Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-arwd-1_05-cv-01034/USCOURTS-arwd-1_05-cv-01034-0/pdf.json

Nature of Suit Code: 110
Nature of Suit: Insurance
Cause of Action: 29:1132 E.R.I.S.A.-Employee Benefits

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AO72A

(Rev. 8/82)

Plaintiff was under two plans provided by Defendant: GLT- 1

205215 and GLT-24554.

1

 IN THE UNITED STATES DISTRICT COURT

WESTERN DISTRICT OF ARKANSAS

EL DORADO DIVISION

PATRICIA JOHNSTON PLAINTIFF

v. Case No. 05-1034

HARTFORD LIFE AND

ACCIDENT INSURANCE CO. DEFENDANT

MEMORANDUM OPINION AND ORDER

Plaintiff brings this action pursuant to the Employee

Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. §§

1001 et seq., against the Defendant, her disability insurance

provider, Hartford Life and Accident Insurance Co. (hereinafter

“Hartford” or “Defendant”). She seeks total disability

benefits from February 21, 2004 and forward as provided under

the policy, a declaration that she is totally disabled under

the terms of the policy, reasonable attorney fees, and prejudgment and post-judgment interest. 

Plaintiff challenges Defendant’s termination of her

benefits under her employer’s, Wal-Mart Stores, Inc., group

disability insurance policy provided by Defendant (hereinafter

“Group Plan”). The matter is before the Court on the 1

Stipulated Administrative Record and the parties’ briefs.

(Exhibit A, Doc. 10, Doc. 13.) For the reasons set forth

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Plaintiff had her right knee replaced in March 2001 and her 2

left knee in May 2001.

“Osteoarthritis” is arthritis characterized by “erosion of 3

articular cartilage, either primary or secondary to trauma or

other conditions, which becomes soft, frayed, and thinned with

eburnation of subchondral bone and outgrowths of marginal

osteophytes; pain and loss of function result; mainly effects

weight-bearing joints.” See PDR Medical Dictionary 1267 (1 ed. st

1995).

2

herein, we REVERSE the plan administrator’s decision to deny

benefits. 

A. Background

Plaintiff began employment with Wal-Mart in 1989,

primarily as a cashier. (AR 175.) While working as a cashier,

she was required to walk and stand regularly, use her hands to

scan items and operate a keyboard, and frequently lift or move

items weighing 10 to 50 pounds. (AR 219-222.) During her

employment, she was included within coverage of Wal-Mart’s

group disability insurance policy provided by Defendant. The

insurance policy included short and long term benefits for

total disability. 

In 2001, Plaintiff underwent bilateral unicompartmental

knee replacement as a result of osteoarthritis in both knees. 2 3

(AR 207.) For this condition, Plaintiff has been under the

care of Dr. Mark Malloy, a doctor of internal medicine, since

1999. (AR 207.) Dr. Malloy was Plaintiff’s treating physician

throughout the actions giving rise to this complaint. 

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The record is vague as to when exactly this second surgery 4

took place. All that is clear is that it was sometime before

September, 2003.

The letter informing Plaintiff that her benefits would 5

expire on September 30, 2002 was written October 3, 2002.

3

As a result of the knee surgery, Plaintiff received short

term disability (STD) benefits through August 19, 2001. (AR

121.) On August 20, Plaintiff returned to work. (AR 119-120.)

Continued pain and swelling after surgery forced Plaintiff to

quit her job for good on August 9, 2002 and, sometime later,

undergo a second surgery on each knee. (AR 129, 188.) 4

Plaintiff was again awarded STD benefits, effective August 24,

2002. (AR 116.)

At Defendant’s request, Dr. Malloy completed a “Physical

Capacities Evaluation Form” on September 25, 2002. (“September

2002 PCE”)(AR 232-234.) On this form, Dr. Malloy stated that:

Plaintiff should not sit for more than two hours in any given

workday and no more than an hour at a time; she should not

stand, walk, or drive for more than an hour a day; and she

should not work for more than an hour in any given day. Taking

Dr. Malloy’s information into account, Defendant revoked

Plaintiff’s STD benefits effective September 30, 2002. (AR 5

114.) Plaintiff appealed this determination and, on December

19, Defendant reinstated Plaintiff’s STD benefits through

February 21, 2003. (AR 112.) 

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Plaintiff applied for long term disability (LTD) benefits,

which Defendant initially approved on February 7, 2003. (AR

108-109.) This determination was based, at least in part, on

Dr. Malloy’s completion of an “Attending Physician’s Statement

of Disability”, dated January 7, 2003. (“January 2003 APS”)(AR

207-208.) The January 2003 APS stated, in relevant part, that

Plaintiff should not stand, drive, or walk for more than an

hour a day, and should not lift, reach, push, or pull at all.

Under “Sitting”, Dr. Malloy wrote only “-“. No further

comments were made. (AR 208.)

Later in February 2003, Plaintiff was awarded Social

Security disability benefits in the amount of $563.50 per

month. (AR 194.) On August 29, 2003, Defendant notified

Plaintiff that it was investigating her claim in order to

decide if her claim would continue to qualify for LTD benefits

under the Group Plan’s changing terms. (AR 106-107.) The old

Group Plan terms, under which Defendant initially awarded

Plaintiff LTD benefits, required Plaintiff to be totally

disabled and unable to perform “the essential duties of your

occupation”. The new terms required Plaintiff to be totally

disabled and unable to perform “the essential duties of any

occupation”. (AR 106)(emphasis added)(hereinafter “any

occupation” standard.) 

As part of its investigation, Defendant once again asked

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Dr. Malloy to complete an Attending Physician’s Statement of

Disability. (“September 2003 APS”.) Dr. Malloy completed this

form and returned it to Defendant on September 10, 2003.Dr.

Malloy listed as limitations that the Plaintiff should stand

not stand or walk for more than an hour and should not lift

anything. Dr. Malloy made no other comments. (AR 145-146.)

Defendant then conducted its employability analysis on

Plaintiff. (AR 179-182.) The results of this analysis state

that Plaintiff could still be employable in “sedentary” jobs,

or those that required “mostly sitting”. (Id.) According to

Defendant, the Plaintiff could do any of four jobs: telephone

solicitor, charge account clerk, food and beverage order clerk,

or surveillance system monitor. (Id.) On October 17,

Defendant requested that Dr. Malloy confirm that Plaintiff

could manage these jobs. (AR 104-105.)

On his reply to Defendant, dated October 22, someone in

Dr. Malloy’s office included a handwritten note that stated,

“Dr. Malloy said he agreed no need to send further reports.”

(AR 143-144)(emphasis in original.) 

On January 28, 2004, Defendant notified Plaintiff that she

would no longer be entitled to LTD benefits, effective February

21. (AR 100-103.) Plaintiff appealed this decision and, in a

letter received by Defendant on February 17, informed Defendant

that their conclusion that she could work sedentary occupations

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was in conflict with what her physician, Dr. Malloy, had

reported to her. She also stated that none of the listed jobs

were available in her area. (AR 156.) Dr. Malloy sent a

letter to Defendant, dated February 17, 2004, confirming

Plaintiff’s account. This letter stated that Plaintiff could

not work “any job” and that she could not sit for any length of

time. (AR 159.)

Defendant rejected Plaintiff’s appeal on March 18, 2004.

(AR 98-99.) Dr. Malloy re-sent the February 17, 2004 letter to

Defendant on September 21, 2004. (AR 140.) Defendant

responded that it had received the letter, but that it’s

position remained unchanged and Plaintiff did not qualify for

LTD benefits under the “any occupation” standard of the Group

Plan. (AR 97.) Plaintiff has exhausted her administrative

remedies and filed this suit.

B. Standard of Review

The Employee Retirement Income Security Act of 1974

(ERISA) affords a plan beneficiary the right to a judicial

review of a benefits determination. See 29 U.S.C. §

1132(a)(1)(B). Such cases are not to be determined under the

standard for granting summary judgment pursuant to Federal Rule

of Civil Procedure 56(c). See Wilkins v. Baptist Healthcare

System, Inc., 150 F.3d 609, 619 (6th Cir. 1998). The Court

must decide whether benefits were properly denied based on a

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review of the record presented to the administrator under the

appropriate standard. See id. Accordingly, the plan

administrator’s decision to deny benefits must be upheld if

“reasonable; i.e., supported by substantial evidence.” See

Donaho v. FMC Corp., 74 F.3d 894, 899 (8th Cir. 1996).

Further, if supported by substantial evidence, such a denial

“should not be disturbed even if a different, reasonable

interpretation could have been made.” See Cash v. Wal-Mart

Group Health Plan, 107 F.3d 637, 641 (8th Cir. 1997). 

If a benefits plan allows the administrator discretionary

authority to determine eligibility for benefits or to construe

the plan, the Court reviews the plan administrator’s decision

only for an abuse of discretion. See Firestone Tire & Rubber

Co. v. Bruch, 489 U.S. 101, 115 (1989); Layes v. Mead Corp.,

132 F.3d 1246, 1250 (8th Cir. 1998). This standard may give

way to a less deferential one if Plaintiff can show that the

administrator’s decision was influenced by a conflict of

interest or serious procedural irregularity. See Woo v. Deluxe

Corp., 114 F.3d 1157, 1161 (8th Cir. 1998). 

In the present case, Plaintiff acknowledges that the LTD

Plan gives the Hartford discretionary authority to administer,

apply, and interpret the plan. (Doc. 10 pp. 5-6.) Plaintiff

asks the Court to assume a conflict of interest by Defendant

because it is both the claim insurer and administrator. (Doc.

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10 p. 6.) However, in order to find a conflict of interest and

thus alter the standard of review, Plaintiff must present

“material, probative evidence demonstrating that a palpable

conflict of interest existed, which caused a serious breach of

the administrator's fiduciary duty.” Farley v. Blue Cross &

blue Shield, 147 F.3d 774, 776 (8th Cir. 1998). Plaintiff

offers no such evidence and the Court reviews the plan

administrator’s decision for an abuse of discretion. 

C. Discussion

Plaintiff asserts two theories of recovery: Defendant

ignored relevant medical information with regard to Plaintiff’s

classification as totally disabled under the “any occupation”

standard; and Defendant improperly relied on its Employability

Analysis in defining which jobs Plaintiff could adequately

perform. 

1. Consideration of All Medical Information

Plaintiff contends Defendant placed undue emphasis on

Defendant’s 2003 correspondence with Dr. Malloy when it denied

Plaintiff’s request for continued LTD benefits. Specifically,

Plaintiff contends Defendant relied solely on the handwritten

note attached to Hartford’s October 2003 letter and the January

2003 APS, wherein Dr. Malloy indicated a “-“ when asked the

length of time Plaintiff could sit. (Doc. 10 p. 10.)

Plaintiff further contends Defendant ignored the parts of the

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record demonstrating Plaintiff’s disability, primarily Dr.

Malloy’s February 2004 letter and the September 2002 PCE. (Id.

at pp.7-8.) 

Defendant states the plan administrator’s decision to deny

LTD benefits was proper, since Plaintiff’s condition did not

meet the definition of total disability under the “any

occupation” standard as construed by it. Defendant offers no

opposing medical testimony, and relies heavily on the January

2003 APS. Defendant states only that Dr. Malloy’s February and

September 2004 letters are “outside the scope of medical care.”

(AR 99.) 

Parties dispute the weight to be given the information

provided by Dr. Malloy, as Plaintiff’s treating physician.

Defendant states correctly that “the treating doctor’s opinion

must be considered along with all the other evidence that

supports or refutes it.” (Doc. 13 p. 11)(citing Black & Decker

Disability Plan v. Nord, 123 S.Ct. 1965 (2003).) Defendant must

also be aware, then, that plan administrators may not

“arbitrarily refuse to credit a claimant’s reliable evidence,

including the opinion of a treating physician.” Black & Decker

Disability Plan, 123 S.Ct. At 1967. As Dr. Malloy’s

correspondence is the only medical evidence available,

Defendant may not arbitrarily refuse to consider other parts of

his correspondence. While deference is due the plan

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administrator’s decision, that decision must be based on the

evidence presented. Defendant has failed to show that it

properly considered all the evidence in the record.

Defendant states that Dr. Malloy’s February 2004 letter

was his “first mention of an impact on the amount of time that

Johnston could sit based on her weakened knees.” (Doc. 13 p.

6.) This representation of the record is less than correct.

Defendant ignores the September 2002 PCE, wherein Dr. Malloy

first stated that Plaintiff could not sit for more than two

hours total, and no more than an hour at a time. (AR 233-234.)

Defendant then characterized Dr. Malloy’s restriction, in the

February 2004 letter, on Plaintiff’s sitting as a “brand new

restriction.” (Doc. 13 p. 10)(emphasis in original.) 

For this “brand new restriction” characterization,

Defendant relies on the January 2003 APS, wherein Dr. Malloy

wrote a “-“ for restrictions on sitting. (AR 233.) Defendant

describes as “inconceivable” the suggestion that Dr. Malloy

forgot to list Plaintiff’s sitting restrictions on the January

2003 APS. (Doc. 13 p. 10.) Yet, eight months later, that is

precisely what Dr. Malloy did. On the September 2003 APS, Dr.

Malloy simply left blank the area provided for sitting

restrictions. (AR 145-146.) On this APS, Dr. Malloy also left

blank the spaces for pushing, pulling, and driving - all

restrictions that had been listed in the January 2003 APS. (AR

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146, 208.) Yet, Defendant makes no assertion that Plaintiff

can successfully perform any of these activities.

While a plan administrator is not automatically required

to accord deference to the treating physician, the

administrator cannot fail to consider Plaintiff’s reliable

evidence from her treating physician’s opinions, especially

when no other medical evidence is offered. See Burch v.

Hartford Life & Acc. Ins. Co., 383 F. Supp. 2d 1119, 1126 (W.D.

Ark. 2005)(plan administrator’s failure to consider Plaintiff’s

physicians’ opinions by relying only on one independent

reviewing physician was an abuse of discretion). Defendant’s

odd characterization of the January 2003 APS, its avoidance of

the September 2002 PCE, and the lack of contradicting objective

medical evidence, make Defendant’s denial of Plaintiff’s LTD

benefits an arbitrary and capricious one, with the Defendant

paying selective attention to only part of the available

evidence.

The Court further finds Defendant’s argument that Dr.

Malloy’s opinion (that Plaintiff was unable to work “any job”,

expressed in the February and September 2004 letters) was

“outside the scope of medical care,” is without merit.

Defendant had previously, expressly asked Dr. Malloy for his

expert judgment on how much Plaintiff should be allowed to

work. (AR 234.) Dr. Malloy, in the September 2002 PCE,

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answered this question. In October 2003, Defendant once again

asked Dr. Malloy to “determine if you concur that [the

occupations provided by Defendant’s employability analysis] are

performable by Ms. Johnston.” (AR 166.) In light of these

previous expressions of confidence in Dr. Malloy’s ability to

judge Plaintiff’s fitness for work, Defendant can not now

arbitrarily dismiss his conclusions.

All of Plaintiff’s physician’s correspondence restricted

her standing and walking ability, and the treating physician

reiterated that she had serious restrictions on sitting as

well. Dr. Malloy stated Plaintiff could not perform the duties

of any job, because Plaintiff could not sit, stand, walk, or

lift for “any length of time necessary to hold a job.” (AR

159.) Applying the abuse of discretion standard in ERISA

matters, the Court must determine whether a reasonable person

could arrive at the same conclusion as the plan administrator.

 See House v. Paul Revere Life Ins. Co., 241 F.3d 1045, 1048

(8 Cir. 2001). The Court finds that based on the facts set th

out above, a reasonable person could and would not arrive at

the same conclusion; therefore, it was an abuse of discretion

by the plan administrator to deny Plaintiff LTD benefits. 

2. Defendant Relied Improperly On Its Employability

Analysis

Plaintiff contends Defendant improperly relied on an

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The Court notes that the last time any physician was 6

actually asked how long Plaintiff could work in any given day,

was in the September 2002 PCE, and the answer was less than one

hour per day.

13

Employability Analysis. Utilizing this procedure, Defendant

entered restrictions into a computer program that searches

12,741 occupations classified by the U.S. Department of Labor

in the 1991 DOT. Of these 12,741 occupations, Defendant

selected four that it believed Plaintiff had the requisite

capacity to perform. Of these four, one occupation was at the

“Good” level and three at the “Fair” level. (AR 177.)

Plaintiff argues that the Defendant failed to take into account

Plaintiff could not perform a regular or consistent work

schedule, and that her condition was permanent. Defendant

argues that there is substantial evidence that Plaintiff could

work a sedentary job as long as she could sit all day and shift

posture. Assuming, arguendo, that Plaintiff is capable of

sedentary work, Defendant’s employability analysis remains

flawed.

Defendant contends Plaintiff could work a sedentary job as

long as she could sit all day and shift posture, but this

conclusion is contrary to the attending physician’s

limitations. Moreover, the Court finds it highly unlikely that

Plaintiff could obtain one of the four of 12,741 occupations,

while only being able to work, at most, one hour a day , and 6

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being permitted to have her feet elevated often throughout the

day.

More curious than Defendant’s disregard of the complete

medical record are the changes Defendant made to Plaintiff’s

“Ability Profile” on October 6, 2003. (AR 176.) These changes

included a downgrade on “Physical Demands” from “Light” to

“Sedentary.” (Id.) We note with interest the unexplained

changes to Plaintiff’s “General Educational Development.”

(Id.)(Where Defendant upgraded Plaintiff’s “Mathematics” and

“Language” categorizations from “2 Grades 4-6" to “3 Grades 7-

8".) One can only assume that Plaintiff’s knee surgeries did

not make her significantly more intelligent. The importance of

these changes becomes apparent when one looks into the

occupations for which Defendant recognized Plaintiff might

still be capable. The “Occupational Requirements” for all four

occupations require “General Learning Ability”, “Verbal

Aptitude”, and “Numerical Aptitude” of at least a category

three. (AR 179-182.) Defendant provided no occupations for

which Plaintiff would have qualified under the prior category

two. 

 The Court finds that Defendant improperly relied on its

employability analysis and abused its discretion in classifying

Plaintiff under the “any occupation” standard of the Group

Plan. Defendant made undocumented changes to Plaintiff’s

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employability profile that have no connection whatsoever to her

disability and illness. The Court can only conclude that

Defendant’s decision was not based upon substantial evidence,

and consequently arbitrary, and an abuse of discretion. 

3. Other considerations 

Plaintiff began receiving Social Security benefits due to

her disability on March 17, 2003. (AR 194.) Although the

Social Security Administrator’s determination is not binding on

this Court, it is relevant admissible evidence to support an

ERISA claim for long-term disability benefits. See Riedl v.

General American Life Insurance Company, 28 F.3d 753, 759 n. 4

(8 Cir. 2001); Duffie v. Deere & Co., 111 F.3d 70, 74 n. 5 th

(8 Cir. 1997). th

D. Attorneys’ Fees

A district court has discretion to award attorneys’ fees

under ERISA. See Sheehan v. Guardian Life Ins. Co., 372 F.3d

962, 968 (8 Cir. 2004); Lawrence v. Westerhaus, 749 F.2d 494, th

494 (8 Cir. 1984). th

“When considering whether to award such fees, the 8th

Circuit has set forth general guidelines for district courts to

follow, including the five factors set forth in Westerhaus.”

Id. These factors include: 

(1) the degree of the opposing parties’ culpability or bad

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faith; 

(2) the ability of the opposing parties to satisfy an

award of attorneys’ fees;

(3) whether an award of attorneys’ fees against the

opposing parties could deter other persons acting under

similar circumstances;

(4) whether the parties requesting attorneys’ fees sought

t o benefit all participants and beneficiaries of an ERISA

plan or to resolve a significant legal question [sic]

regarding ERISA itself; and

(5) the relative merits of the parties’ positions. 

Westerhaus, 749 F.2d at 496 (alteration in original); Sheehan,

372 F.3d at 968.

Reviewing the relevant considerations, this Court finds

that Plaintiff is entitled to fees and costs. First, the Plan

Administrator’s decision was a clear abuse of discretion.

Second, there is nothing before the Court to indicate that

Defendant would be unable to pay fees and costs. Third, the

award in this instance would help deter such abuse of

discretion in the future. Fourth, by example, Plaintiff’s

action benefits all Group Plan participants by providing

judicial interpretation of “total disability” under the policy.

Finally, the relative merits of the case clearly favor the

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Plaintiff. Accordingly, Plaintiff is entitled to attorneys’

fees and costs, and Plaintiff is directed to submit to the

Court a proposal for reasonable attorneys’ fees and costs.

E. Prejudgment Interest

“Prejudgment interest awards are permitted under ERISA

where necessary to afford the Plaintiff ‘other appropriate

equitable relief’ under section 1132(a)(3)(B).” Kerr v.

Charles F. Vattervott & Co., 184 F.3d 938, 945 (8th Cir. 1999).

One purpose of the remedy is to compensate the prevailing party

for financial damages incurred. Id. At 946. Another important

purpose is to “promote settlement and deter attempts to benefit

unfairly from the inherent delays of litigation.” Stroh

Container Co. v. Delphi Indus., Inc., 783 F.2d 743, 752 (8th

Cir.), cert. denied, 476 U.S. 1141(1986). “A common thread

throughout the prejudgment interest cases is unjust enrichmentthe wrongdoer should not be allowed to use the withheld

benefits or retain interest earned on the funds during the time

of the dispute.” Kerr, 184 F.3d at 946. Based on these

considerations Plaintiff should be awarded prejudgment interest

to make her whole, and to promote settlement on behalf of the

Defendant. Finally, Plaintiff would not be unjustly enriched

by such an award. Accordingly, Plaintiff is entitled to

prejudgment interest. The Court relies on 28 U.S.C. § 1961 to

determine the appropriate rate of interest. See Sheehan,

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supra. Plaintiff is awarded prejudgment interest at a rate of

5.22 percent compounded annually from February 21, 2004 to the

date of this judgment. 

F. Post-judgment Interest

Under 28 U.S.C. § 1961, district courts are required to

award post-judgment interest. The statute provides that

“[such] interest shall be calculated from the date of the entry

of judgment,” and “shall be computed daily to the date of

payment.” 28 U.S.C. § 1961(a), (b). The statute “mandates the

imposition of post-judgment interest, thus removing the award

of such interest from the discretion of the District Court.”

Bricklayers’ Pension Trust Fund v. Taiariol, 671 F.2d 988, 989

(6th Cir. 1982). The federal post-judgment interest statute

allows interest on “all money judgments,” including those in

ERISA cases. Hoover v. Provident Life & Accident Ins. Co., 290

F.3d 801, 810 (6th Cir. 2002). Moreover, Plaintiff is entitled

to post-judgment interest on this Court’s award of prejudgment

interest. See Caffey v. UNUM Life Ins. Co., 302 F.3d 576, 586

(6th Cir. 2002). 

G. Conclusion

Based on the foregoing reasons, Plaintiff is entitled to

a judgment against Defendant, and the decision to deny benefits

is REVERSED, and this case is remanded to the plan

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administrator for a benefits determination consistent with this

opinion. 

IT IS SO ORDERED, this 31st day of July, 2006.

/s/ Robert T. Dawson

Honorable Robert T. Dawson

United States District Judge

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