Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-cand-3_05-cv-03399/USCOURTS-cand-3_05-cv-03399-6/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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United States District Court

For the Northern District of California

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Docket No. 65.

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Docket No. 63.

United States District Court

For the Northern District of California

IN THE UNITED STATES DISTRICT COURT

FOR THE NORTHERN DISTRICT OF CALIFORNIA

NOLAN,

 Plaintiff,

 v.

 HEALD COLLEGE ET AL,

Defendant. /

No. C05-03399 MJJ

ORDER DENYING PLAINTIFF’S

MOTION TO ALTER OR AMEND

JUDGMENT AND CLARIFYING

PREVIOUS ORDER DENYING

PLAINTIFF’S MOTION FOR SUMMARY

JUDGMENT AND GRANTING

DEFENDANTS’ MOTION FOR

SUMMARY JUDGMENT 

INTRODUCTION

Before the Court is Plaintiff Jeanne Nolan’s (“Plaintiff” or “Nolan”) Motion to Alter or

Amend Judgment.1

 Defendants Heald College (“Heald”), Heald College Long Term Disability Plan

(the “Plan”), and Metropolitan Life Insurance Company (“MetLife”) (collectively, “Defendants”)

oppose the motion. For the following reasons, the Court DENIES Plaintiff’s Motion to Alter or

Amend Judgment and clarifies its previous Order Denying Plaintiff’s Motion for Summary

Judgment and Granting Defendants’ Motion for Summary Judgment.2

FACTUAL BACKGROUND

This suit was brought under the Employee Retirement Income Security Act of 1974

(“ERISA”), 29 U.S.C. § 1001, et seq., seeking past and future long term disability (“LTD”) benefits

under the Plan administered and insured by MetLife. Plaintiff alleges that she is eligible for LTD

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benefits due to a disabling condition, which has prevented her from working since April 10, 2002. 

Plaintiff received benefits under the Plan for 24 months, until July 9, 2004. At that point, MetLife

terminated her benefits believing that her condition fell within the “neuromusculoskeletal” 24-month

limit. Plaintiff twice appealed the termination decision. MetLife denied both of Plaintiff’s appeals. 

Except as otherwise noted, the factual background of Plaintiff’s claim history as taken from this

Court’s Order Denying Plaintiff’s Motion for Summary Judgment and Granting Defendants’ Motion

for Summary Judgment (“Summary Judgment Order”) is as follows. (See Docket No. 63, Nolan v.

Heald College et al., Case No. C05-3399 MJJ.) 

I. Long-Term Disability Under the Plan

The Plan provides LTD benefits which are funded through a group policy of insurance issued

by MetLife to Heald. (Administrative Record (“MET”) 1-59.) The maximum Benefit Duration

under the Plan for LTD benefits for employees such as Plaintiff, who were under age 60 at the time

they allegedly became disable, is age 65. (MET 12.)

Plan participants are entitled to receive LTD benefits if they are “Disabled” (as that term is

defined in the Plan), and they became “Disabled” while covered under the Plan. (MET 17.) The

Plan defines “Disabled” in pertinent part as follows:

“Disabled” or “Disability” means that, due to sickness, pregnancy, or

accidental injury, you are receiving Appropriate Care and Treatment

from a Doctor on a continuing basis; and 

(1) during your Elimination Period and the next 24 month period, you

are unable to earn more than 80% of your Predisability Earnings or

Indexed Predisability Earnings at your Own Occupation form any

employer in your Local Economy; or 

(2) after the 24 month period, you are unable to earn more than 60% of

your Indexed Predisability Earnings from any employer in your Local

Economy at any gainful occupation for which you are reasonable

qualified taking into account your training, education, experience and

Predisability Earnings.

(MET 19-20.) The “Elimination Period” for LTD benefits is 90 days of continuous disability. 

(MET 12, 18.) Monthly LTD benefits under the Plan begin on the date following the day the

participant completes the Elimination Period. (MET 17.) Monthly LTD benefits may end for a

variety of reasons, such as when the participant is no longer “Disabled,” reaches the Maximum

Benefits Duration, or fails to provide required information. (MET 17-18.)

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Certain conditions are subject to limits under the Plan. The maximum benefit period for

disability due to Neuromusculoskeletal or Soft Tissue Disorder is 24 months. (MET 14, 32-34.) A

“Neuromusculoskeletal or Soft Tissue Disorder” includes any disease or disorder of the spine or

extremities and the surrounding soft tissue, including sprains and strains of joints and adjacent

muscles. (MET 33.) Exceptions to this limitation include radiculopathies (defined as disease of

peripheral nerve roots supported by objective clinical findings of nerve pathology). (MET 33-34.) 

II. Chronological Summary of Claim

1. Injury and Payment of Benefits For First 24 Months Under the Plan

On April 10, 2002, Plaintiff was injured at work when her shoe caught on a plastic mat under

her chair and she fell backwards, landing on her back. (MET 330.) Plaintiff consulted Dominic Tse,

M.D., an orthopedist, who noted that she was unable to sit but could stand, lean against the wall and

walk. (MET 330-331.) Dr. Tse ordered x-rays which revealed a fracture of the left wrist and

compression fracture of the lumbar spine. (MET 265, 331.) 

On April 17, 2002, one week later, Dr. Tse reevaluated Plaintiff. Dr. Tse recorded that

Plaintiff was more comfortable and no longer in acute distress. (MET 262.) Dr. Tse’s prognosis

was that Plaintiff would be off work for three to four weeks. (Id.) On April 23, 2002, Dr. Tse again

evaluated Plaintiff and noted that the intensity of Plaintiff’s back pain had subsided. (Id.) 

On May 1, 2002, Dr. Tse evaluated Plaintiff and reported that Plaintiff was “obviously a lot

better.” (MET 260.) Dr. Tse stated, “She is making good progress and will improve further with

time.” (Id.) During that office visit, Dr. Tse released Plaintiff to return to work on May 6, 2002

with a single work restriction of no lifting over 15 pounds for two weeks, at which point her

condition would be reassessed. (MET 260, 344.)

On May 15, 2002, Dr. Tse evaluated Plaintiff and reported that Plaintiff informed him she

had been laid off from Heald on May 10, 2002. (MET 258.) Dr. Tse noted that Plaintiff was

negotiating with Heald to see if another position would become available. (Id.) Dr. Tse stated that

Plaintiff would have the same restrictions of no lifting over 15 pounds, and no repetitive bending. 

(Id.)

On June 14, 2002, Dr. Tse provided an update regarding Plaintiff’s condition. (MET 257.) 

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The record indicates additional discrepancies in Plaintiff’s July 10, 2002 clarification. In particular, as of July 10,

2002, there is nothing in the record suggesting that Dr. Tse had restricted Plaintiff to working only three hours per day. 

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Dr. Tse noted that Plaintiff does most things while standing rather than sitting, that Plaintiff remains

disabled from the full range of usual and customary occupation, and that Plaintiff was released to

return to work but with modifications to avoid prolonged sitting. (Id.) 

On June 27, 2002, after failing to secure a new position with Heald, Plaintiff submitted a

claim for LTD benefits under the Plan. (MET 123-24.) On Plaintiff’s claim form, she stated that her

date last worked was April 10, 2002 (the date of the accident), not May 10, 2002 (her actual date last

worked). (MET 123.) 

Subsequently, Dr. Tse submitted an Attending Physician Statement (“APS”), dated July 5,

2002, as part of the LTD claim, describing Plaintiff’s condition as an acute compression fracture of

the lumbar spine and a fracture of the left wrist. (MET 108.) Dr. Tse disclosed that Plaintiff could

work eight hours per day with a job modification of avoiding lifting, repetitive bending or prolonged

sitting. (MET 109.) Dr. Tse further stated that he expected improvement of Plaintiff’s condition in

three to six months, and revealed that he advised Plaintiff to return to work as of May 6, 2002, with

modifications. (Id.) 

 On July 10, 2002, Plaintiff responded to MetLife’s request for clarification of the 

discrepancies between her claim form and Dr. Tse’s APS. (MET 315.) Plaintiff explained that she

had wanted to return to work; that Dr. Tse reluctantly agreed to allow her to attempt to return to

work; that subject to Dr. Tse’s limitations, she should not exceed 3 hours work in a day; that after

attempting to work on 5 occasions it became clear that she could not perform even light duty; that

she cannot work because she is still limited in her movement and experiencing a great deal of pain

and discomfort. (Id.) Plaintiff did not inform MetLife that she had been laid off from her position or

that she had unsuccessfully negotiated to obtain another position.3

 Plaintiff copied Dr. Tse on her

clarification letter to MetLife. (MET 315.) Plaintiff also sent Dr. Tse a separate note stating she

wanted to make sure MetLife “understood” that she was unable to work. (MET 314.) 

On July 10, 2002, MetLife commenced Plaintiff’s LTD benefits in accordance with the 90-

day Elimination Period, which ran from April 10, 2002 (the date Plaintiff claimed to have last

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At summary judgment, Defendants argued Dr. Tse’s July 19, 2002 letter contradicts his earlier reports on May 1

and May 15, 2002, where Dr. Tse described improvement in Plaintiff’s condition and her ability to work subject to certain

limitations.

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worked). (MET 152.) Plaintiff later received benefits from Social Security, which Plaintiff offset

from her LTD benefits received under the Plan. (MET 137-39, 151, 196.) 

On July 19, 2002, Dr. Tse issued a letter echoing Plaintiff’s representations made in her July

10, 2002 clarification letter. (MET 328-29, 335.)4 Between August 2002 and October 2002,

Plaintiff continued to complain of pain (MET 254), continued to have poor sitting tolerance (MET

251), and continued to engage in physical therapy (Id). 

On November 21, 2002, Plaintiff received a Functional Capacity Evaluation (“FCE”) by Mr.

David Pringle (“Pringle”), a physical therapist. (MET 134-35.) Mr. Pringle concluded that Plaintiff

could not sit in a sedentary position for more than 8 minutes at a time and that sitting was not

suggested for more than 1 hour per day at no greater than 10 minute increments, although Mr.

Pringle opined that Plaintiff was capable of engaging in sedentary work. (MET 135, 582, 601)

On December 11, 2002, Plaintiff saw Dr. Tse for a review of an MRI of her spine taken on

November 26, 2002 and review of Mr. Pringle’s FCE. (MET 248.) Dr. Tse noted that Plaintiff

could work in a sedentary physical demand level although her sitting tolerance was poor, as noted by

Mr. Pringle. (Id.) Dr. Tse noted that Plaintiff would be changing her treating physician to Robert

Minkowsky, M.D. for future consultation. (Id.)

On March 23, 2004, MetLife issued a letter to Plaintiff stating that in order for her benefits to

continue past July 9, 2004, she had to provide evidence of total disability from any occupation for

which she was reasonably qualified. (MET 152-53.) Under the Plan, eligibility benefits change

after 24 months from being disabled from the participant’s own occupation to being disabled from

any gainful occupation for which the participant is reasonably qualified. (MET 19, 152.)

On June 16, 2004, MetLife issued a letter notifying Plaintiff that benefits would terminate

effective July 9, 2004, in light of a report by Dr. Minkowsky. (MET 171-72.) Specifically, MetLife

cited to Dr. Minkowsky’s report of May 22, 2003, related to Plaintiff’s claim for workers’

compensation, where Dr. Minkowsky noted that Plaintiff had improved functionally, pain was

intermittent rather than constant, her ability to walk, sit and stand had markedly increased, and that

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Plaintiff still had a problem with her spine and musculoskeletal system. (MET 181-82.) 

MetLife informed Plaintiff that Dr. Minkowsky’s diagnoses was subject to the Plan’s Limited

Benefit Condition. (MET 172.) 

On August 2, 2004, Plaintiff wrote to MetLife requesting copies of various documents. 

(MET 173.) On August 5, 2004, MetLife responded, provided documents to Plaintiff, and notified

Plaintiff of her appeal rights. (MET 191-92.)

On August 6, 2004, Plaintiff returned to Dr. Tse for an examination. (MET 242.) Dr. Tse

issued a report supporting Plaintiff’s claim. (Id.) Dr. Tse noted that he had not seen Plaintiff since

December 2002 and that Plaintiff continued to have wide-spread areas of musculoskeletal pain with

chronic myofacial pain disorder and cervical radicular involvement into a left upper extremity with

cervical radiculopathy. (MET 243.) 

2. Plaintiff’s First Appeal

 On September 10, 2004, Plaintiff appealed the termination of her LTD benefits. (MET 198-

200.) Plaintiff advised MetLife that additional information would be needed before she could

complete the appeal. (MET 198.) MetLife sent an acknowledgment on September 17, 2004,

advising Plaintiff that she had 180 days from the termination of benefits to submit additional

information. (MET 201.)

On September 20, 2004, Plaintiff saw William W. Anderson, M.D., a neurologist. Dr.

Anderson concluded that Plaintiff’s “problem in the upper extremities is due to bilaterial thoracic

outlet syndrome manifested by rib dysfunction, the first rib being superiorly displaced on the right

and evidence of rib torsions on the upper ribs on the left side” and that this problem was causing

radicular pain. (MET 527-28)

On December 13, 2004, Plaintiff sent another appeal letter, with medical records, stating,

“We are still awaiting one further medical report, but will submit it as soon as it is received.” (MET

202-12.) On December 16, 2004, MetLife responded that the 180-day period to submit her appeal

was expiring that day, but in light of her request to submit additional information, an extension of 30

days would be granted. (MET 367.)

On December 17, 2004, Plaintiff sent another report to MetLife that contained Dr. Tse’s

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report and a summary of Plaintiff’s medical visits with various doctors. (MET 368-73.) On

December 21, 2004, MetLife responded that the additional report had been received and the claim

had been referred for an independent medical review. (MET 380.)

MetLife submitted Plaintiff’s file to Richard Silver, M.D., an orthopedic surgeon, for a

physician medical review. (MET 386-391.) On January 17, 2005, Dr. Silver issued a report opining

that Plaintiff 

“is capable of being gainfully employed and has been capable of being

gainfully employed for a prolonged period of time dating back to the

FCE on 11/21/02, which shows that she could do sedentary gainful

employment. . . [Plaintiff] is able to work in a sedentary capacity . . .

[T]he medical documentation does not support functional limitations .

. . [Plaintiff’s] subjective complaints are unsubstantiated by objective

clinical findings that would preclude her from working as an

administrator in a sedentary capacity . . . [Plaintiff] is capable of

working.” 

(MET 387-88.)

Dr. Silver also opined that the records did not show a condition that fell within one of the

exceptions to the Plan’s 24-month benefits limitation for neuromusculoskeletal disorders. (MET

389.) “From an orthopedic perspective, [Plaintiff] does not have a radiculopathy . . . and the

condition that she is claiming does not support functional limitations from 7/10/04 to the present

time.” (Id.) Dr. Silver also conducted a Physical Capacities Evaluation and found Plaintiff could

work with limited restrictions of no lifting over 20 pounds or frequently lifting over ten pounds,

among other limitations. (MET 390-391.) 

On January 24, 2005, MetLife denied Plaintiff’s appeal on two grounds: (1) insufficient

evidence of an exception to the 24-month limitation on neuromusculoskeletal disorders, and (2)

insufficient evidence of impairment of a severity that would prevent Plaintiff from performing “any

occupation.” (MET 392-396.) MetLife informed Plaintiff that she had exhausted her administrative

remedies under the Plan, that no further appeal would be considered, and that Plaintiff had a right to

bring a civil action under ERISA. (MET 396.)

On February 15, 2005, Plaintiff wrote to MetLife contesting the denial of her appeal. (MET

397-98.) Plaintiff argued that denial was improper because the denial added an additional grounds

for denial when compared with the original termination letter. (Id.) Plaintiff complained that the

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result was unfair because she had no opportunity to rebut Dr. Silver’s findings, and because the full

record supported her continued receipt of benefits. (Id.) 

MetLife agreed to provide a further appeal review and on February 24, 2005, MetLife issued

a letter to Plaintiff’s counsel enclosing a copy of the claim file. (MET 530.) On March 31, 2005,

MetLife notified Plaintiff that even though she was previously informed that she had exhausted her

administrative review process, MetLife would nevertheless conduct one further review of her claim. 

(MET 531-32.) MetLife gave Plaintiff until June 10, 2005 to provide any additional information she

wished to submit. (MET 532.)

3. Plaintiff’s Second Appeal

On June 9, 2005, Plaintiff submitted her second appeal. (MET 533-536.) Plaintiff argued

that Dr. Silver was wrong in opining that she could hold a sedentary job. (Id.) Plaintiff submitted

additional medical documents and opinions from her own doctors. (Id.) Subsequently, Plaintiff

submitted a July 14, 2005 report from Jeff Malmuth, M.S., a vocational counselor, opining that

Plaintiff was not capable of performing sedentary work. (MET 599-605.)

MetLife submitted Plaintiff’s file, including all of Plaintiff’s appellate paperwork for a

second physician medical review. James Jares, III, M.D., a neurologist, conducted the review. 

(MET 580-89.) On July 1, 2005, Dr. Jares issued a report in which he opined that Plaintiff

“retain[ed] the ability to work full time in a sedentary position with the allowance of reposition as

necessary for comfort.” (MET 585.) Regarding the Plan’s 24-month limitation for

neuromusculoskeletal disorders, Dr. Jares noted that Plaintiff “has some clinical features consistent

with the exclusionary diagnosis [i.e., conditions that are an exception] but these appear to have

occurred later in the course of her illness and not at the exact time of her injury in April 2002.” 

(MET 586.) 

MetLife asked Dr. Jares to clarify when Plaintiff had developed a condition that could be

within an exception to the 24-month limit. (MET 608-609.) On July 25, 2005, Dr. Jares prepared a

supplemental report explaining that the opinion at issue was reflected by Dr. Minkowsky on January

27, 2003, and Dr. Tse on August 6, 2004. (MET 608-09.) However, Dr. Jares opined, “My

conclusions about [P]laintiff’s ability to work [that is, that she was able to work] have not changed.” 

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As more fully explained below, the Court incorrectly cited to the contents of the September 19, 2005 letter in the

Summary Judgment Order.

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(Id.)

MetLife asked Dr. Jares for further clarification. Dr. Jares prepared another report dated

August 10, 2005. (MET 611-12.) Dr. Jares stated, “Upon review, the L1 compression fracture that

[Plaintiff] experienced in April 2002 does not fall into one of the listed exclusionary categories.” 

(MET 612.) Dr. Jares did note that cervical radiculopathy was present prior to July 10, 2004, based

upon Dr. Tse’s earlier findings. (Id.)

On September 19, 2005, MetLife issued a letter to Plaintiff denying her second appeal.5

(MET 613-15.) Regarding Plaintiff’s diagnosis of radiculopathy, the letter reads,

We have completed our review of the termination of [Plaintiff’s] claim

for disability benefits. Based on our review of the available

information, it has been determined that [Plaintiff] as [sic] been

diagnosed with one of the exclusions in the limited benefit condition

of the Plan. It has been concluded that [Plaintiff] does have been [sic]

diagnosed with radiculopathy and does have a condition that is noted

as one of the exclusions of the plan. . . . Review of the information

that has been submitted on appeal, along with the information on

record, does support that [Plaintiff] has been diagnosed with one of the

exclusions in the limited benefit condition of the Plan.

(MET 613-614.) Regarding Plaintiff’s ability to perform her own occupation, the letter reads that

it has been determined that the medical information does not support a

severity of impairment that would prevent [Plaintiff] from performing

her own job. . . . Review of the information on file is also insufficient

to support a severity of functional impairment that would prevent

[Plaintiff] from working in a sedentary capacity. Therefore [Plaintiff]

can not be considered disabled as defined by [the Plan] and no further

benefits are payable.

(Id.) The letter noted that a physician consultant, board certified in neurology, reviewed the entire

claim file and determined “that from a neurological perspective, the medical records support that

[Plaintiff] retains the ability to work full time in a sedentary position with the ability to reposition as

necessary for comfort.” (MET 614.) The letter further indicated that another physician consultant,

board certified in orthopedic surgery, similarly determined that Plaintiff “has no loss of functionality

in any aspect of the cervical thoracic, lumbrosacral spine, or of the entire vertebral spine. The

consultant notes that [Plaintiff] is capable of working in a sedentary capacity.” (Id.) 

PROCEDURAL HISTORY

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On September 12, 2006, the parties filed cross motions for summary judgment. The parties

filed over 1000 pages of administrative record in support of their motions. The administrative

record consisted primarily of claims history, medical records, and correspondence. On November

14, 2006, after consideration of the pleadings, the administrative record, and the arguments of

counsel, this Court denied Plaintiff’s motion for summary judgment and granted Defendants’ motion

for summary judgment. (See id.) Plaintiff’s now seek reconsideration of the Court’s grant of

summary judgment.

LEGAL STANDARD

A district court may reconsider its grant of summary judgment under either Federal Rule of

Civil Procedure 59(e) (motion to alter or amend a judgment) or Rule 60(b) (relief from judgment). 

School Dist. No. 1 J v. ACandS, Inc., 5 F.3d 1255, 1263 (9th Cir.1993), cert. denied, 512 U.S. 1236

(1994). While Rule 59(e) permits a district court to reconsider and amend a previous order, the rule

offers an “extraordinary remedy, to be used sparingly in the interests of finality and conservation of

judicial resources.” Carroll v. Nakatani, 342 F.3d 934, 945 (9th Cir. 2003) (citing Carroll 12 James

Wm. Moore et al., Moore’s Federal Practice § 59.30[4] (3d ed. 2000)). Indeed, “a motion for

reconsideration should not be granted, absent highly unusual circumstances, unless the district court

is presented with newly discovered evidence, committed clear error, or if there is an intervening

change in the controlling law.” Kona Enterprises, Inc. v. Estate of Bishop, 229 F.3d 877, 890 (9th

Cir. 2000) (citations omitted). A Rule 59(e) motion may not be used to raise arguments or present

evidence for the first time when they could reasonably have been raised earlier in the litigation. Id.

The Ninth Circuit has identified three reasons sufficient to warrant a court’s reconsideration

of a prior order: (1) an intervening change in controlling law; (2) the discovery of new evidence not

previously available; and (3) the need to correct clear or manifest error in law or fact, to prevent

manifest injustice. ACandS, Inc., 5 F.3d at 1263. Upon demonstration of one of these three

grounds, the movant must then come forward with “facts or law of a strongly convincing nature to

induce the court to reverse its prior decision.” Donaldson v. Liberty Mut. Ins. Co., 947 F. Supp. 429,

430 (D. Haw. 1996). Whatever may be the purpose of Rule 59(e) it should not be supposed that it is

intended to give an unhappy litigant one additional chance to sway the judge. Illinois Central Gulf

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Railroad Company v. Tabor Grain Company, 488 F. Supp. 110, 122 (N.D. Ill. 1980) (a rehash of the

arguments previously presented affords no basis for a revision of the court’s order).

ANALYSIS

I. Summary Judgment

In deciding the parties’ cross motions for summary judgment, this Court found that the

proper 

standard of review was abuse of discretion because the Plan unequivocally conferred discretion on

MetLife to determine eligibility benefits and to construe the terms on the Plan. (Summary Judgment

Order, 12:13-13:1.) Recognizing that MetLife acted as both the Plan administrator and funding

source, this Court reviewed the case “tempered by skepticism commensurate with the plan

administrator’s conflict of interest,” as the Ninth Circuit has instructed. Abatie, 458 F.3d at 959. 

In making its determination, this Court found that MetLife’s decision to grant LTD benefits

to Plaintiff during the initial 24-month period belied Plaintiff’s contention that the decision-making

process was tainted by a conflict of interest. (Summary Judgment Order, 16:2-14.) The Court also

noted that MetLife agreed to pay LTD benefits to Plaintiff despite the fact that Plaintiff’s own doctor

had initially found her able to return to work, and that MetLife afforded Plaintiff a second appeal

despite the fact that neither ERISA or the Plan required MetLife to do so. (Id.) As a result, the

Court did not find evidence of a conflict of interest that effected the decision-making process.

Next, this Court determined that MetLife’s benefit determinations were not inconsistent. 

This Court stated, “[a]s a result of the Plaintiff’s subsequent appeals and her efforts to generate

evidence for continued benefits, MetLife considered new evidence and determined that Plaintiff was

not functionally impaired from performing her job and that her medical records did not show the

existence of any diagnosis that would be an exclusion to the 24-month limitation for Plan benefits.” 

(Id. at 17:1-5.)

Lastly, in concluding that MetLife did not abuse its discretion in terminating and denying

Plaintiff’s LTD benefits, the Court made two findings. First, regarding the exception to the 24-

month limitation under the Plan, the Court found that MetLife did not abuse its discretion in

determining that Plaintiff did not suffer from radiculopathy. (Id. at 17:8-20:16.) Second, regarding

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Plaintiff’s “disability” under the Plan, the Court found that MetLife did not abuse its discretion in

determining that Plaintiff was able to return to work and earn 60% of her disposable income. (Id. at

20:17-23:14.) Accordingly, the Court stated, “[a]s a result of MetLife’s review and consideration of

the entire record, the Court finds that MetLife’s decision to terminate and subsequently deny

Plaintiff’s LTD benefits was not arbitrary and capricious.” (Id. at 23:12-14.) 

In the current motion, Plaintiff argues that the Court erred in fact and law by: (1) finding that

MetLife determined that Plaintiff did not suffer from radiculopathy; and (2) failing to conduct the

analysis and make findings as required by Abatie v. Alta Health & Life Ins. Co., 458 F.3d 955 (9th

Cir. 2006). Defendants counter and insist that the Court did not commit error in its factual findings

or legal analysis. The Court now turns to Plaintiff’s arguments on reconsideration. 

I. Factual Error - Radiculopathy

Plaintiff points to MetLife’s denial letter of September 19, 2005 as evidence that the Court

factually erred in finding that MetLife determined that Plaintiff did not suffer from radiculopathy. 

(MET 613-615.) Plaintiff insists that MetLife’s denial letter of September 19, 2005 terminated

benefits solely on the ground that MetLife determined that Plaintiff was able to perform her own job

and was therefore not disabled under the Plan. Pointing to the Court’s alleged error, Plaintiff argues

that MetLife was therefore inconsistent in paying benefits to Plaintiff for the first 24 months, thereby

not disputing that Plaintiff could not perform her own job, and then later terminating benefits on

grounds that Plaintiff could perform her own job. Plaintiff contends that termination of LTD

benefits was improper because the record was not supplemented by any new evidence demonstrating

that Plaintiff’s ability to perform her job had improved after 2004. In opposition, Defendants argue

that regardless of whether Plaintiff had radiculopathy, MetLife determined that Plaintiff was not

functionally impaired from working in her own occupation and therefore termination of LTD

benefits was appropriate. (MET 614.) Defendants also contend that the Court was correct in finding

that MetLife did not abuse its discretion in determining that Plaintiff was not disabled under the

Plan. 

A review of the administrative record reveals that the Court erred in its Summary Judgment

Order. In particular the Court erred in finding that MetLife ultimately determined that Plaintiff did

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not suffer from radiculopathy. (Summary Judgment Order at 9:25.) As indicated by MetLife’s

September 19, 2005 letter to Plaintiff, MetLife ultimately denied LTD benefits not because MetLife

had determined that Plaintiff did not have radiculopathy, but instead because MetLife determined

that Plaintiff was capable of performing her own job and was therefore not “disabled” under the

Plan. (MET 613-614.) Additionally, MetLife’s Appeal Unit’s records support Plaintiff’s contention

that the Court erred here. Specifically, the Appeal Unit’s records indicate that a “[r]eview of the

claim file supports that [Plaintiff] has radiculopathy supported by objective evidence . . . Claim unit

needs to determine if medical information submitted supports a disability.” (MET 645.) Here,

having found that the Court erred regarding MetLife’s determination on Plaintiff’s radiculopathy,

the issue now becomes whether the Court’s other finding, regarding MetLife’s determination on

Plaintiff’s “disability,” is sound. 

The Court concludes that its previous finding, that MetLife did not abuse its discretion in

determining that Plaintiff was able to return to work, is correct and supported by the record. The

definition of “Disabled” under the Plan changed after the first 24-month period. The Plan reads,

“Disabled” in pertinent part as follows:

“Disabled” or “Disability” means that, due to sickness, pregnancy, or

accidental injury, you are receiving Appropriate Care and Treatment

from a Doctor on a continuing basis; and 

(1) during your Elimination Period and the next 24 month period, you

are unable to earn more than 80% of your Predisability Earnings or

Indexed Predisability Earnings at your Own Occupation from any

employer in your Local Economy; or 

(2) after the 24 month period, you are unable to earn more than 60% of

your Indexed Predisability Earnings from any employer in your Local

Economy at any gainful occupation for which you are reasonable

qualified taking into account your training, education, experience and

Predisability Earnings.

(MET 19-20.) As the record indicates, MetLife sought additional medical evidence of ongoing

disability prior to the expiration of the initial 24-month period. MetLife based its request on the fact

that the Plan’s disability definition changed after the initial 24-month period and the express

language of the Plan, indicating that Plaintiff’s benefits may be denied if she failed to provide

satisfactory documents within 60 days of the request. (MET 5, 40.) “Under the terms of the Plan, it

is the employee who must continue to supply on demand proof of continuing disability to the

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satisfaction of the insurance company.” Miller v. Metropolitan Life Ins. Co., 925 F.2d 979, 985 (6th

Cir. 1991). After the initial 24-month period, MetLife determined that Plaintiff was able to earn at

least 60% of her predisability earnings at “any gainful occupation” for which Plaintiff was qualified

to take. Despite the existence of differing medical opinions, MetLife’s determination was supported

by the record and was therefore not arbitrary and capricious. (Summary Judgment Order at 21:4-6.)

A review of the record demonstrates that there was ample evidence for MetLife to ultimately

determine that Plaintiff was able to return to work and therefore was not “disabled” under the Plan. 

Admittedly, the record indicates that Mr. Malmuth and Plaintiff’s own doctors concluded that

Plaintiff was not able to engage in sedentary work. In contrast, Mr. Pringle, Dr. Jares, and Dr. Silver

concluded that Plaintiff was able to engage in sedentary work. Dr. Jares and Dr. Silver considered

the relevant record and relied on their own Physical Capacities Evaluation and found Plaintiff could

work with limited restrictions. (MET 390-91.) Nothing in the record suggests that MetLife or

MetLife’s reviewing professionals, ignored Plaintiff’s complaints or the conclusions and diagnoses

of Plaintiff’s treating physicians. Instead, Met Life’s professionals found Plaintiff’s evidence to be

either unsubstantiated by objective medical evidence or found that the evidence was not sufficient to

justify continuation of LTD benefits. As a result of MetLife’s review and consideration of the entire

record, the Court finds that MetLife’s decision to deny Plaintiff’s LTD benefits on grounds that she

not “disabled” under the Plan was not arbitrary and capricious. The Court further finds that its

previous error regarding MetLife’s determination that Plaintiff did not suffer from radiculopathy

does not effect the outcome of the final judgment and was therefore harmless.

II. Legal Error

 Plaintiff argues that the Court legally erred by failing to apply the analytical process 

required by Abatie. In particular, Plaintiff avers that the Court erred in: (1) treating the crossmotions for summary judgment as motions for summary judgment, rather than for judgment on the

administrative record under Federal Rule of Civil Procedure 52(a); (2) failing to make a

determination between competing expert opinions; (3) failing to analyze the independence and the

alleged conflict of interest between MetLife and its reviewing physicians. (Plaintiff’s Motion to

Alter or Amend Judgment (“Mot.”) at 5:8-23.) The Court will address Plaintiff’s contentions in

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turn.

A. Bench Trial

Plaintiff argues that under an “arbitrary and capricious” review Abatie requires courts to 

conduct a bench trial under Rule 52(a) when there is conflicting evidence in the record. (Mot. at

5:26-6:2.) The Court disagrees with Plaintiff’s interpretation of Abatie. Abatie but does mandate a

bench trial in the face of conflicting evidence in the record, but instead instructs that when a court

does conduct a bench trial, the court must make findings of fact on all contested issues and issue a

ruling under Rule 52 which is sufficiently explicit to give the appellate court an understanding of the

basis for the court’s decision. Abatie, 459 F.3d at 973 (citation omitted). Here, the Court did not

conduct a bench trial and therefore was not required to make findings under Rule 52 as Plaintiff

contends. 

B. Competing Expert Opinions

Plaintiff argues that the Court improperly followed non-Ninth Circuit authority in refusing to

make a credibility determination between competing expert opinions. Plaintiff’s argument

misinterprets the Court’s inquiry under an abuse of discretion standard of review as set forth in

Abatie. Abatie, 459 F.3d at 968-69. Under Abatie, as more fully explained below, the Court

considered the conflicting evidence in determining the appropriate weight to give the structural

conflict of interest that was present on this record. Id. at 970. Plaintiff fails to provide the Court

with authority permitting the Court to make credibility determinations between competing expert

opinions when reviewing a denial of benefits under an arbitrary and capricious review. Compare

Semien v. Life Ins. Co. of N. Am., 436 F.3d 805, 814 (7thCir. 2006) (finding that plan

administrator’s physician’s reports demonstrated a thorough consideration of available information

to support finding of disqualification from LTD coverage and although claimant’s treating

physicians reached different conclusions, under an arbitrary and capricious review, the court will not

attempt to make a determination between competing expert opinions.) Accordingly, the Court finds

Plaintiff’s argument here unavailing.

C. Conflict of Interest

Plaintiff’s remaining contentions are that the Court erred in placing the burden on Plaintiff to

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affirmatively show “misconduct” in order to establish a conflict of interest, that the Court

improperly deferred to MetLife’s physician reviewers’ opinions despite conflicting evidence from

Plaintiff’s physicians, and that the Court erred in failing to analyze the “independence” of MetLife’s

physician medical reviewers. Defendants respond that the Court properly considered and evaluated

the alleged conflict of interest and correctly determined that there was no abuse of discretion. 

Abatie establishes the abuse of discretion approach to ERISA cases in which a conflict of

interest exists. Abatie 458 F.3d at 955. When reviewing to determine whether an abuse of

discretion has occurred, the proper review is one “tempered by skepticism commensurate with the

plan administrator’s conflict of interest.” Id. Such a review requires a case by case balance

weighing the conflict of interest as a factor in the abuse of discretion review. Id. at 968. In Abatie,

the court stated,

The level of skepticism with which a court views a conflicted

administrator’s decision may be low if a structural conflict of interest

is unaccompanied, for example, by any evidence of malice, of

self-dealing, or of a parsimonious claims-granting history. A court

may weigh a conflict more heavily if, for example, the administrator

provides inconsistent reasons for denial, fails adequately to investigate

a claim or ask the plaintiff for necessary evidence, fails to credit a

claimant’s reliable evidence, or has repeatedly denied benefits to

deserving participants by interpreting plan terms incorrectly or by

making decisions against the weight of evidence in the record. 

Id. at 968 (citing Lang v. Long-Term Disability Plan of Sponsor Applied Remote Tech., Inc., 125

F.3d 794, 799 (9th Cir. 1997), Booton v. Lockheed Med. Benefit Plan, 110 F.3d 1461, 1463-64 (9th

Cir.1997); Black & Decker Disability Plan v. Nord, 538 U.S. 822, 834 (2003). Unlike de novo

review, review for an abuse of discretion is generally limited to the administrative record before the

plan administrator at the time of its decision. Id. at 970. However, a court may, in its discretion,

consider evidence outside the administrative record to decide the nature, extent, and effect on the

decision-making process of any conflict of interest; the decision on the merits, though, must rest on

the administrative record once the conflict (if any) has been established, by extrinsic evidence or

otherwise. Id. (citing Doe v. Travelers Ins. Co., 167 F.3d 53, 57 (1st Cir.1999)). 

Here, the Court properly weighed MetLife’s structural conflict of interest and the

independence of its physician medical reviewers. Contrary to Plaintiff’s contention, the Court did

not place the burden on Plaintiff to show “misconduct” in order to establish a conflict of interest and

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In her motion, Plaintiff incorrectly states, “The Court apparently assumed that Dr. Silver and Dr. Jares conducted

some sort of physical examination or testing of Plaintiff, but his is incorrect.” In clarification of the Summary Judgment

Order, the Court was aware that Dr. Jares and Dr. Silver conducted Physical Capacity Reviews in reliance on Plaintiff’s

medical records and assigned weight to those reviews accordingly. 

17

a less deferential standard of review. To the extent Plaintiff’s interpreted the Court’s Summary

Judgment Order as placing the burden on them, the Court clarifies that the Order was merely

recognizing that there was no evidence of “misconduct” by MetLife in the record, offered by

Plaintiff or otherwise. The Court did not intend to imply that Plaintiff had an affirmative duty to

produce such evidence. See Abatie, 458 F.3d at 967. Furthermore, the Court notes that the record is

absent of any “material probative evidence” tending to show that MetLife’s conflict of interest

caused a breach of its fiduciary obligations to Plaintiff. Id. at 966. Rather, the record contains

affirmative evidence which demonstrates that MetLife did not breach its fiduciary obligations. For

example, as set forth in the Summary Judgment Order, MetLife afforded Plaintiff two opportunities

to appeal the termination of her LTD benefits, and also granted Plaintiff benefits for the initial 24-

month period despite contradictory reports from her own physician initially indicating that Plaintiff

could return to work for 8 hours per day with minor restrictions. Rather than deny Plaintiff’s claim

due to her doctor’s diagnosis, MetLife sought clarification and considered a revised and somewhat

contradictory report from Plaintiff’s doctor. The Court further notes that MetLife granted Plaintiff

extensions of time to augment her appellate submissions. 

Regarding MetLife’s physician reviewers’ independence, the Court considered evidence

offered by both parties. In support of Plaintiff’s argument that the reviewers were biased, the Court

considered extrinsic evidence showing the number of MetLife file reviews completed by Dr. Silver

and Dr. Jares, the amount of compensation they received from MetLife, and their retention through

Network Medical Review (“NMR”). In contrast, and in support of the physician reviewer’s

independence, the Court examined the substance of the actual file reviews. As explained previously,

both Dr. Jares and Dr. Silver reviewed Plaintiff’s voluminous medical history containing opinions

from each of Plaintiff’s doctors, including evidence that one of Plaintiff’s doctors had offered

conflicting opinions about her ability to work after the accident. Dr. Jares and Dr. Silver considered

the records and competing opinions and relied on their own Physical Capacities Evaluation6

 and

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found Plaintiff could work with limited restrictions. The medical records indicated that Plaintiff’s

own doctors had diagnosed Plaintiff as having a condition that would improve over time and they

remained optimistic she would eventually return to work. “[I]t is not the case that every time a plan

administrator discontinues disability benefits, it must produce evidence of medical improvement.” 

Lawrence v. Motorola, Inc., 2006 WL 2460921 at *9 (D. Ariz. 2006). As a result of MetLife’s

review and consideration of the entire record, the Court finds that MetLife’s decision to deny

Plaintiff’s LTD benefits was not arbitrary and capricious. Therefore, the Court DENIES Plaintiff’s

Motion to Alter or Amend Judgment.

CONCLUSION

For the foregoing reasons, the Court finds DENIES Plaintiff’s Motion to Alter or Amend

Judgment and clarifies its Summary Judgment Order as set forth above.

IT IS SO ORDERED.

Dated: March 19, 2007 

MARTIN J. JENKINS

UNITED STATES DISTRICT JUDGE

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