Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-casd-3_16-cv-02613/USCOURTS-casd-3_16-cv-02613-0/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.: Civil Enforcement of Employee Benefits

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UNITED STATES DISTRICT COURT

SOUTHERN DISTRICT OF CALIFORNIA

LIZBETH VALDEZ,

Plaintiff,

v.

AT&T UMBRELLA BENEFIT 

PLAN No. 1,

Defendant.

Case No.: 16-cv-2613-BTM-BGS

ORDER GRANTING PLAINTIFF’S 

MOTION FOR SUMMARY 

JUDGMENT IN PART AND 

DENYING DEFENDANT’S 

MOTION FOR SUMMARY 

JUDGMENT 

[ECF Nos. 31, 41, 42]

I. INTRODUCTION

Plaintiff Lizbeth Valdez brings this action for short and long term disability 

benefits under 29 U.S.C. § 1132(a)(1)(B), which provides for civil enforcement of 

employee benefit plans pursuant to the Employee Retirement Income Security 

Act of 1974 (“ERISA”), 29 U.S.C. §§ 1001 et seq. Plaintiff asserts her short term 

disability benefits were wrongfully denied and that but for the wrongful denial, she 

would be entitled to long term benefits. Pending before the Court are crossmotions for summary judgment submitted by Plaintiff and Defendant AT&T 

Umbrella Benefit Plan No. 1 (“the Plan”). The question before the Court on 

summary judgment is whether the Plan administrator’s decision to deny Plaintiff’s 

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short term disability benefit claim was an abuse of discretion. For reasons set 

forth below, the Court concludes that it was. 

II. BACKGROUND

A. FACTS

1. The Disability Plan

As an employee of Pacific Bell Telephone Company (“PacBell”), Plaintiff 

was a participant in AT&T Umbrella Benefit Plan No. 1 (“the Plan”), which is 

governed by the Employee Retirement Income Security Act of 1974 (“ERISA”). A 

third-party claims administrator, Sedgwick Claims Management Services

(“Sedgwick” or “the claim administrator”), determines all claims and appeals for 

benefits under the Plan. (AR 88). Regular claims are determined by Sedgewick 

employees at AT&T Integrated Disability Service Center; Sedgewick’s Quality 

Review Unit decides appeals and denials of benefit claims under the Plan. (AR 

93, 94). 

The Plan provides short term disability (“STD”) benefits upon a showing of 

disability. Under the Plan, a participant is disabled when she has “a sickness, 

injury or other medical, psychiatric or psychological condition that prevents [her] 

from engaging in [her] normal occupation or employment . . . in accordance with 

[her employer’s] normal practices.” (AR 64, 69). If a participant is “able to 

perform a modified duty” and her employer “is able to accommodate [her] 

restrictions,” then the participant is not considered disabled. (AR 64, 69). 

In order to be considered for STD benefits under the Plan, the participant 

must “be under the care of a physician and follow a treatment plan that is 

reasonably designed (where practicable) to result in [the participant’s] recovery 

and return to work.” (AR 69). The participant must periodically file medical 

evidence of her disability, and her medical providers must furnish medical reports 

and necessary information to the claims administrator in a timely manner. (AR 

69). STD benefits are terminated if the participant “fail[s] to furnish objective 

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Medical Evidence” of her alleged disability or “fail[s] to follow a medically 

appropriate treatment plan that is reasonably designed (where practicable)” to 

facilitate her recovery and eventual return to work. (AR 75). The claim 

administrator may require claimants to undergo additional medical examinations

before making an STD benefits determination. (AR 70). Claimants are not 

required to pay for these requested medical examinations. (AR 70). 

2. Plaintiff’s Job Duties and Diagnoses

In April 2015, Plaintiff Lizbeth Valdez began working as a sales consultant 

at PacBell. (AR 124). Plaintiff’s work duties included answering customer phone 

calls while wearing a headset and entering customer data into the computer. 

(Id.) The work was largely sedentary, involving reading, typing, and using a 

mouse while viewing a computer screen. (Id.). However, Plaintiff had been in ill 

health for some time. 

In November 2012, when Plaintiff was 25 years old, she was diagnosed 

with multiple sclerosis (“MS”). Her MRI showed “innumerable dawsons fingers 

as well as high cervical lesion,” and subsequent MRI’s revealed increasing 

numbers of active brain lesions. (AR 119, 431-32). Between November 2012 

and October 2015, Plaintiff suffered five MS related relapses. (AR 119, 436). In 

addition to her MS diagnosis, Plaintiff began suffering from headaches in May 

2014 and was hospitalized with viral meningitis in July 2014. (AR 340). The 

following year, she was diagnosed with depression secondary to her MS. (AR 

340). As early as July 2015, Plaintiff began suffering from chronic migraine 

headaches that led her to seek medical attention. (AR 117, 340). These chronic 

migraines are the basis for Plaintiff’s STD benefits claims and appeals. 

Migraines are defined as “painful, throbbing headaches” that “may cause 

nausea and vomiting and make you sensitive to light, sound or smell.” (AR 468). 

Left untreated, migraines can last from four hours to a few days. (AR 468). 

Prescription medication helps resolve migraines, and Plaintiff’s self-care 

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instructions included “rest[ing] in a quiet, dark room until [her] headache is gone” 

and avoiding watching TV or reading. (AR 469). The self-care instructions told 

Plaintiff to seek immediate medical care if she experienced “new or worse 

nausea and vomiting,” “a new or higher fever,” or a progressively worse 

headache. (AR 470). 

3. History of Plaintiff’s Benefits Claims From October 2015 to April 

2016 

In early October 2015, Plaintiff was hospitalized for two days after reporting 

head pain and vertigo. (AR 117). She was admitted for a migraine, anxiety, and 

possible exacerbation of multiple sclerosis. (AR 117). Her MRI was unchanged 

from August 2015, but showed more lesions than her November 2012 MRI. (AR 

436). Plaintiff submitted her first STD claim during that hospital stay. (AR 98, 

104). Her medical provider, Kaiser Permanente, submitted a work status report 

and a discharge summary for October 6, 2015, which stated she “was started on 

i/v solumedrol, was seen by [inpatient] neurology consult, had MRI head which is 

negative for acute issues, and . . . [was] stable to be discharged home.” (AR 

140). The claim administrator noted it was “unclear why [Plaintiff] could not 

return to work shortly after the discharge while only on [prescription 

management]” and without a “complex [treatment] plan.” (AR 108-09). Plaintiff’s 

claim was approved, but the claim administrator told Plaintiff she would need to 

submit additional medical information should she remain out of work. (AR 109). 

Plaintiff continued to suffer weeks-long migraine headaches after her 

discharge, prompting nine medical visits between October 14 and November 17. 

(AR 113-122, 430, 501-09, 680). Her other symptoms included severe fatigue, 

insomnia, and weakness. (AR 447). 

Plaintiff opened her second STD benefits claim on October 20, 2015. 

Kaiser Permanente submitted a work status report by Plaintiff’s treating 

neurologist, Dr. Cynthia Elizabeth Spier, placing her off work from October 25, 

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2015 through November 2, 2015. (AR 200-201, 646-654). At that time, attempts 

to treat Plaintiff’s chronic migraines included adjusting medications, providing 

injections, recommending once-monthly magnesium infusions, attending 

headache classes, adjusting her diet, obtaining therapy for anxiety and stress, 

and stopping narcotic medication. (AR 446-48).

The claim administrator was again skeptical of the submission. The 

administrator noted Plaintiff has “a history of MS” but that her MRI’s showed no 

new lesions or complications and her chronic migraines did “not appear to be a 

clinical occurrence of the condition.” (AR 203). The administrator concluded that 

the medical documentation did not establish why Plaintiff could not continue her 

sedentary job under the treatment plan. (AR 203). Plaintiff’s claim was referred 

to third-party Physician Advisor, Dr. Katherine Duvall, who submitted two reports. 

(AR 641-42). 

Dr. Duvall’s initial report, which was written without consulting Plaintiff’s 

treating physicians, recommended denying the claim. (AR 641-43). However,

after making contact with Plaintiff’s treating neurologist, Duvall submitted a 

second report that reached the opposite conclusion. (AR 633). In her second

report, Duvall noted, “[i]n general, one would not expect significant objective 

physical exam findings or test results with migraine type headaches; however, if 

headaches are severe and refractory, the condition can be disabling.” (AR 633). 

Duvall averred that “the severity of the headaches is supported by [Plaintiff’s] ER 

visit, medication adjustments and changes, and need for steroids” and that “[h]er 

condition may also be complicated by her Multiple Sclerosis.” (AR 634). 

Because Plaintiff’s treatment regime changed after her November 6 visit, Duvall 

concluded it was medically reasonable to “allow one week” for improvement and 

added that “[u]pdated, objective medical information would be needed [thereafter] 

to support an ongoing inability to work or the need for restrictions/limitations if 

applicable at that time.” (AR 634). Duvall concluded from an occupational 

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medicine perspective, Plaintiff would be unable to work until November 13, 2015 

“due to severe headaches and treatment.” (AR 633). 

Plaintiff’s benefits were approved from October 20 through November 16, 

2015. (AR 633-34). However, she was denied STD benefits from November 16 

onward. (AR 447). A letter to Plaintiff explained that Plaintiff’s submitted 

documents, “a work status note and several After Visit Summary sheets dated 

from November 6 to November 17 2015,” did not provide “detailed clinical 

information” and “did not contain observable findings to support an extension of 

disability.” (AR 447). 

Between December 2015 and mid-January 2016, Plaintiff sought repeated 

medical attention for severe headaches and worsening MS symptoms. At a 

December 7 visit, Dr. Spier increased Plaintiff’s nortriptyline dosage, instructed 

her to attend a headache class and obtain a magnesium infusion, and placed her 

off work through early January. (AR 576-78). On December 24, 2015, Plaintiff 

again reported headaches, dizziness, and nausea. (AR 428). Dr. Spier 

administered a Toradol injection. Toradol is used in emergencies and treatment 

of severe migraine attacks when other medications have not worked and, 

because of its severe side effects, should not be used for more than five days.1

(AR 428; ECF No. 41 at 6, n.3). 

Plaintiff reported “transformed migraines,” i.e., episodic migraine attacks,

on January 5 and 7, 2016, prompting her neurologist to re-start Topamax and 

increase her nortiptyline dosage. (AR 572-73). Topamax, which helps to reduce 

the frequency of migraines, is accompanied by side-effects that include

dizziness, loss of coordination, tingling of hands and feet, slowed thinking, 

 

1 The National Institute of Health’s website states that a toradol injection, also known as a ketorolac injection, “is 

used for the short-term relief of moderately severe pain” and “should not be used for longer than 5 days for .. . 

pain from chronic (long-term) conditions.” The drug “may cause serious side effects.” See Ketorolac Injection, 

MedlinePlus, (last updated Dec. 18, 2018) https://medlineplus.gov/druginfo/meds/a614011.html.

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nervousness, memory problems and speech problems. (AR 574). On January 

18, Plaintiff sought help for bilateral leg muscle pain, weakness, and blurred 

vision, and was prescribed intravenous Solu-Medrol infusion, a short-term 

treatment for worsening MS. (AR 420, 515; ECF No. 41 at 7, n.6). On January 

20, Plaintiff began experiencing extreme, burning pain that traveled from her feet 

to her legs, in addition to headaches, that led to additional Solu-Medrol 

treatments on January 21 and 22. (AR 415-417). 

Kaiser Permanente sent the claim administrator additional medical 

information on January 21, 2016. On January 25, the claim was denied because 

the medical evidence was not sufficiently clear on why Plaintiff could not perform 

“the essential duties of [her] occupation.” (AR 441). According to the the claim 

administrator, Plaintiff’s submission consisted of over “30 pages of listed 

[prescriptions]” and “labs without context.” (AR 223). The administrator noted 

“these are all raw data without interpretation” that were duplicated from other 

submissions or corresponded with previously reviewed time periods. (AR 223). 

The November denial-of-benefits was upheld and Plaintiff was advised of her 

right to appeal. (AR 448).

In February 2016, Plaintiff appealed the denial. (AR 225, 372, 408). The 

Plan’s Quality Review Unit referred Plaintiff’s claim to four independent Physician 

Advisors: (1) Michael A. Rater, M.D., Psychiatry; (2) Bradley Davitt, M.D., 

Opthalmology; (4) Amy Hopkins, M.D., Internal Medicine; and (4) Charles Brock, 

M.D., Neurology. 

 The first three Physician Advisors, who reviewed Plaintiff’s claim from 

psychiatric, opthamologic, and internal medicine perspectives, found she did not 

have a disability that would prevent her from returning to work. (AR 374, 378, 

390). In relevant part, Dr. Spier made statements to Dr. Rater about Plaintiff’s 

disability from a psychiatric perspective. Dr. Rater’s report details the 

conversation as follows: 

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Dr. Spier stated Ms. Valdez is very complicated. She did not show 

for her last visit. She was supposed to get a spinal tap to see if there 

was any evidence of viral meningitis. She had viral meningitis in 

2014. Dr. Spier stated she is working on finding out why she has so 

many headaches. She stated the meningitis could be causing it. Dr. 

Spier stated she put Ms. Valdez off of work because every time she is 

due to go back she comes into the office stating that her symptoms 

are very severe. She cries in the office and will go to the ER. Dr. 

Spier stated she has real illnesses. She has MS (multiple sclerosis). 

The last visit, her legs were weak. Her exams are not reliable 

because she gives way and it is impossible to identify if there is any 

real weakness. Dr. Spier stated she cannot figure out what is going 

on with Ms. Valdez. She stated she does suspect that she has some 

secondary gain. Dr. Spier stated she is going to send Ms. Valdez for 

a psych evaluation. (AR 371). 

Dr. Charles Brock, who reviewed Plaintiff’s claim from a neurological 

perspective, concluded on March 16, 2016 that Plaintiff was disabled from 

“November 16, 2015 through present.” (AR 381). Dr. Brock averred that Plaintiff 

was disabled and incapable of work because the documentation demonstrated 

“the presence of ongoing migraine headache” requiring “repeated medical 

visitations and medical administrations” and a “history of multiple sclerosis with a 

progressive episode, and experiencing weakness of bilateral lower extremities 

that required IV Solu-Medrol.” (AR 382-83). Dr. Brock concluded Plaintiff was 

supported for “restrictions and limitations including no walking and no ability to 

tolerate working in a brightly lighted environment, prolonged viewing of a 

computer screen, or noisy environment due to the presence of ongoing persistent 

migraine headache and presence of bilateral lower extremity weakness due to 

the MS exacerbation.” Dr. Brock added it was unreasonable to expect Plaintiff 

“to perform her job duties of using a headset to speak to the caller while 

simultaneously entering information into the computer to record caller 

information.” (AR 383). In sum, Dr. Brock found Plaintiff was disabled from a 

neurological perspective. (AR 383). Plaintiff’s STD benefits were approved from 

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October 20, 2015 through April 17, 2016. (AR 356). 

On March 21, 2016, Plaintiff saw her neurologist for headaches, MS, 

anxiety, and dizziness. (AR 286). Dr. Spier prescribed meclizine2for her 

dizziness and referred Plaintiff to psychiatry and counseling “re mood affecting 

headaches/depression.” (AR 286). Plaintiff went to the emergency room on April 

4 and reported a week-long constant, severe headache and nausea. (AR 341-

47). She stated her prednisone taper was not working. (AR 340). 

The Emergency Department physician described Plaintiff’s headache 

status as “severe exacerbation” and “inadequately controlled.” (AR 342). After 

consulting with Dr. Spier and the on-call neurologist, Plaintiff was prescribed 

Compazine, Benadryl, and DHE, which helped resolve the headache. (AR 344). 

The Emergency Department physician ruled out subarachnoid hemorrhage and 

meningitis, and decided to discharge Plaintiff. (AR 344). He concluded her 

symptoms “appear[ed] to be a complication from her chronic migraines,” and 

recommended that Plaintiff contact her neurologist the next day. (AR 344). In a

follow-up call with Dr. Rodriguez on April 6th, Plaintiff stated her headache was 

better on Naproxen and Tylenol, but she was worried because “she is needing 

the Tylenol more often, ~ 4 hrs.” (AR 345). Two days later, Plaintiff received a 

Toradol injection. (AR 347). 

Kaiser Permanente submitted medical information to the claim 

administrator on April 15, 2016, which included: a no-show note for a doctor 

appointment on April 4; a progress note from Plaintiff’s April 4 Emergency 

Department visit; documentation of Plaintiff’s April 8 Toradol injection; and a 

January 14, 2016 Work Status Report placing Plaintiff off work through July 3, 

2016. (AR 338-348). The claim administrator concluded the medical information 

 

2 The NIH website states Meclizine “is used to prevent and treat nausea, vomiting, and dizziness caused by 

motion sickness” and may be injested as “a regular and chewable tablet and a capsule.” Meclizine, MedlinePlus 

(last updated July 25, 2018) https://medlineplus.gov/druginfo/meds/a682548.html. 

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did not support Plaintiff’s request for an extension of her established disability

because the documents revealed “no objective abnormalities” and instead 

showed that Plaintiff “reported relief of symptoms after being seen.” (AR 241). 

The claim administrator once more referred Plaintiff’s claim to Physician Advisor

Dr. Duvall for review. (AR 241). 

Dr. Duvall called but was unable to make contact with Plaintiff’s treating 

neurologist before writing her April 22, 2016 report. (AR 332). Dr. Duvall noted 

that after Plaintiff’s April 4 emergency room visit, Plaintiff’s headache was 

resolved and was better on Naproxen and Tylenol. (AR 333). Although Dr. 

Duvall received documentation that Plaintiff received a Toradol injection a few 

days later, the document contained no additional information about Plaintiff’s 

symptoms or their resolution. (AR 333). Dr. Duvall concluded that from an 

occupational medicine perspective, “the objective findings are insufficient to 

support inability to do her usual job duties including sitting, typing and talking,” or 

the need for restrictions and limitations from April 18, 2016 forward. (AR 333). 

Plaintiff’s disability claim was rejected. (AR 320-321). 

On May 24, 2016, Dr. Spier saw Plaintiff and noted her active problems 

included: anemia, MS, leukocytosis (increased white blood cells in blood), 

headache, MS exacerbation, atypical migraine, migraine, transformed migraine, 

chronic migraine with status migrainosus, major depressive disorder, and 

anxiety. (AR 290). Dr. Spier increased Plaintiff’s Topamax dosage, continued 

nortriptyline, referred Plaintiff for acupuncture and massage therapy, and 

prescribed additional injections for Plaintiff’s headache in conjunction with Zofran 

and Benadryl. (AR 289-90). 

Plaintiff appealed the denial in June 2016. (AR 254-55, 312, 316-17). Dr. 

Spier submitted a work status report placing Plaintiff off work from July 5, 2016 

through September 30, 2016. (AR 310). The Quality Review Unit referred 

Plaintiff’s appeal to two Physician Advisors: (1) Woodley B. Mardy-Davis, M.D., 

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Anesthesiology (AR 305); and (2) Ekokobe Fonkem, D.O., Neurology (AR 301). 

Dr. Mardy-Davis concluded Plaintiff was capable of work from a pain 

medicine perspective, because “symptoms of headaches may be improved with 

intermittent Solu-Medrol IV infusion and adjustment of work environment 

including noise and light reduction.” (AR 304). Dr. Mardy-Davis observed 

“[c]omplete pain relief often does not occur until after resumption of normal 

acitivites” and “it is not necessary for the patient to wait until all pain is eliminated 

before returning to work.” (AR 304). Dr. Mardy-Davis further noted “a lack of 

evidence of pain and disability non-responsive to conservative therapy” and “a 

lack of documentation of diagnostic testing such as EMG/NCV demonstrating 

motor or sensory deficits.” (AR 304). No contact was made with Dr. Spier prior to 

writing the report. (AR 303). 

Dr. Fonkem concluded Plaintiff was not disabled from her regular job from 

a neurological perspective. (AR 299). Dr. Fonkem explained that although “the 

patient has headaches associated with nausea and MS,” the documentation did 

not “detail objective evidence of significant functional deficits that would prevent 

the patient from performing her job.” (AR 300). Dr. Fonkem’s synopsis detailed 

Plaintiff’s medical history at length, but the rationale noted only the April 6, 2016 

follow-up call in which Plaintiff stated she felt better after taking naproxen and 

Tylenol. (AR 300). Dr. Fonkem concluded the April 2016 documentation supplied 

only “subjective complaints but does not provide updated objective evidence of 

significant functional deficits that would prevent the patient from performing her 

occupation from a neurology perspective.” (AR 300).

Plaintiff appeals.

III. LEGAL STANDARD

A denial of benefits claim in an ERISA case “is to be reviewed 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 

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of the plan.” Firestone Tire and Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989). 

If the benefit plan confers such discretionary authority, then the decision to deny 

benefits is reviewed for abuse of discretion. Id. Courts should also consider any 

conflict of interest in the plan’s administration. Abatie v. Alta Health & Life Ins. 

Co., 458 F.3d 955, 965 (9th Cir. 2006). “[A]n insurer that acts as both the plan 

administrator and the funding source for benefits operates under what may be 

termed a structural conflict of interest.” Id. (citing Tremain v. Bell Indus., Inc., 196 

F.3d 970, 976 (9th Cir.1999)). In the event of a structural conflict of interest, the 

Ninth Circuit has instructed courts to apply abuse of discretion in a manner 

“informed by the nature, extent, and effect on the decision-making process of any 

conflict of interest that may appear in the record.” Id. 

Although Plaintiff initially argued that a conflict of interest existed that 

warranted an “enhanced skepticism” standard of review, Plaintiff has since 

conceded “because AT&T delegated decision-making authority to a third-party 

administrator, no conflict of interest exists and the correct standard of review is 

abuse of discretion.” (ECF No. 37 at 1). As it is undisputed that AT&T delegates 

its authority to a third-party, Sedgewick, to render benefits determinations, and 

because the Court finds no other basis in the record to infer a conflict of interest, 

the Court reviews the denial under the abuse of discretion standard. See

Hegarty v. AT & T Umbrella Benefit Plan No. 1, 109 F. Supp. 3d 1250, 1255 

(N.D. Cal. 2015); May v. AT&T Umbrella Plan No. 1, 2012 WL 1997810 at *13-14 

(N.D. Cal. June 4, 2012). 

“Where, as here, the abuse of discretion standard applies in an ERISA 

benefits denial case, a motion for summary judgment is, in most respects, 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.” Stephan v. Unum Life Ins. Co. of Am., 697 F.3d 917, 929–30 (9th 

Cir.2012) (citations, internal quotation marks omitted). “In the absence of a 

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conflict, judicial review of a plan administrator's benefits determination involves a 

straightforward application of the abuse of discretion standard.” Montour v. 

Hartford Life & Acc. Ins. Co., 588 F.3d 623, 629 (9th Cir. 2009). A court’s review 

is generally limited to the administrative record; however, if the court in its 

discretion examines evidence outside the administrative record, then traditional 

summary judgment rules apply. Abatie, 458 F.3d at 970; Nolan v. Heald College, 

551 F.3d 1148, 1150 (9th Cir. 2009). 

“An ERISA administrator abuses its discretion only if it (1) renders a 

decision without explanation, (2) construes provisions of the plan in a way that 

conflicts with the plain language of the plan or (3) relies on clearly erroneous 

findings of fact.” Boyd v. Bert Bell/Pete Rozelle N.F.L. Ret. Plan, 410 F.3d 1173, 

1178 (9th Cir. 2005). Under the “deferential” abuse of discretion standard, “a 

plan administrator’s decision ‘will not be disturbed if reasonable.’ ” Stephan, 697 

F.3d at 929. “This reasonableness standard requires deference to the 

administrator’s benefits decision unless it is ‘(1) illogical, (2) implausible, or (3) 

without support in inferences that may be drawn from the facts in the record.’ ” Id.

(quoting Salomaa v. Honda Long Term Disability Plan, 642 F.3d 666, 676 (9th 

Cir. 2011)). 

IV. DISCUSSION

Plaintiff challenges the reasonableness of the claim administrator’s denial 

of her appeal. The crux of Plaintiff’s argument is that the decision was 

unsupported and premised upon clearly erroneous findings of fact. (See ECF No. 

41 at 16-25). Plaintiff contends it was an abuse of discretion to rely on medical 

opinions of Physician Advisors (PA) Dr. Mardy-Davis and Dr. Fonkem because 

neither PA examined Plaintiff or consulted with her treating physicians; both 

unreasonably rejected her complaints of migraine pain as subjective and without 

support; and both ignored objective evidence of her disability. (ECF No. 41 at 16-

23). Plaintiff asserts it was illogical to determine Plaintiff’s condition had improved 

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based on the resolution of one migraine after an ER visit, and that the PA’s 

ignored the medical opinions of Dr. Brock and Dr. Spier, both of whom found 

Plaintiff was disabled. (ECF No. 41 at 25). Accordingly, Plaintiff claims she is 

entitled to Long Term Disability (LTD) benefits based on the record. (ECF No. 41 

at 25). 

Defendant contends that the claim administrator provided a detailed 

explanation for its decision, the decision does not conflict with the Plan language, 

and the decision was well supported and not based on any clearly erroneous 

factual findings. (ECF No. 42-1 at 21-24). Defendant argues that Plaintiff’s MS 

diagnosis does not automatically render her disabled under the Plan, and that the

claim administrator reasonably found that the submitted medical information was 

conclusory and did not constitute updated objective evidence of a disability to 

support her claim from April 18, 2017 onward. (ECF No. 35 at 12-13). Defendant 

further asserts the claim administrator properly relied on Dr. Mardy-Davis and Dr. 

Fonkem’s analyses and opinions, and that the scant medical information supplied 

supported the denial. (ECF No. 35 at 11-19). 

The Ninth Circuit has recognized that reports of pain are often necessarily 

subjective, and has remanded claims that were denied for lack of “objective” 

evidence of disabling pain when it was difficult to provide such objective 

measurements. See Salomaa v. Honda Long Term Disability Plan, 642 F.3d 

666, 676 (9th Cir. 2011) (holding it was arbitrary to deny claim of chronic fatigue 

syndrome for lack of objective evidence because “conditioning an award on the 

existence of evidence that cannot exist is arbitrary and capricious”); Saffon v. 

Wells Fargo & Co. Long Term Disability, 522 F.3d 863 9th Cir. 2008) (noting

“individual reactions to pain are subjective and not easily determined by 

reference to objective measurements”). Courts also consider factors such as 

whether, after citing a lack of objective evidence as a basis for denial, the plan 

administrator failed to conduct its own examination or address the contrary 

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opinion of a treating physician. See, e.g., Salomaa, 642 F.3d at 676; Hegarty v. 

AT&T Umbrella Benefit Plan No. 1109 F.Supp.3d 1250, 1258 (N.D. Cal. 2015). 

In situations where a claimant was previously determined eligible for 

disability benefits and the documentation shows no changes or improvements in 

the disabling symptoms, courts have found subsequent denials “illogical” and 

clearly erroneous. See Saffon, 522 F.3d at 871 (rejecting defendants’ rationale 

that claimant’s LTD benefits should be denied because documentation showed 

no “progression in degeneration” and holding “[i]n order to find [claimant] no 

longer disabled, one would expect the MRIs to show an improvement, not a lack 

of degeneration”); May v. AT&T Umbrella Ben. Plan No. 1, No. c-11-02204, 2012 

WL 1997810 at *15-16 (N.D. Cal. June 4, 2012) (holding “to the extent the 

updated medical records document essentially the same disabling symptoms that 

the Plan previously found to be disabling, the Plan’s termination of [STD] benefits 

was illogical and . . . supports a finding of clear error”). However, although an 

initial finding of disability “may be considered evidence of the claimant’s 

disability” in a subsequent claim or appeal, paying benefits at one point does not 

“operate[ ] forever as an estoppel so that an insurer can never change its mind.” 

Muniz v. Amec Const. Mgmt., Inc., 623 F.3d 1290, 1296-97 (9th Cir. 2010). And 

to the extent an administrator received medical documentation containing 

numerous contradictions between self-reported pain and objective findings, a 

denial of benefits will be upheld. See Jordan v. Northrop Grumman Corp. 

Welfare Benefit Plan, 370 F.3d 869 (9th Cir. 2004) (holding administrator did not 

abuse discretion because claimant’s chart “had a number of objective and 

subjective indications” that her fibromyalgia pain was not disabling, including 

physician’s observations that claimant was in no acute distress and was freely 

ambulatory, as well as claimant’s self-reported physical activities) overruled on 

other grounds by Salomaa v. Honda Long Term Disability Plan, 642 F.3d 666 

(9th Cir. 2011); Martin v. Aetna Life Ins. Co., 223 F.Supp.3d 973, 985-86 (C.D. 

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Cal. 2016) (upholding denial of benefits because treating physician’s findings 

were in conflict with claimant’s self-reported pain and PA’s were not required to 

take treating physician’s “one sentence recommendation . . . as conclusory 

evidence of [claimant’s] disability”). 

Upon reviewing the full administrative record, and applying these holdings, 

the Court concludes that the decision was illogical and without support in 

inferences that may be drawn from the facts in the record. See Stephan, 697 

F.3d at 929. The decision was an abuse of discretion because the claim 

administrator (1) unreasonably discounted Plaintiff’s subjective reports of pain; 

(2) erroneously concluded that Plaintiff’s symptoms had improved; and (3) failed 

to conduct its own examination or address the conflicting opinion of previous 

PA’s and treating physicians. 

A. The Claim Administrator Unreasonably Discounted Plaintiff’s 

Subjective Reports of Pain.

“A plan’s denial is arbitrary to the extent that it was based on a consulting 

phyisician’s implicit rejection of a Plaintiff’s subjective complaints of pain.” James 

v. AT&T West Disability Benefits Program, 41 F.Supp.3d 849, 880 (N.D. Cal. 

2014) (internal quotations and alterations omitted). Migraine pain is not readily 

proven by laboratory tests, and work limitations that are consequential to that 

pain “are likely to defy objective clinical proof.” Hegarty, 109 F.Supp. 3d at 1257; 

see also Salomaa, 642 F.3d at 677 (finding significant the absence of any 

objective test for chronic fatigue syndrome). “By effectively requiring ‘objective’ 

evidence for a disease that eludes such measurement” a plan “establishe[s] a 

threshold that can never be met by claimants who suffer . . . no matter how 

disabling the pain.” James, 41 F.Supp.3d at 881 (quoting Minton v. Deloitte & 

Touche USA LLP Plan, 631 F.Supp.2d 1213, 1220 (N.D. Cal. 2009)). 

Here, the primary ground for denying Plaintiff’s disability benefits was that 

the documentation of her disability was too subjective. Dr. Fonkem deemed 

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Plaintiff’s “subjective complaints” insufficient evidence “of significant functional 

deficits that would prevent [her] from performing her occupation.” (AR 300). Dr. 

Mardy-Davis made general statements that “symptoms of headaches may be 

improved” by adjusting work environments and administering medication, and 

remarked upon a “lack of evidence of pain” and “lack of documentation of 

diagnostic testing such as EMG/NCV demonstrating motor or sensory deficits.” 

(AR 304). But there is no objective test for migraine pain, and the PA’s discount 

the available evidence of years of repeated emergency visits and Plaintiff’s selfreported debilitating pain from rebound migraines. The Court concludes that this 

disregard for Plaintiff’s subjective complaints of pain and “reliance on the 

absence of medical evidence that cannot exist [is] arbitrary and capricious and 

thus unreasonable.” Hegarty, 109 F.Supp. 3d at 1257 (quoting Salomaa, 642 

F.3d at 678). 

B. The Claim Administrator Ignored Objective Evidence And 

Erroneously Concluded Plaintiff’s Symptoms Had Improved. 

The Court finds Defendant’s reasoning, that Plaintiff is no longer disabled 

because she experienced brief relief between a migraine that sent her to the ER 

and a migraine that required a Toradol injection, illogical given the nature of 

migraines and the objective evidence of pain and attempts at pain management

in the record. See James, 41 F.Supp.3d at 880 (concluding administrator 

abused discretion when it “essentially disregarded” plaintiff’s history of pain and 

pain treatment since 2007 and failed to explain why that history was “insufficient 

to find her unable to work). 

The medical submission shows the same objective evidence of Plaintiff’s 

pain that previous PA’s deemed disabling. In Dr. Duvall’s November 2015 report, 

she stated, “[i]n general, one would not expect significant objective physical 

exam findings or test results with migraine type headaches; however, if 

headaches are severe and refractory, the condition can be disabling.” (AR 633). 

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She found Plaintiff disabled because “the severity of the headaches is supported 

by [Plaintiff’s] ER visit, medication adjustments and changes, and need for 

steroids” and that “[h]er condition may also be complicated by her Multiple 

Sclerosis.” (AR 634). Similarly, Dr. Brock averred that Plaintiff was disabled and 

incapable of work because the documentation demonstrated “the presence of 

ongoing migraine headache” requiring “repeated medical visitations and medical 

administrations” and a “history of multiple sclerosis with a progressive episode, 

and experiencing weakness of bilateral lower extremities that required IV SoluMedrol.” (AR 382-83). 

From April onward, Plaintiff submitted objective evidence of symptoms 

consistent with Plaintiff’s history of pain and pain management that PA’s 

previously found showed she was unable to work. Contrary to Defendant’s 

characterization of Plaintiff’s claim, Plaintiff does not rely on the fact of her MS 

diagnosis alone. (See ECF No. 35 at 12). The evidence submitted included 

documentation of an emergency room visit for a severe and uncontrolled 

migraine headache associated with MS, administration of different medications, a 

Toradol injection two days later, and a note from her treating physician placing 

her off work. The claim administrator thus improperly ignored updated subjective 

and objective evidence demonstrating Plaintiff’s disability. 

The claim administrator’s conclusion that Plaintiff’s follow-up call with Dr.

Rodriguez, in which she stated her symptoms were mitigated after the ER visit, 

demonstrated that Plaintiff had improved and could work is unreasonable for a 

couple of reasons. First, it is illogical to presume that Plaintiff’s statement 

admitting reprieve from pain between migraines showed that she was able to 

work. Plaintiff suffers from chronic, severe refractory migraine headaches; she 

experienced some relief after receiving strong medications at her ER visit, and 

attempted to manage her pain with Tylenol only to be administered a Toradol 

injection two days later. (AR 339-345, 347). The nausea and headache she 

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experienced, described by the ER physician as “severe exacerbation” and 

“inadequately controlled,” had persisted for a week prior to the ER visit. (AR 339-

345). The logical inference given her medical history is that her headache 

returned and increased in severity over the intervening days, just as it had 

previously. Migraines render individuals unable to withstand light or sound, 

which Plaintiff’s work necessitates and previous PA’s have acknowledged, and 

she was still suffering from them. (AR 469). Although Dr. Mardy-Davis and Dr. 

Fonkem stated Plaintiff’s migraines could be controlled with medication, the 

record shows that Plaintiff continued to take medications that failed to do so. (AR 

342, 415-17, 420-21, 424, 428, 572-73). 

Second, there are no inconsistencies between Plaintiff’s self-reporting and 

the objective findings, as there were in cases cited by Defendant in which the 

presiding court upheld the claim administrator’s decision. See Jordan v. Northrop 

Grumman Corp. Welfare Benefit Plan, 370 F.3d 869, 880 (9th Cir. 2004); Martin 

v. Aetna Life Ins. Co., 223 F.Supp.3d 973, 985-86 (C.D. Cal. 2016). Unlike the 

claimant in Jordan, who reported performing very physical household chores that 

the court found “cut against a determination of severe pain” from fibromyalgia,

here, Plaintiff has not reported any such inconsistent activities. Jordan, 370 F.3d 

at 880. Plaintiff’s case is similarly distinguishable from Martin, where the 

claimant complained of multiple joint pain and ligament tearing, but his xrays 

“revealed a well-healed metacarpal trapezial fusion,” and he demonstrated 

normal range of motion, strength, and sensations in a hand and wrist 

examination. Id. at 977-78. To the contrary, no medical exam suggested Plaintiff 

was not suffering from chronic migraines or that she was not debilitated when 

one or a cluster struck. Moreover, Plaintiff’s diagnosis of chronic migraines and 

MS exacerbation was supported by numerous ER and doctor’s visits, as well as

a history of meninigitis and MRIs showing multiple brain lesions from MS. Cf.

Jordan, 370 F.3d at 881 (concluding there was nothing arbitrary or capricious “in 

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finding inadequate, with the support of qualified physicians, a claim of disability 

supported only by a diagnosis of fibromyalgia with no explanation of why it 

should amount to a disabling condition”). 

Finally, the Court notes that Dr. Fonkem mistakenly described Plaintiff’s 

follow-up call with Dr. Rodriguez as an in-person exam. (See AR 300 (stating 

“the patient saw V. Rodriguez following her ER visit for headache” and describing 

it as an “exam”) (emphasis added)). Dr. Fonkem thus relied on more than one 

clearly erroneous finding of fact in determining Plaintiff was not disabled. 

Given the foregoing, it was clear error to conclude Plaintiff was able to work 

simply because she experienced a reprieve between chronic, severe migraines

after an ER visit. The PA’s ignored objective evidence of unchanged debilitating 

migraines, required clinical proof of Plaintiff’s pain that is unlikely to exist, and 

erroneously characterized Plaintiff’s history of pain management. The claim 

administrator’s denial of benefits was therefore arbitrary and capricious. See 

Saffon v. Wells Fargo & Co. Long Term Disability, 522 F.3d at 871; May, 2012 

WL 1997810 at *15-16. 

C. The Claim Administrator Failed to Conduct its Own Examination or 

Address the Conflicting Opinions of previous PA’s and treating 

physicians. 

Further reinforcing the Court’s conclusion that the claim administrator’s 

decision was unreasonable is the administrator’s failure to (1) conduct its own 

examination or (2) address the medical opinions of previous PA’s and Plaintiff’s

treating physician supporting a disability finding. See, e.g., Salomaa, 642 F.3d at 

676; Hegarty v. AT&T Umbrella Benefit Plan No. 1109 F.Supp.3d 1250, 1258 

(N.D. Cal. 2015). 

The claim administrator did not meaningfully address the opinions of its 

previous PA’s and Dr. Spier, Plaintiff’s treating physician. Although plan 

administrators need not “accord special deference to the opinions of treating 

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physicians,” these opinions are relevant to determining whether the claim 

administrator abused its discretion. See Black & Decker Disability Plan v. Nord, 

538 U.S. 822, 823 (2003). Defendant contends that Dr. Spier’s conclusion that 

Plaintiff is disabled is undermined by statements she made to a PA evaluating 

Plaintiff from a psychiatry perspective. (ECF No. 42-1 at 23). Defendant urges 

the Court to consider that after Dr. Spier relayed that Plaintiff’s legs were weak at 

her last visit, she said Plaintiff’s “exams are not reliable because she gives way 

and it is impossible to identify if there is any real weakness.” (AR 371). But this 

statement relates to her leg weakness, not to her headaches, which are Plaintiff’s 

primary disability for STD benefit purposes. (AR 371). Although Dr. Spier was 

still “working on finding out why [Plaintiff] has so many headaches,” and she 

suspected “some secondary gain,” she also said Plaintiff “has real illnesses” and 

that she was investigating whether meningitis could be causing Plaintiff’s 

headaches. (AR 371). Dr. Spier’s statements to the psychiatry PA therefore did 

not “undermine[ ] any claim of disability,” as Defendant argues. (ECF No. 42-1 at 

23). In addition, this was not one of the bases cited by the reviewing PA’s for 

denying Plaintiff’s STD benefits, and so does not support Defendant’s argument. 

Furthermore, Dr. Spier’s statements to the PA investigating Plaintiff’s 

psychiatric fitness does not change the fact that neither Dr. Mardy-Davis nor Dr. 

Fonkem successfully contacted Dr. Spier about Plaintiff’s migraine pain during 

the period in question. The Court notes that a previously skeptical Dr. Duvall 

changed her mind after consulting with Dr. Spier about Plaintiff’s condition. (AR 

633-34). This failure to consult is not insignificant in this case, particularly where, 

as Duvall noted, “[i]n general, one would not expect significant objective physical 

exam findings or test results with migraine type headaches.” (AR 634). 

Finally, to the extent that Dr. Mardy-Davis found fault in Plaintiff’s 

submission because it lacked diagnostic testing, such as EMG/NCV 

demonstrating motor or sensory deficits, Defendant should have ordered further 

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tests. (AR 304). The claim administrator reserved discretion to order such an 

examination before determining whether to grant STD benefits under the Plan. 

(AR 69-70). Nevertheless, no additional examination of the Plaintiff was 

requested.

Accordingly, the Court concludes the claim administrator abused its 

discretion in denying Plaintiff’s claim. The Court remands Plaintiff’s claim for the 

awarding of STD benefits.

D. Long Term Disability Benefits

The Court agrees with Defendant that it is improper to make a 

determination regarding LTD benefits at this juncture, and denies Plaintiff’s 

request to hold she is entitled to LTD benefits before she has applied for them. 

The Court remands this matter to the claims administrator to determine whether 

Plaintiff is entitled to LTD benefits or would have been entitled to LTD benefits 

had her STD benefits not terminated. 

V. CONCLUSION

Plaintiff’s Motion for Summary Judgment is granted in part, and 

Defendant’s Motion for Summary Judgment is denied. The Court remands 

Plaintiff’s claim for further proceedings consistent with this opinion. The Clerk 

shall enter a final judgment accordingly.

IT IS SO ORDERED.

Dated: March 4, 2019

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