the first four weeks after her accident, significant nausea limited her ability to carry on

daily and work activities. She tried during this time to work a few hours from home, but found

this difficult. (Aetna 453.) On April 29, 2002, Dr. Bradley Wrubel, to whom Plaintiff was

referred for a neurologic consultation, wrote that Plaintiff has not been working since the

accident and likely would not go back to work for several more weeks. (Aetna 455.)

Plaintiff’s symptoms lingered and on June 5, 2002, Plaintiff was seen by Dr. Yuen T. So

for another neurological consultation. (Aetna 451.) Dr. So stated that her symptoms were

severe in the first month after the accident, but had become tolerable and intermittent in the

second month. Dr. So reported that “[s]he tried to work through all of this initially, but about

two weeks ago has stopped and taken a disability leave.” (Id.)

By July 12, 2002, Plaintiff had improved 70 to 80 %. (Aetna 450.) Plaintiff had a CT

scan which was normal. Doctors found no abnormalities upon a physical examination. (Id.; see

also Aetna 453-54.)

Dr. Raskin diagnosed Plaintiffs as “post concussional,” and opined that, based on her

rate of improvement, she was likely to be asymptomatic within a year. (Aetna 450; see also

Aetna 452, 454, 642.) Dr. Raskin noted that her condition was somewhat complicated by the

migraines Plaintiff had developed at the age of 40. Her head injury had activated her migraines. 

(Aetna 450.) 

As her symptoms from the post-concussive syndrome improved, Plaintiff developed

additional medical problems. In early August 2002, Plaintiff was examined by Dr. Jonathan P.

Terdiman in the UCSF Mt. Zion Gastroenterology Facult Practice. (Aetna 447.) Plaintiff had

symptoms suggestive of gastroesophageal reflux disease. Possibly as a result of taking large

doses of Advil due to her post-concussive syndrome, Plaintiff “developed worsening of

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epigastric discomfort, as well as substernal buring, regurgitation of acid in her throat, and chest

pain.” (Id.) Plaintiff stopped taking Advil, but these symptoms continued. (Id.) Due to her

symptoms, Plaintiff could not sleep at night. (Id.) Dr. Terdiman found her symptoms were

“suspicious for gastroesophageal reflux disease,” but noted that she was not responding to

medications for this condition. (Id.)

Plaintiff went to the emergency room in August 2002 due to her severe abdominal pain. 

(Aetna 649.) Plaintiff explained that between August and December of 2002, her abdominal

pain “became persistently worse and by December 2002 was no longer intermittent but had

become constant.” (Aetna 650) According to Plaintiff’s husband, Manny Krakaris, Plaintiff’s

abdominal pain became increasingly more intense during the summer and fall of 2002. (Aetna

660.) He testified that “During the summer and fall of 2002, [Plaintiff] had a very difficult time

with may of the things that she had taken for granted prior thereto. ... She was unable to

participate in any of the sports she had loved. She would need to rest for extended periods

during the day ... .” (Id.) 

On December 10, 2002, Plaintiff had an ultrasound. (Aetna 332-33.) On December 18

and 20, 2002, Dr. David H. Watts ran several tests on Plaintiff’s blood. (Aetna 419-20.) On

December 23, 2002, Plaintiff was still experiencing abdominal pain and Dr. Watts conducted an

endoscopy. The endoscopy did not reveal any pathologic abnormality. (Aetna 415-16.) On the

same day, Dr. Watts also tested Plaintiff for pancreatitis by conducting a CT scan of her

abdomen and pelvis, which revealed no evidence of acute pancreatitis and was otherwise

unremarkable. (Aetna 417-18.) 

Due to her pain, Plaintiff went to the emergency room again on December 24, 2002,

Christmas Eve. (Aetna 074, 650, 660.) On December 30, 2002, a doctor noted that Plaintiff’s

endometriosis, which she previously suffered from last in 1987, had reoccurred. (Aetna 552.)

On January 29, 2003, Dr. James R. Sakamoto performed an exploratory and therapeutic

laparoscopy on Plaintiff. (Aetna 439, 442.) Dr. Sakamoto’s preoperative diagnosis was:

“[i]ncreasing lower abdominal pain, history of extensive endometriosis, presumptive recurrent

endometriosis.” (Aetna 442.) After the laparascopy, Dr. Sakamoto diagnosed Plaintiff as: “[n]o

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evidence of active endometriosis, dense adhesion, rectosigmoid, posterior lower segment, with

possible endometriosis. Dr. Sakamoto identified a fine adhesion to the right ovarian fossa and a

fairly dense adhesion in her cul-de-sac area. He further noted whitish nodules possibly

consistent with endometrial implants. (Aetna 442.) However, Dr. Sakamoto later described his

findings as “no specific evidence of endometriosis.” (Aetna 439.) During the procedure in

January 2003, Dr. Sakamoto lysed the adhesions and fulgurated the possible areas of

endometriosis. (Aetna 439.)

After the surgery in January 2003, Plaintiff was placed on continuous oral contraceptive

suppression and experienced some improvement. (Aetna 316.) As of mid-February 2003, Dr.

Sakamoto found that Plaintiff was recovering slowly from the surgery, but was steadily

improving, and anticipated that she would be able to return to her usual work activities

approximately four weeks after the surgery. (Aetna 074.) However on March 5, 2003, Dr.

Watts noted that she was in continuous abdominal pain and would need an additional six weeks

of recovery time. (Aetna 411.) Notes from a doctor indicate that Plaintiff was experiencing

“bloating and pain” and that her pain felt like a “stitch in one side.” (Aetna 412.)

In April, May and June 2003, Plaintiff experienced break through bleeding and

continued abdominal pain. (Aetna 508, 650.) Plaintiff provided the following description of her

condition: “By June 2003 I was all tied up again inside. I was unable to stand for more than 30

minutes at a time. ... Frequently I was doubled over in pain and would just stay in bed all day.” 

(Aetna 650.)

On August 18, 2003, Plaintiff had a total abdominal hysterectomy for “worsening lower

abdominal and pelvic pain and presumptive endometriosis.” (Aetna 439, 495.) Dr. Sakamoto’s

pre- and post-operative diagnosis was “increasing pelvic and lower abdominal pain.” (Aetna

495.) Before the surgery, he diagnosed her with “severe pelvic endometriosis.” After the

surgery, he refined his diagnosis to be “severe pelvic endometriosis plus cul-de-sac scarring and

endometriosis.” (Id.) He found filmy adhesions on her right fallopian tup and ovary, filmy

dense adhesions “obliterating the cul-de-sac,” and small power burns consistent with

endometriosis. (Id.)

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On the forms submitted to Defendant for Plaintiff’s claim, Dr. Kurt Wharton stated that

Plaintiff suffered from endometriosis and had symptoms such as vasomotor depression,

migraine headaches, musculoskeletal pain, pelvic pain, insomnia, decreased cognition, agitation,

and diffuse neuropathies starting in August 2002. (Aetna 183.) Dr. Wharton further stated she

was under medical restrictions such as “enforced rest each day” and that he prescribed these

work restrictions in December 2002. (Aetna 184.)

 The Court will address the additional specific facts as required in the analysis.

ANALYSIS

A. Legal Standard on Summary Judgment.

A principal purpose of the summary judgment procedure is to identify and dispose of

factually unsupported claims. Celotex Corp. v. Cattrett, 477 U.S. 317, 323-24 (1986). 

Summary judgment is proper when the “pleadings, depositions, answers to interrogatories, and

admissions on file, together with the affidavits, if any, show that there is no genuine issue as to

any material fact and that the moving party is entitled to judgment as a matter of law.” Fed. R.

Civ. P. 56(c). 

A party moving for summary judgment who does not have the ultimate burden of

persuasion at trial, must produce evidence which either negates an essential element of the nonmoving party’s claims or show that the non-moving party does not have enough evidence of an

essential element to carry its ultimate burden of persuasion at trial. Nissan Fire & Marine Ins.

Co. v. Fritz Cos., 210 F.3d 1099, 1102 (9th Cir. 2000). A party who moves for summary

judgment who does bear the burden of proof at trial, must produce evidence that would entitle

him or her to a directed verdict if the evidence went uncontroverted at trial. C.A.R. Transp.

Brokerage Co., Inc. v. Darden, 213 F.3d 474, 480 (9th Cir. 2000). 

Once the moving party meets his or her initial burden, the non-moving party must go

beyond the pleadings and by its own evidence “set forth specific facts showing that there is a

genuine issue for trial.” Fed. R. Civ. P. 56(e). In order to make this showing, the non-moving

party must “identify with reasonable particularity the evidence that precludes summary

judgment.” Keenan v. Allan, 91 F.3d 1275, 1279 (9th Cir. 1996). It is not the Court’s task to

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“scour the record in search of a genuine issue of triable fact.” Id. (quoting Richards v.

Combined Ins. Co., 55 F.3d 247, 251 (7th Cir. 1995)). If the non-moving party fails to make

this showing, the moving party is entitled to judgment as a matter of law. Celotex, 477 U.S. at

323. 

An issue of fact is “genuine” only if there is sufficient evidence for a reasonable fact

finder to find for the non-moving party. Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 248-49

(1986). A fact is “material” if it may affect the outcome of the case. Id. at 248. “In considering

a motion for summary judgment, the court may not weigh the evidence or make credibility

determinations, and is required to draw all inferences in a light most favorable to the nonmoving party.” Freeman v. Arpaio, 125 F.3d 723, 735 (9th Cir. 1997).

B. Cross-Motions for Summary Judgment

ERISA allows a participant in an employee benefit scheme to bring a civil action to

recover benefits due under the terms of a plan. 29 U.S.C. § 1132(a)(1)(B). Courts review a

denial of benefits challenged under § 1132(a)(1)(B) “under a de novo standard unless the benefit

plan gives the administrator or fiduciary discretionary authority to determine eligibility for

benefits or to construe the terms of the plan.” Firestone Tire & Rubber Co. v. Bruch, 489 U.S.

101, 115 (1989). Here, the parties have stipulated that the Court should review the denial of

benefits de novo. Under the de novo standard, “in considering motions for summary judgment,

the district court must decide whether there are genuine issues of material fact, not whether there

was substantial or ample evidence to support the plan administrator’s decision.” Mongeluzo v.

Baxter Travenol Disability Benefit Plan, 46 F.3d 938, 942 (9th Cir.1995). Here, there are

questions of fact regarding when Plaintiff when Plaintiff became disabled. 

1. Plaintiff’s Disability.

The parties do not dispute that as of August 2003, Plaintiff was disabled by surgically

induced menopause and continued to be disabled until October 31, 2005. What is in dispute is

whether Plaintiff was disabled starting in 2002.

In April 2002, Plaintiff hit her head in a skiing accident. (Aetna 450.) Plaintiff contends

that from April through August 2002, she suffered from post-concussive syndrom and that she

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 At the hearing, Plaintiff’s counsel represented that Plaintiff received short-term

disability benefits in the spring of 2002 when she suffered from post-concussive syndrome. 

If true, evidence of her receipt of such benefits would be probative as to whether Plaintiff was

working during that time or whether she was suffering from an injury which interfered with

her ability to work, at least in the short term.

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was not working during this time period due to this condition.1 Plaintiff further contends that as

she recovered from the post-concussive syndrome, she started developing severe abdominal pain

which her doctors later diagnosed as a reoccurrence of endometriosis. According to Plaintiff,

she was in disabling pain from August 2002 through August 2003 due to endometriosis, and

thus could not work.

On Plaintiff’s claim for long-term disability benefits, she stated that the first day of work

she missed due to her alleged disability was December 23, 2002. (Aetna 382.) While Plaintiff

argues that she was mistaken when she wrote this date and that she actually stopped working on

April 1, 2002, her claim form creates a question of fact regarding when she last worked due to

her alleged disability and whether she was continuously disabled prior to December 23, 2002. 

With respect to whether Plaintiff was suffering from endometriosis from the summer of

2002 through August 2003, Defendant points to the Dr. Sakamoto’s findings of “no specific

evidence of endometriosis” after he conducted a laparoscopy on Plaintiff on January 29, 2003. 

(Aetna 439.) This evidence creates a question of material fact regarding whether Plaintiff was

disabled from endometriosis from sometime in 2002 through August 2003. Accordingly, the

Court denies Plaintiff’s motion for summary judgment.

On the issue of whether Plaintiff was disabled in 2002, the Court cannot find in

Defendant’s favor as a matter of law either. Plaintiff presents evidence from which a reasonable

juror could find that she was disabled in 2002 through August 2003. Accordingly, the Court

denies Defendant’s motion for summary judgment on this ground.

2. Notice-Prejudice Rule.

Defendant argues that regardless of when Plaintiff last work or when Plaintiff became

disabled, even it was before August 2003, Plaintiff is barred from recovering benefits because

she waited too long to file her claim for benefits. Under California law, an insurer may raise the

insured’s failure to give timely notice of a claim as a defense, but to do so, the insurer must

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prove that the claim was late and that it suffered substantial prejudice. Cineros v. UNUM Life

Ins. Co. of Amer., 134 F.3d 939, 944 (9th Cir. 1998) (citing Shell Oil Co. v. Winterthur Swiss

Ins. Co., 12 Cal. App. 4th 715, 760 (1993)); see also O’Neil v. Fireman’s Fund Amer.

Retirement, 2005 WL 1562799, * 5 (N.D. Cal. June 22, 2005) (holding that to prevail under

notice-prejudice rule, insurer must show: “(1) the claimant failed to submit timely proof of

claim, and (2) the delay actually caused the insurer substantial prejudice.”). 

Here, Defendant has not demonstrated that Plaintiff submitted her claim late. To

establish the deadline for filing claims, Defendant points to the summary plan descriptions,

which provide that an applicant for long-term disability benefits should “contact the ABC for

claim forms as soon as possible after [the] disability occurs. [The applicant] and [his or her]

doctor should complete and return the forms within 20 days after [the applicant’s] disability

begins, or soon as reasonably possible.” (Anderson 014; see also Anderson 027 (“Claims

should be filed within 20 days after the disability occurs or as soon as reasonably possible.”),

Anderson 048 (same).) Defendant further relies on provisions in the policy to demonstrate the

time period for filing claims. (Defendant’s Mot. at 5 (citing Aetna 598).) The policy provides

that Defendant will not pay benefits until it is given a written proof of loss. (See Aetna 598.) 

The policy then provides under the section entitled “Proof of Loss” that:

1. A request for Initial Application for Group Long-Term Disability (LTD) Benefits

must be made to the Benefits Administrator (Section VII, number 11).

This request should be made:

a. Within 20 days after a disability occurs; or

b. As soon as reasonably possible.

If the covered individual does not receive the form within 15 days, he or she can

meet the proof of loss requirement by giving Aetna a written statement of what

happened. Aetna must receive a written statement within 90 days by not later

than one year after the disability occurs (unless the applicant is not legally

capable).

2. The covered individual must complete and sign the form. Have the physician

complete and sign his or her part.

3. The covered individual must return the form to the Benefits Administrator

(Section VII, number 11). The form is due within 90 days after the end of the

Waiting Period (Section VII, number 30), and thereafter at least once each 90

days as long as the covered individual is disabled. If he or she does not send

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Aetna the form when due, Aetna will still honor the claim if he or she sends

Aetna the form as soon as reasonably possible. The form must be sent to Aetna

not later than one year after it is otherwise required....

(Aetna 598.) Defendant relies on this description to argue that claims are due, at the latest, “not

later than one year after the disability occurs.” However, this phase describes when the written

statement is due which may be provided by the applicant as proof of loss if he or she does not

receive the forms from the benefits administrator. (Id.) If the applicant makes the request and

receives the applicable forms, the policy provides that the form is due “90 days after the end of

the Waiting Period.” The policy then continues to provide that Defendant will still honor the

claim if the applicant fails to submit the form within this time period so long as the applicant

submits the form “as soon as reasonably possible” and sets one-year from the deadline (i.e. 90

days after the end of the Waiting Period) as the cutoff point. (Id.)

At the hearing on the cross-motions for summary judgment, Defendant argued that

although there appears to be a conflict between the summary plan description and the policy as

to when the deadline to file a claim expires, the summary plan description is controlling. The

Court disagrees. See Bergt v. Retirement Plan for Pilots Employed by MarkAir, Inc., 293 F.3d

1139, 1145 (9th Cir.2002) (holding that inconsistencies between the language of an ERISA

master plan document and a summary plan description must be resolved in the employee’s

favor). Because the policy and the summary plan description set forth conflicting deadlines, the

document more favorable to Plaintiff – the policy – controls. 

Regardless of whether Plaintiff was disabled starting in early April 2002 and subject to a

one-year waiting period or was disabled starting at the end of December 2002 and subject to a

90-day waiting period, her waiting period would have expired by the end of March 2003. The

final deadline for her to submit the forms for a long-term disability claim would have expired by

the end of June 2004, one year after the 90 days after the waiting period ended. Plaintiff

submitted her claim in January 2004, which is before the final deadline expired. (Aetna 382.) 

Accordingly, Defendant has not shown that Plaintiff filed her claim late. The Court thus denies

Defendant’s motion on the grounds of notice-prejudice.

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CONCLUSION

For the foregoing reasons, the Court denies the parties’ cross-motions for summary

judgment. At the hearing on the parties’ cross-motions, while Defendant made clear it had no

objection to converting its summary judgment briefs into trial briefs and having the Court

conduct a bench trial de novo based entirely on the administrative record, Plaintiff wanted the

opportunity to submit trial briefs and reserved on whether she wanted to submit additional

evidence for the Court’s review. Accordingly, the Court directs the parties to meet and confer

regarding whether they intend to submit evidence beyond the administrative record and to

establish a briefing schedule for submitting trial briefs. If the parties intend to submit additional

evidence, they should make a showing under Mongeluzo, 46 F.3d at 943-44, that the

circumstances demonstrate that the additional evidence is necessary for the Court to conduct an

adequate de novo review of the benefit decision. The parties shall file a stipulation on these

issues or, if unable to agree, a brief summary of the parties’ respective positions, by no later than

September 22. 

IT IS SO ORDERED.

Dated: August 31, 2006 

JEFFREY S. WHITE

UNITED STATES DISTRICT JUDGE

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