Document ID: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-caed-2_06-cv-02245/USCOURTS-caed-2_06-cv-02245-1/pdf.json

Parties Involved:
Laura J. Chadwick
Plaintiff
Metlife
Defendant
Metropolitan Life Insurance Company
Defendant

Document Text:

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UNITED STATES DISTRICT COURT

EASTERN DISTRICT OF CALIFORNIA

----oo0oo----

LAURA J. CHADWICK,

NO. CIV. 06-2245 FCD EFB

Plaintiff,

v. MEMORANDUM AND ORDER

METROPOLITAN LIFE INSURANCE

COMPANY, aka MetLife, DOE

INSURANCE AGENT and DOES 2 to

100,

Defendants.

----oo0oo----

This matter is before the court on defendant Metropolitan

Life Insurance Company, aka MetLife’s (“defendant”) motion for

summary judgment as to plaintiff Laura J. Chadwick’s

(“plaintiff”) complaint raising claims under the Employee

Retirement Income Security Act (“ERISA”). (See Notice of

Removal, filed Oct. 12, 2006 [Docket #2].) Plaintiff seeks longterm disability (“LTD”) benefits under the EdFund Employee

///

///

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1 Because oral argument will not be of material

assistance, the court orders this matter submitted on the briefs. 

E.D. Cal. L.R. 78-230(h). 

2 The following statement of the facts is primarily drawn

from defendant’s motion for summary judgment (Docket #16), as the

facts stated therein derive from the underlying administrative

record and Plan documents. In her opposition, plaintiff attempts

to dispute certain facts as described in defendant’s motion. 

However, the court finds that there are no material facts in

dispute. (See Def.’s Reply to Pl.’s Statement of Disputed Facts,

filed June 22, 2007 [Docket #33].) Also, as the court discusses

below, it does not consider the Social Security Administration’s

(“SSA”) record filed by plaintiff in support of her opposition.

See infra Analysis, Part A. 

3 The Plan is attached as Exhibit 1 to Defendant’s Notice

of Filing of Administrative Record [Docket #17]. The Plan bears

the production number range of ADMIN 0001-0041. All further

references to the Plan will be to the applicable production

number. The remainder of the administrative record bears the

production number range of ADMIN 0042-0129. All further

references to the administrative record documents will be to the

applicable production number. 

2

Welfare Plan (“Plan”).1

For the reasons set forth below, the court finds that the

proper standard of review of this matter is abuse of discretion,

as opposed to de novo, and thereunder, the court cannot find that

defendant acted arbitrarily or capriciously in denying

plaintiff’s LTD benefits claim. As such, the court GRANTS

defendant’s motion for summary judgment. 

BACKGROUND2

A. Terms of the Plan

Edfund, plaintiff’s employer, adopted the Plan3 to provide

its employees with income in the event of certain disabilities. 

Plaintiff was a financial aid analyst at Edfund until April 2,

2004, when she alleged she was disabled from working due to

fibromyalgia--a syndrome consisting of aching pain and stiffness

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3

in one or numerous parts of the body. (ADMIN 0117.) Plaintiff

sought LTD benefits under the Plan. 

Defendant both funds and acts as the claims administrator

for the Plan. (Def. Mem. of P. & A., filed May 25, 2007

[“Mot’n”], at 1 [Docket #16].) For defendant to approve a claim

for LTD benefits, a plan participant must become and remain

disabled, as that term is defined in the Plan, while covered

under the Plan. (Mot’n at 2.) The Plan defines “disabled” in

pertinent part as follows:

“Disability” or “Disabled” means that, due

to an Injury or Sickness, you require the

regular care and attendance of a Doctor and: 

(1) you are unable to perform each of the

material duties of your regular job; and

(2) after the first 24 months of benefit

payments, you must also be unable to 

perform each of the material duties of any

gainful work or service for which you are

reasonably qualified taking into 

consideration your training, education, 

experience and past earnings; or

(3) you, while unable to perform all of the

material duties of your regular job on a 

full-time basis, are: (a) performing at 

least one of the material duties of your

regular job or of any other gainful work

or service on a part-time or full-time 

basis; and (b) earning currently at least 

20% less per month than your Indexed Basic 

Monthly Earnings due to that same Injury 

or Sickness 

(ADMIN 0029.) To be eligible for benefits under the Plan,

participants must first demonstrate 180 days of disability, known

as the “Elimination Period.” (Id. at 0005, 0029.) After

completing the Elimination Period, participants will receive

monthly LTD benefits if they remain disabled, as defined in the

Plan. (Id. at 0031.)

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4

B. Defendant’s Discretion Under the Terms of the Plan

Defendant has full discretion to interpret the terms of the

Plan and to determine the eligibility of plan participants. (Id.

at 0041.) Specifically, the Plan states:

In carrying out their respective 

responsibilities under the Plan, the Plan

administrators and other Plan fiduciaries 

shall have discretionary authority to 

interpret the terms of the Plan and to 

determine eligibility for and entitlement 

to Plan benefits in accordance with the 

terms of the Plan. Any interpretation 

or determination made pursuant to such 

discretionary authority shall be given 

full force and effect, unless it can be 

shown that the interpretation or 

determination was arbitrary and capricious. 

(Id.) When filing a claim, the claimant must provide

satisfactory proof to defendant describing the nature and extent

of the injury or sickness. (Id. at 0034.) 

C. Defendant’s Denial of Plaintiff’s Claim for LTD

Benefits 

Plaintiff began work with Edfund as a financial aid analyst

on October 27, 1997. (Pl.’s Opp’n, filed June 8, 2007 [“Opp’n”],

at 4 [Docket #19].) Plaintiff’s position was fully sedentary in

nature and required repetitive use of hands, fine finger

dexterity for three to four hours per day, and the ability to

occasionally lift or carry up to ten pounds. (ADMIN 0118.) 

Plaintiff ceased working for Edfund on April 2, 2004 and sought

disability benefits based primarily on a diagnosis of

fibromyalgia. (Id. at 0117.) 

Defendant received plaintiff’s initial claim for LTD

benefits on June 17, 2004. (Id. at 0042.) Plaintiff submitted

several documents, including two Attending Physician Statements

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(“APS”) from her treating physician, Dr. Robin L. Wong. (Id. at

126-29.) On the first APS, Dr. Wong diagnosed plaintiff with

fibromyalgia and stated that plaintiff could operate a motor

vehicle, perform fine finger movements with both hands, and

occasionally lift up to twenty pounds. (Id. at 126-27.) Dr.

Wong did not recommend plaintiff cease work; instead, she advised

plaintiff to continue her regular occupation part-time for

twenty-five hours per week. (Id.) However, on the second APS,

dated the same as the first, April 8, 2004, Dr. Wong changed her

ultimate opinion and recommended that plaintiff cease work due to

“too much discomfort.” (Id. at 0129.) While Dr. Wong changed

her conclusion, her assessment of plaintiff’s health remained

unchanged. (Id. at 0126-29.) 

On June 29, 2004, defendant sent a letter to plaintiff

requesting additional information. (Id. at 0115-16.) Defendant

requested plaintiff send, by July 29, 2004, among other

information, “all medical records from current treating

physicians” and “copies of your medical records from April 2004-

present.” (Id.) (emphasis in original). On July 27, 2004,

defendant sent another letter to plaintiff notifying her that it

had not received the requested information, and therefore, her

file would be closed. (Id. at 0103.) Two months later, on

September 22, 2004, plaintiff contacted defendant regarding her

claim. (Id. at 0044.) Defendant informed plaintiff that her

claim had been deemed abandoned because of her failure to supply

the required information. (Id.) Plaintiff later sent defendant

one page of medical notes regarding an August 13, 2004 visit with

Dr. Wong. (Id. at 0101-02.) On January 3, 2005, defendant

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called plaintiff and informed her that no medical information had

been received other than the medical notes of the one office

visit and the APS. (Id. at 0045.) Plaintiff responded that she

could not send any more records because she had not seen her

attending physician since August and had not followed up with

anyone regarding her diagnosis. (Id.) Defendant informed

plaintiff that her claim would be reviewed on the available

records. (Id.) 

On January 19, 2005, defendant called Dr. Wong to obtain

plaintiff’s medical records but was told that such requests must

be made in writing. (Id. at 0046.) The same day, defendant

mailed a letter to Dr. Wong restating its request. (Id. at

0099.) Specifically, defendant requested readable medical

documentation to support plaintiff’s inability to perform her

sedentary job from March 1, 2004 to the present. (Id.) On

February 1, 2005, in response to defendant’s request, Dr. Wong

sent four pages of handwritten office visit notes, which included

the one page of notes dated August 13, 2004, previously sent to

defendant. (Id. at 0095-98.) 

Matthew M. Dubai, a nurse consultant and clinical

specialist, reviewed plaintiff’s claim based on the documentation

defendant had received. (Id. at 0047.) In the written report,

Dubai remarked that most of Dr. Wong’s notes were unreadable, but

he could decipher that plaintiff had a fall, was diagnosed with

fibromyalgia, and had chronic lower back pain; however, he

concluded that the “extent this effect[ed] her functional ability

is not known.” (Id.) Dubai described that the medical records

did not demonstrate plaintiff’s conditions affected her

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functional ability as there were no physical exams indicating any

functional loss, no indication that tender points were tested for

a diagnosis of fibromyalgia, no tests to rule out other causes

for her pain, and no radiological studies indicating the

pathology of her lower back pain. (Id.) Dubai concluded that

the information provided did not demonstrate a functional

impairment that would preclude plaintiff from performing her

occupation full-time. (Id.) On February 7, 2005, defendant sent

plaintiff a letter denying her claim for LTD benefits. (Id. at

0091-92.) Therein, defendant advised plaintiff of her right to

appeal the determination and the procedures for submitting an

appeal. (Id.) 

On April 8, 2005, defendant received four additional pages

of medical records from Dr. Wong: a MRI report dated February 19,

2004, and three pages of lab results dated January 16, 2004. 

(Id. at 0086-90.) On April 18, 2005, defendant informed

plaintiff that it received additional information, and if she

wanted to appeal the denial of her claim she had to follow the

review procedures explained in the February 7, 2005 denial

letter. (Id. at 0085.) In response, on April 28, 2005,

plaintiff sent a letter stating she was appealing the denial of

her claim. (Id. at 0082.) 

Defendant then submitted plaintiff’s medical records for

review by Dr. Tanya C. Lumpkins. Dr. Lumpkins is a Boardcertified Rheumatologist, a medical doctor specialized in the

non-surgical treatment of rheumatic illness, who attested that

her review of plaintiff’s file did not constitute a conflict of

interest. (Id. at 0077.) Dr. Lumpkins’ report noted that

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plaintiff’s MRI test was negative and her lab tests were

unremarkable. (Id. at 0076.) In her conclusion, Dr. Lumpkins

stated that “there is insufficient data to support an impairment

of sufficient severity to prevent the claimant from performing

the duties of [her] sedentary job full time.” (Id. at 0077.) On

May 16, 2005, defendant denied plaintiff’s appeal. (Id. at 0062-

64.) Defendant explained that it had determined that the medical

records submitted by plaintiff did not substantiate a severity of

symptoms that would prevent plaintiff from performing the

material duties of a financial aid analyst. (Id.) 

On August 8, 2006, plaintiff filed the instant suit against

defendant in state court seeking damages for the denial of LTD

benefits under the Plan. (Compl., filed Aug. 8, 2006, [Docket

#2].) Defendant removed the action to this court on grounds of

ERISA-preemption on October 12, 2006. (Notice of Removal, filed

Oct. 12, 2006.) Defendant now moves for summary judgment as to

plaintiff’s claims. In response to defendant’s motion, plaintiff

preliminarily moved to continue the motion for summary judgment

to allow further discovery; alternatively, plaintiff responded to

the merits of defendant’s motion. 

ANALYSIS

A. Plaintiff’s Request for Further Discovery

Plaintiff seeks a continuance of defendant’s motion for

summary judgment to allow further discovery regarding defendant’s

inherent structural conflict of interest in both administrating

and funding the Plan. (Opp’n at 13.) For several reasons,

plaintiff’s request for further discovery is DENIED: 

///

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4 In moving for a continuance of the motion, plaintiff

did not comply with the requirements of Federal Rule of Civil

Procedure 56(f). For this alternative reason, plaintiff’s

request for discovery is properly denied. 

9

First, plaintiff’s request is untimely. Pursuant to the

court’s Status (Pre-Trial Scheduling) Order, issued December 14,

2006, discovery closed March 2, 2007. Importantly, during the

discovery period, plaintiff knew of the issues she now raises in

her opposition; her contention that defendant “for the first time

in its motion, stated unequivocally the Plan is discretionary” is

false. (Opp’n at 4.) As stated above, the Plan expressly states

that the administrator has full discretion when reviewing a

claim. Defendant produced the Plan as part of its initial

disclosures pursuant to Federal Rule of Civil Procedure 26. 

Also, in the parties’ Joint Status Report, filed December 11,

2006, defendant stated it “denies that plaintiff is entitled to

any relief in this action, and contends that its determination to

deny plaintiff’s claim was not an abuse of discretion.” (Docket

#10, 2:6-8.) Thus, plaintiff was well aware of defendant’s

position that it had full discretionary authority in reviewing

her claim from the outset of the action or, at a minimum, since

December 2006. Yet, plaintiff conducted no discovery regarding

defendant’s alleged bias during the discovery period and did not

request an extension of the deadline. Indeed, even now she

presents no explanation for why she failed to seek the

information she claims is necessary to a fair adjudication of

this action.4

 

Second, plaintiff’s arguments in support of extending

discovery are not persuasive. Plaintiff baldly questions the

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background, training, experience, and financial relationship of

defendant’s independent physician, Dr. Lumpkins. (Opp’n at 7.) 

However, the record establishes that Dr. Lumpkins is a physician

specialized in rheumatology who reasonably concluded, based on

the information at her disposal, that plaintiff was not fully

prevented from working. Plaintiff presents no reasons or

evidence to find otherwise, and thus, the court cannot find that

the requested discovery would demonstrate the existence of a

conflict beyond the inherent conflict present because defendant

administrates and funds the Plan.

Plaintiff also asserts that since the SSA granted her claim

for benefits, defendant’s denial of her claim should be further

investigated. (Opp’n at 7, 10-11.) However, precedent and

practicability lend no credence to plaintiff’s assertion. Claims

for SSA benefits are bound by the “treating physician rule,”

where deference is paid to the treating physician’s analysis. 

Black & Decker v. Nord, 538 U.S. 822, 829 (2003). Thus, the SSA

had to afford deference to Dr. Wong’s conclusory statement that

plaintiff could not work. However, in ERISA cases, the treating

physician rule does not apply. Id. at 834 n.4. Therefore,

defendant was not required to accept Dr. Wong’s conclusory

assertion of plaintiff’s inability to work at face value and was

entitled to credit other reliable evidence establishing plaintiff

was not unable to work. 

Furthermore, a chronological impossibility hinders

plaintiff’s assertion that further discovery is needed because

SSA approved plaintiff’s claim while defendant did not: SSA

granted plaintiff’s claim in April 2006, almost a year after

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5 For this reason, the court sustains defendant’s

objection to the admission of the SSA record. (Def.’s Objs. to

Pl.’s Notice of Filing SSA Record, filed June 22, 2007 [Docket

#35].) Information not in the administrative record before the

claims administrator is generally not admissible in an ERISA

benefits case. Id. at 1472. 

11

defendant denied plaintiff’s appeal. Thus, defendant could not

have considered SSA’s ruling in their analysis. Taft v.

Equitable Life Ins. Co., 9 F.3d 1469 (9th Cir. 1994) (recognizing

that a claim administrator cannot be deemed to have abused its

discretion based on evidence not before it at the time the

decision was made).5

Finally, plaintiff’s reliance on Frost v. MetLife, 414 F.

Supp. 2d 961 (C.D. Cal. 2006), is unavailing as that case is

readily distinguishable. In Frost, defendant MetLife, shared the

same inherent conflict of interest found in this case of both

administrating and funding the disability plan. Id. at 963. 

Metlife objected to the subpoenas the plaintiff served on three

doctors who reviewed the medical records when the plaintiff first

sought discovery on MetLife’s conflict of interest. Id. MetLife

then filed a motion for protective order, “seeking to bar any

depositions, written interrogatories or document production by

the doctors.” Id. The court concluded that limited discovery

was permissible. Id. at 965. The circumstances are widely

different in this case: here, there was a nearly three month

discovery period when plaintiff could have sought the requested

information but did not do so even though defendant did not

demonstrate any reluctance to divulge or bar information

obtainable from the nurse consultant or Dr. Lumpkins. 

/// 

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6 In an ERISA benefits case, the “traditional” summary

judgment standards are not necessarily appropriate. Fed. R. Civ.

P. 56. Where, as here, the administrator’s decision is reviewed

for abuse of discretion, “a motion for summary judgment is merely

the conduit to bring the legal question before the district court

and the usual tests of summary judgement, such as whether a

genuine dispute of material fact exists, do not apply.” Bendixen

v. Standard Ins. Co., 185 F.3d 939, 942 (9th Cir. 1999) (finding

that “[a]lthough there may be contradictory evidence in the

record, we hold that, as a matter of law, the plan administrator

did not abuse its discretion”). 

12

In sum, in this case, the only purported “evidence” of a

conflict of interest is the fact of defendant’s role as

administrator and funder of the Plan. In such cases, courts have

not granted discovery. See e.g. Shemano-Krupp v. Mut. of Omaha

Ins. Co., 2006 U.S. Dist. LEXIS 84352, *29-31 (N.D. Cal. Nov. 20,

2006) (denying discovery where there was no evidence of a

conflict of interest beyond the “apparent conflict which exists

when the insurer both funds and administers the plan”); Baldoni

v. Unumprovident, Ill. Tool Works, Inc., 2007 U.S. Dist. LEXIS

14127, *15 (D. Or. Feb. 26, 2007) (denying discovery when an

insurer both administers and funds the plan unless the plaintiff

makes “a threshold showing”); Newman v. Standard Ins. Co., 997 F.

Supp. 1276, 1280-81 (C.D. Cal. 1998) (denying discovery when an

insurer both administers and funds the plan because of “immense

practical problems associated with this position,” including

expensive litigation which “flies in the face of the purpose of

ERISA”). 

B. Applicable Standard of Review –- Abuse of

Discretion6

Before reaching the merits of defendant’s motion, the court

must determine whether to apply de novo or abuse of discretion

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review to defendant’s denial of plaintiff’s LTD benefits. The

Plan at issue here is governed by ERISA. In Firestone Tire &

Rubber Co. v. Bruch, the United States Supreme Court held that a

challenge to the denial of benefits under an ERISA plan is

reviewed 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.” 489 U.S. 101,

115 (1989). When a plan document gives an administrator such

discretionary authority, a court must apply the “abuse of

discretion” or “arbitrary and capricious” standard of review to

its decision to deny benefits. Id. at 111; see also Abatie v.

Alta Health & Life Ins. Co., 458 F.3d 955, 963 (9th Cir. 2006). 

In this case, the Plan unambiguously grants defendant

discretion when reviewing claims. The Plan expressly states that

“the Plan administrator and other Plan fiduciaries shall have

discretionary authority to interpret the terms of the Plan and to

determine eligibility for and entitlement to Plan 

benefits . . . .” (ADMIN 0041.) Only where there are procedural

violations “so flagrant as to alter the substantive relationship

between the employer and employee, thereby causing the

beneficiary substantive harm,” does the court apply de novo

review despite the discretionary grant of authority. Gatti v.

Reliance Standard Life Ins. Co., 415 F.3d 978, 985 (9th Cir.

2005). As an example of what constitutes “wholesale and flagrant

violations of the procedural requirements of ERISA,” the Ninth

Circuit in Abatie cited the facts in Blau v. Del Monte Corp., 748

F.2d 1348 (9th Cir. 1984), noting that in Blau, “the

administrator had kept the policy details secret from the

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employees, offered them no claims procedure, and did not provide

them in writing the relevant plan information.” Abatie, 458 F.3d

at 971. 

No such failure “to comply with virtually every applicable

mandate of ERISA” is at issue here. Id. Defendant notified

plaintiff, shortly after she filed her claim, that she must

provide additional information, including “all medical records

from current treating physicians.” (ADMIN 0115-16.) A month

later, defendant notified plaintiff that the requested

information had not been received. (Id. at 0103.) Defendant

also attempted to obtain plaintiff’s records by initiating

contact with plaintiff’s physician, Dr. Wong. (Id. at 0046.) 

Furthermore, defendant informed plaintiff of her right to an

appeal and of the procedures for filing one. (Id. at 0091-92,

0064.) Under these facts, the court concludes that defendant

committed no “wholesale and flagrant violations” during the

claims process and thus finds that abuse of discretion review is

proper.

Nevertheless, plaintiff contends that further discovery

could demonstrate a significant bias by defendant. (Opp’n at 8.) 

Plaintiff cites Atwood v. Newmont Gold Co., 45 F.3d 1317 (9th

Cir. 1995) and its progeny, arguing that this bias would shift

the burden to defendant to prove that such a conflict did not

exist and if defendant failed to do so, the court would have to

review the decision de novo. Id. However, Abatie explicitly

overruled Atwood in its entirety; the Atwood burden-shifting

analysis is no longer valid. Abatie, 458 F.3d at 966-67. 

Firestone and Abatie make clear that if a benefit plan explicitly

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confers discretion on the administrator, then abuse of discretion

review applies, unless “wholesale and flagrant” violations exist.

In addition, abuse of discretion review applies even if the

administrator has a structural conflict of interest, so long as

the Plan unambiguously grants the administrator discretion. 

Abatie, 458 F.3d at 965. Thus, the fact that defendant both

administrates and funds the Plan is not sufficient, in itself, to

invoke de novo review. However, a conflict of interest should

not be ignored. Firestone requires that “if a benefit plan gives

discretion to an administrator or fiduciary who is operating

under a [structural] conflict of interest, that conflict must be

weighed as a ‘factor in determining whether there is an abuse of

discretion.’ RESTATEMENT (SECOND) OF TRUSTS § 187, cmt. d (1959).” 

Firestone, 489 U.S. at 115. Therefore, the court recognizes that

the inherent conflict of interest found in this case is a factor

to consider when analyzing defendant’s denial of Plan benefits;

however, the conflict of interest does not alter the standard of

review, which, in this case, the court concludes is abuse of

discretion.

C. Defendant’s Denial of Plaintiff’s LTD Benefits Claim

Applying the abuse of discretion standard of review, the

sole issue before the court is whether defendant abused its

discretion, or in other words, acted arbitrarily and

capriciously, in denying plaintiff’s LTD claims. An

administrator’s decision is an abuse of discretion only when it

is “without reason, unsupported by substantial evidence or

erroneous as a matter of law.” Abnathya v. Hoffman-LaRoche,

Inc., 2 F.3d 40, 45 (3rd Cir. 1993) (citations omitted); Taft v.

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Equitable Life Ins. Co., 9 F.3d 1469, 1472 (9th Cir. 1994). So

long as the administrator’s decision has a rational basis, the

court is not free to substitute its own judgment for that of the

administrator in determining the eligibility for plan benefits

even if the court disagrees with that decision. Id. Under the

abuse of discretion standard, the only issue is whether, on the

evidence considered, the administrator’s determination was

“reasonable.” Horan v. Kaiser Steel Retirement Plan, 947 F.2d

1412, 1417 (9th Cir. 1991); see also Clark v. Wash. Teamsters

Welfare Trust, 8 F.3d 1429, 1432 (9th Cir. 1993) (“Our inquiry is

not into whose interpretation of plan documents is most

persuasive, but whether the plan administrator’s interpretation

is unreasonable.”) 

Moreover, the scope of review under the arbitrary and

capricious standard is very limited. The focus of an abuse of

discretion inquiry is the administrator’s analysis of the

administrative record--it is not an inquiry into the underlying

facts. Alford v. DCH Found Group Long-Term Disability Plan, 311

F.3d 955, 957 (9th Cir. 2002). Thus, the court will not consider

information outside the administrative record, as it would be

improper to find a claims administrator abused its discretion

based on evidence not before it at the time the decision was

made. The Ninth Circuit explained the reasoning in Taft, 9 F.3d

at 1472:

Permitting a district court to examine 

evidence outside the administrative record 

would open the door to the anomalous 

conclusion that a plan administrator abused 

its discretion by failing to consider 

evidence not before it. Moreover, such 

expanded review would impede an important 

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purpose of the federal statute under which 

district courts have jurisdiction to review 

these administrative decisions:

A primary goal of ERISA was to provide a 

method for workers and beneficiaries to 

resolve disputes over benefits inexpensively 

and expeditiously. Permitting or requiring 

district courts to consider evidence from 

both partes that was not presented to the 

plan administrator would seriously impair 

the achievement of that goal. 

Here, a review of the administrative record reveals that

defendant did not abuse its discretion in denying plaintiff’s LTD

benefits claim. The evidence shows that defendant made a

reasonable conclusion based on the materials and records at its

disposal. The initial claim was denied by a nurse consultant who

determined, based on the information presented, that plaintiff

was not precluded from performing her occupation. Plaintiff was

employed as a financial aid analyst, which is a fully sedentary

position. The record that the nurse consultant reviewed

contained Dr. Wong’s notes stating that plaintiff suffered lower

back pain and had a diagnosis of fibromyalgia. The APS

statements remarked, contradictory, that plaintiff could work no

more than twenty-five hours per week and also that plaintiff

could not work at all. However, the second APS failed to address

the reason for plaintiff’s purported inability to work; instead,

it provided the same analysis of plaintiff’s health condition as

the first APS, which stated that plaintiff could work twenty-five

hours per week. The notes did not indicate the extent of

plaintiff’s disabilities and thus the consultant reasonably

concluded that there was insufficient evidence to support

plaintiff’s claim. Defendant is permitted to refuse the analysis

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of the claimant’s treating physician. “Plan administrators are

not obligated to accord special deference to the opinions of

treating physicians.” Black & Decker v. Nord, 538 U.S. 822, 825

(2003). 

Additionally, defendant did not abuse its discretion in

denying plaintiff’s appeal. After defendant denied plaintiff’s

initial claim, plaintiff submitted four additional pages of

medical records from Dr. Wong: a MRI report and three pages of

lab results. Defendant then submitted plaintiff’s medical

records for review by Dr. Lumpkins. Dr. Lumpkins, a Boardcertified Rheumatologist, reported that plaintiff’s MRI test was

negative and her lab tests were unremarkable. In her conclusion,

Dr. Lumpkins stated that “there is insufficient data to support

an impairment of sufficient severity to prevent the claimant from

performing the duties of [her] sedentary job full time.” (ADMIN

0077.) On the other hand, Dr. Wong’s conclusory opinion, which

was unsupported by her own findings, stated plaintiff should not

work. Defendant was warranted in crediting Dr. Lumpkins

conclusion over Dr. Wong’s. See Mitchell v. Aetna Life Ins. Co.,

359 F. Supp. 2d 880, 890 (C.D. Cal. 2005) (granting summary

judgment in favor of defendants on the grounds that the plan

administrator did not abuse its discretion in denying the

employee’s LTD benefits claim based on the employee’s “subjective

reports of pain and her doctors’ unexplained conclusory opinions

that she was disabled from performing any job”). 

In sum, in reviewing the administrative record, the court

cannot conclude that defendant abused its discretion in denying

plaintiff’s initial claim or appeal. Defendant’s conclusion,

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based on the review by a nurse consultant and Dr. Lumpkins, was

supported by the evidence and was both reasonable and rational. 

In a case involving similar facts, the District Court for

the Central District of California reached the same conclusion. 

In Jordan v. Northrop Grumman Corp., 63 F. Supp. 2d 1145, 1148-49

(C.D. Cal. 1999), aff’d, 370 F.3d 869 (9th Cir. 2004), the

plaintiff, which had a sedentary job as a secretary, filed suit

against MetLife under ERISA seeking benefits under Northrop’s

welfare benefits plan. As in this case, MetLife both

administrated and funded the plan. Id. at 1155. The plaintiff

submitted limited materials to MetLife, which, in turn, requested

from the plaintiff and her doctors the required materials to

support her claim. Id. at 1151. Despite two requests by

MetLife, the plaintiff failed to submit the requested records. 

Id. Similar to this case, MetLife concluded that the plaintiff

failed to sustain a claim for benefits because the evidence

submitted to MetLife did not demonstrate the plaintiff’s

inability to work. Id. On appeal, the plaintiff identified her

condition as fibromyalgia. Id. MetLife again requested medical

information which “supports a condition of total disability.” 

Id. at 1152. An independent doctor, specialized in rheumatology,

examined the additionally supplied information and concluded that

the plaintiff’s records did not support her inability to work. 

Id. MetLife, crediting its doctor’s analysis, denied the

plaintiff’s appeal. Id. at 1153. 

The district court, applying the abuse of discretion

standard of review, emphasized that the burden in substantiating

a claim for benefits rests on the plaintiff. Id. at 1155. Thus,

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as in this case, MetLife was not responsible for the fact that

there was insufficient evidence to establish the plaintiff’s

inability to work. MetLife made several attempts to acquire

medical records articulating the plaintiff’s inability to perform

her occupation and the court concluded these attempts were

sufficient to demonstrate MetLife’s effort in providing a fair

review of the plaintiff’s claim. Id. at 1152-53. 

This court finds similarly here. Defendant provided

plaintiff with ample opportunity to submit documents to prove she

was unable to work. The information plaintiff supplied did not

demonstrate this inability. Dr. Wong presented no reason for her

contrary opinion in the second APS, which stated plaintiff could

not work. The MRI report and three pages of lab results

submitted on plaintiff’s appeal did not support plaintiff’s claim

for benefits: the MRI report was negative and the lab results

were unremarkable. An independent medical doctor, specialized in

rheumatology, opined that the evidence failed to demonstrate

plaintiff’s inability to perform her occupation full-time. The

court finds defendant’s acceptance of this determination

reasonable.

Finally, the fact that MetLife both administrated and funded

the plan was not dispositive to the court’s ruling in Jordan. 

Although an apparent conflict of interest exists when an insurer

both funds and administers a plan, abuse of discretion review

still governs a court’s analysis if the ERISA plan grants

discretion to the plan administrator. Abatie v. Alta Health &

Life Ins. Co., 458 F.3d 955, 967 (9th Cir. 2006). “The level of

skepticism with which a court views a conflicted administrator’s

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decision may be low if a structural conflict of interest is

unaccompanied, for example, by any evidence of malice, of selfdealing, or of parsimonious claims-granting history.” Id. at

968. Because no such malice is evident in defendant’s denial of

plaintiff’s claim here, the court’s skepticism of defendant is de

minimus. Thus, while the court considers the inherent conflict

of interest found in defendant because it both administrates and

funds the Plan, that conflict, coupled with no other significant

factor, does not provide the court grounds to find an abuse of

discretion when considering defendant’s denial of plaintiff’s LTD

benefits claim. 

CONCLUSION

For the foregoing reasons, the court GRANTS defendant’s

motion for summary judgment. The Clerk of the Court is directed

to close this file.

IT IS SO ORDERED.

DATED: July 25, 2007.

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