Source: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-cand-4_18-cv-02965/USCOURTS-cand-4_18-cv-02965-4/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

Northern District of California

UNITED STATES DISTRICT COURT

NORTHERN DISTRICT OF CALIFORNIA

JANE DOE,

Plaintiff,

v.

SUN LIFE ASSURANCE COMPANY OF 

CANADA,

Defendant.

Case No. 4:18-cv-02965-HSG (KAW)

ORDER REGARDING 2/6/19 JOINT 

LETTER

Re: Dkt. No. 34

On February 6, 2019, the parties filed a joint letter concerning Plaintiff’s Interrogatory 

Nos. 1-4. (Joint Letter, Dkt. No. 34.) Specifically, the parties dispute whether discovery outside of 

the administrative record is appropriate. Id. at 1-2. Upon review of the joint letter, the Court finds 

that Plaintiff has not met her burden of showing that an exceptional circumstance exists in which 

the introduction of evidence beyond the administrative record could be considered necessary.

I. BACKGROUND

Plaintiff Jane Doe filed a lawsuit under the Employee Retirement Income Security Act of 

1974, 29 U.S.C. § 1001, et seq. (“ERISA”), as it involves a claim for employee benefits under an 

employee benefit plan regulated and governed under ERISA. This case involves Plaintiff’s claim 

for additional long-term disability benefits, which were administered and funded by Sun Life.

(Joint Letter at 1.)

Dr. Michael Villanueva, a clinical neuropsychologist, was hired through a third-party 

vendor to review the claim on appeal for Sun Life. (Joint Letter at 3.) Dr. Villanueva prepared a 

24-page report and addendum, which was included in the administrative record. Id. Plaintiff’s 

appeal was denied. Sun Life’s position is that Plaintiff received her monthly disability benefits for 

the maximum benefit period allowed by the Group Policy, based on Sun Life’s determination that 

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Plaintiff’s disability was due to her depression and/or alcohol use. Id. Plaintiff contends that her 

long-term disability is due to cognitive deficits arising “from the removal of a brain tumor in 2009 

and a concussion she allegedly sustained in a car accident in 2013.” (Dkt. No. 22 at 2:21-22.)

II. LEGAL STANDARD

The district court’s standard of review to a challenge to an ERISA plan’s denial of benefits 

is de novo “unless the benefit plan gives the administrator or fiduciary discretionary authority to 

determine eligibility for benefits or to construe the terms of the plan.” Opeta v. Nw. Airlines 

Pension Plan for Contract Employees, 484 F.3d 1211, 1216 (9th Cir. 2007) (quoting Firestone 

Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989) (internal quotations omitted)). Under de 

novo review, “[t]he court simply proceeds to evaluate whether the plan administrator correctly or 

incorrectly denied benefits.” Abatie v. Alta Health & Life Ins. Co., 458 F.3d 955, 963 (9th Cir. 

2006).

Nonetheless, a district court may exercise its discretion to look beyond the administrative 

record only where circumstances clearly establish that additional evidence is necessary to conduct 

an adequate de novo review of the benefits decision. Gonda v. Permanente Med. Grp., Inc., 300 

F.R.D. 609, 613 (N.D. Cal. 2014) (citing Mongeluzo v. Baxter Travenol Long Term Disability 

Ben. Plan, 46 F.3d 938, 943 (9th Cir. 1995); see also Opeta, 484 F.3d at 1217. The non-exhaustive 

list of “exceptional circumstances” include:

claims that require consideration of complex medical questions or 

issues regarding the credibility of medical experts; the availability of 

very limited administrative review procedures with little or no 

evidentiary record; the necessity of evidence regarding interpretation 

of the terms of the plan rather than specific historical facts; instances 

where the payor and the administrator are the same entity and the 

court is concerned about impartiality; claims which would have been 

insurance contract claims prior to ERISA; and circumstances in which 

there is additional evidence that the claimant could not have presented 

in the administrative process.

Opeta, 484 F.3d at 1217 (quoting Quesinberry v. Life Ins. Co. of N. Am., 987 F.2d 1017, 1027 (4th 

Cir. 1993).

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III. DISCUSSION

Here, Plaintiff requests to compel responses1to Interrogatory Nos. 1-4, which seek 

information pertaining to Dr. Villanueva’s review of other disability insurance claims, whether 

claims were rejected or denied after Dr. Villanueva’s review, and his compensation from 

reviewing those claims. (Joint Letter at 1, 5.)

As an initial matter, the parties do not dispute that the standard of review is de novo. (Joint 

Letter at 1.) Plaintiff, however, argues that additional information sought “is discoverable, as this 

information is relevant to the issue of [Dr. Villanueva’s] credibility as a medical expert.” (Joint 

Letter at 2.)

In opposition, Defendant contends that no additional discovery should be allowed absent 

Plaintiff making a showing that an exceptional circumstance exists. (Joint Letter at 3.) The Court 

agrees.

Plaintiff has not met her burden of showing that Dr. Villanueva has a conflict of interest 

based on being compensated for reviewing medical records for the purposes of making benefits 

determinations. Plaintiff relies on Gonda, in which the district court permitted discovery 

pertaining to Dr. Villanueva’s services reviewing insurance claims, because “the information 

sought by Plaintiff may be helpful in comparing the reports of the two doctors.” 300 F.R.D. at 

615. Gonda, however, is neither controlling nor does it stand for the proposition that information 

pertaining to a medical expert’s potential conflict is always discoverable in an ERISA proceeding

where the standard of review is de novo. Indeed, the plaintiff in Gonda had filed a second appeal, 

which was supported by a report disputing Dr. Villanueva’s finding. Id. at 612. There, the plaintiff 

argued that the conflicting medical report “call[ed] into question the reliability of Dr. Villanueva's 

report, as well as Dr. Villanueva's qualifications and impartiality.” Id. Moreover, the Gonda 

plaintiff argued that the “purported deficiencies in Dr. Villanueva’s report also raise concerns that 

PsyBar has an institutional bias.” Id.

Here, however, Plaintiff does not make any such claims, let alone explain what exceptional 

 

1 Sun Life’s discovery responses consisted solely of objections. (Joint Letter, Ex. 1.)

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circumstance exists that would permit additional discovery. Instead, she cites to cases where 

limited discovery was permitted without explaining how they apply to the facts of her case. In fact,

the undersigned notes that, here, the parties have vastly different positions regarding the source of 

Plaintiff’s disability: brain tumor and traumatic brain injury versus depression and substance 

abuse. 

Thus, based on the information provided, the undersigned does not find that extrinsic 

evidence pertaining to Dr. Villanueva’s workload and compensation is necessary to conduct an 

adequate de novo review of Sun Life’s benefits determination. To find otherwise would be an 

abuse of discretion. See Opeta, 484 F.3d at 1218.

Accordingly, Plaintiff’s request to compel responses to Interrogatory Nos. 1-4 is denied.

IV. CONCLUSION

Since Plaintiff has failed to carry her burden of showing that an exceptional circumstance 

exists, Defendant need not respond to Interrogatory Nos. 1-4.

IT IS SO ORDERED.

Dated: February 28, 2019

__________________________________

KANDIS A. WESTMORE

United States Magistrate Judge

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