Document ID: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-cand-3_04-cv-00839/USCOURTS-cand-3_04-cv-00839-3/pdf.json

Parties Involved:
Epicentric, Inc. Health & Welfare Plan
Defendant
Illiena Volynskaya
Plaintiff

Document Text:

United States District Court

For the Northern District of California

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 The following is largely taken from Judge Conti’s December 2, 2004 order. Neither party

disputes the accuracy of the background section of that order.

United States District Court

For the Northern District of California

IN THE UNITED STATES DISTRICT COURT

FOR THE NORTHERN DISTRICT OF CALIFORNIA

ILLIENA VOLYNSKAYA,

Plaintiff,

 v.

EPICENTRIC, INC. HEALTH & WELFARE

PLAN, an ERISA plan,

Defendant. /

No. C 04-0839 SI

ORDER GRANTING SUMMARY

JUDGMENT IN FAVOR OF PLAINTIFF 

On October 12, 2007, the Court heard argument on the parties’ summary judgment submissions

after remand. After consideration of the parties’ arguments and the administrative record, and applying

the standard of review enunciated in Abatie v. Alta Health & Life Insurance Company, 458 F.3d 955

(9th Cir. 2006) (en banc), the Court hereby GRANTS summary judgment in favor of plaintiff, and

REMANDS to the plan administrator for further proceedings consistent with this order.

BACKGROUND

I. Factual background1

Plaintiff Illiena Volynskaya was employed as a customer support engineer for Epicentric, Inc.,

and was covered under Epicentric’s employee welfare benefit plan, insured by Metropolitan Life

Insurance (“MetLife”). The Plan provides long-term disability benefits in the event of a “disability.”

The Plan defines “disability” as a condition requiring a physician’s care which prevents a claimant from

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 Dr. Lieberman’s letter referred to “compelling objective evidence.” MetLife’s quotation from

Dr. Lieberman’s letter omitted “objective.”

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working “at your Own Occupation” during the first 24 months of the condition. EPI00030. Plaintiff’s

job responsibilities required that she “[i]nterface with customers and prospective customers for

troubleshooting and other technical assistance. Replicate and report problems and bugs. Generate

technical notes and similar documentation.” Id. at EPI00149. According to information provided by

Epicentric, plaintiff’s job “requires 100% typing while talking on the phone with customers.” Id. 

Plaintiff stopped working and was placed on short-term disability in April 2002. EPI00310-313.

She filed a claim for long-term disability (“LTD”) benefits in November 2002, claiming disability due

to “overuse syndrome,” fibromyalgia, and chronic fatigue syndrome. EPI00302-304. MetLife, serving

as claims administrator, reviewed plaintiff’s medical records and conducted telephone interviews with

plaintiff’s treating physicians. By letter dated January 9, 2003, MetLife informed plaintiff that her

application for LTD benefits was approved based solely on the diagnosis of depression. EPI00088-89.

The letter stated “[y]our medical records provided no objective evidence that either fibromyalgia or

chronic fatigue syndrome causes a functional impairment severe enough to prevent the performance of

your job duties.” EPI00088. 

Several months later while plaintiff continued to receive disability benefits, MetLife sought

review of plaintiff’s medical records by two Independent Physician Consultants (“IPCs”). The first, a

board-certified psychiatrist, concluded in June 2003 that plaintiff was not disabled from a psychiatric

condition. EPI00102-105. The second IPC, a board-certified rheumatologist, concluded in August 2003

that plaintiff’s medical records did not provide “compelling objective evidence . . . to indicate that the

[plaintiff] would not be able to perform the duties of a light or sedentary occupation.” EPI00094. 

On August 29, 2003, MetLife informed plaintiff by letter that it was terminating her LTD

benefits based on its determination that plaintiff did not suffer from a “physical or mental functional

impairment severe enough to prevent” plaintiff from performing her own job. EPI00195-196. With

regard to plaintiff’s claim of disability due to fibromyalgia, the letter stated,

On 8-28-03, an IPC review was completed by a Board certified rheumatologist. His

findings were as follows: “There is no compelling evidence2

 in the records reviewed to

indicate that the claimant would not be able to perform sedentary to light duties.

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 As discussed infra, the parties dispute whether MetLife in fact provided the file to plaintiff.

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 The date on the nurse consultant’s report is October 20, 2003. EPI00085.

3

According to the NIH Consensus Report on fibromyalgia (Dr. Frederick Wolfe, 1997),

most patients with fibromyalgia should be able to perform the duties of a sedentary or

light occupation. Wrist actigraphy analysis has shown fibromyalgia patients to be

functional similar to control groups despite subjective complaints of pain. There is

nothing specific in the records which would indicate that this claimant was different

from typical patients with fibromyalgia.”

EPI00196. The letter advised plaintiff of her right to an appeal, and instructed her to include with the

appeal letter her reasons for protesting the decision and any additional information in support of the

appeal. Id.

By an undated letter, plaintiff appealed the termination of her LTD benefits. EPI00087.

Plaintiff’s letter stated,

As of today, I am unable to dress myself, cook, clean, drive and shop. I had someone

type this for me. I can not sit for more than 5 minutes without being in pain and having

to lie down. Because of pain, I am unable to focus and have to take naps every 2 hours.

I also do not understand what wrist actigraphy has to do with pain which I have in my

entire body. I believe that the standards on which you base your medical evaluations are

unfair, outdated and biased in favor of your company. I am currently communicating

with my doctor about additional medical evaluation.

Id. Plaintiff requested that MetLife send her the complete medical file MetLife reviewed in denying her

claim, including a copy of the insurance policy and the report of the IPC rheumatologist. Id.

3

After receiving plaintiff’s appeal letter on September 30, 2003, MetLife had a “nurse consultant”

review plaintiff’s medical file, including the IPC reports. The nurse consultant concurred with the

conclusion of the IPC reports that the file contained no objective medical findings indicating that

plaintiff would be unable to perform a light or sedentary occupation. EPI00085-86. Although the nurse

consultant opined that further medical documentation would have required additional medical review,

no such additional material had been received at the time of the nurse consultant’s review.4

 

Based on the nurse consultant’s report, MetLife affirmed its decision terminating plaintiff’s LTD

benefits in a letter dated October 27, 2003. EPI00186-87. The letter stated,

We had our nurse consultant review all the medical documentation previously provided

by you as well as the 2 Independent Physician Consultant (IPC) reviews. As you did not

provide any additional medical documentation regarding your diagnoses of Chronic

Fatigue Syndrome and Chronic pain, there was nothing new to review. The nurse

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consultant did indicate that the medical documentation did not provide objective findings

that would prevent you from performing a sedentary to light occupation. This was also

the findings of the 2 IPC reviews.

Even though you have the diagnoses of Chronic Fatigue Syndrome and Chronic Pain

the medical documentation supplied by your physicians does not provide objective

medical findings that would support your inability to perform your sedentary occupation

as a Support Engineer. Therefore, the original claim determination was appropriate.

EPI00186-87. The letter informed plaintiff that she had exhausted her administrative remedies under

the Plan, that no further appeals would be considered, and that she had the right to file a civil action.

EPI00187.

By letter dated February 19, 2004, plaintiff’s counsel advised MetLife that plaintiff was now

represented by counsel, and requested that MetLife re-review plaintiff’s claim. EPI00181. Mr.

Fleishman’s letter stated that MetLife’s denial of plaintiff’s claim was “precipitous” because plaintiff’s

appeal letter stated that she was currently communicating with her doctor about additional medical

evaluation, and “[y]et, before she could send any additional medical information to you, you denied the

appeal on October 27, 2003.” Id. Mr. Fleishman enclosed a report written by Dr. Claire Targoff dated

February 6, 2004. Dr. Targoff’s report, addressed to plaintiff, states,

You have been my patient since May 9, 2003. As you are well aware, you have had

problems with chronic fatigue syndrome for approximately 10 years. . . . 

On physical examination you were noted to have the diffuse trigger points that are

consistent with a diagnosis of fibromyalgia.

Currently you continue to be unable to work. This is very common in patients with

fibromyalgia and chronic fatigue. The pain becomes very intense and often the

medications required to help control pain can also cause cognitive problems. One of the

major problems I see so often in patients with fibromyalgia and chronic fatigue is that

their symptoms are so variable, and they may have a good day in which they will be

quite functional follows by days of severe pain and diminished level of function.

Unfortunately it makes for a totally unreliable employee as you can never ben counted

on to show up and work on any kind of a consistent basis. Additionally, the medications

used for pain control can also cause problems with your cognitive function as well. 

EPI00183. MetLife did not re-review plaintiff’s claim or consider the February 6, 2004 report from Dr.

Targoff.

II. Procedural background

On March 1, 2004, plaintiff filed this action challenging MetLife’s termination. The parties filed

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cross-motions for summary judgment, and Judge Conti granted summary judgment in favor of

defendants. Judge Conti held that the Plan vested MetLife with discretion to interpret the terms of the

Plan and determine eligibility for benefits, and thus that MetLife’s termination of plaintiff’s benefits for

should be reviewed for an abuse of discretion. Judge Conti also held that MetLife acted reasonably

when it determined that the medical evidence did not sufficiently establish the level of plaintiff’s

disability. Judge Conti noted that “MetLife relied on . . . the two ICP reports concluding that no

objective medical evidence supported a functional impairment based on depression or fibromyalgia, the

nurse consultant’s review concluding the same, the lack of any statement by Plaintiff’s treating

physician that plaintiff’s condition was totally disabling, and the absence of any objective testing to

determine the severity of plaintiff’s condition.” Judge Conti also found that MetLife put plaintiff on

notice as early as January 2003 that a diagnosis of fibromyalgia and self-reported symptoms were

insufficient to support a claim under the Plan.

Plaintiff appealed, and by memorandum decision filed April 10, 2007, the Ninth Circuit affirmed

in part and vacated and remanded in part. The Ninth Circuit affirmed Judge Conti’s holding that the

Plan unambiguously conveys discretion on MetLife. The court vacated and remanded the remainder

of Judge Conti’s decision in light of Abatie v. Alta Health & Life Insurance Company, 458 F.3d 955 (9th

Cir. 2006) (en banc). The Ninth Circuit instructed:

After the district court issued its decision, this Circuit fundamentally changed the manner

in which courts review a decision by a fiduciary with a conflict of interest. Abatie held

that a district court, even when reviewing for an abuse of discretion, must nonetheless

consider a defendant’s conflict of interest. The greater the conflict, the greater the “level

of skepticism” a court must apply. Relevant to this inquiry are, among other things, the

degree of an insurer’s conflict and any failure to comply with procedural requirements.

Both factors appear to be relevant here.

From the existing record, it appears that MetLife has a structural conflict of interest; that

is, it both funds the plan and determines whether to pay benefits. In addition,

Volynskaya argues that MetLife violated several procedural requirements. For example,

MetLife was required to inform Volynskaya “of any additional material or information

necessary . . . to perfect [her] claim and an explanation of why such material or

information [wa]s necessary.” MetLife may not have done so. MetLife now complains

that Volynskaya never submitted to objective diagnostic testing for fibromyalgia.

However, Volynskaya argues that MetLife never informed her of the need for such

testing. Similarly, MetLife was required to provide “upon request and free of charge,

reasonable access to, and copies of, all documents, records, and other information

relevant to the claimant’s claim for benefits.” It is unclear from the current record

whether MetLife satisfied this obligation after Volynskaya requested her records.

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Memorandum Decision at 3-4 (internal citations omitted). The Ninth Circuit instructed the district court

on remand to “consider the degree of any conflict, to make factual findings regarding the alleged

procedural violations, and to consider, in the first instance, the effect of Abatie.” Id. at 4.

DISCUSSION

I. Standard of review as clarified in Abatie

In Abatie, the Ninth Circuit explained that where an ERISA plan grants discretion to a plan

administrator, courts review the plan’s decisions for abuse of discretion, but that such review is

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

that may appear in the record.” Abatie, 458 F.3d at 967.

The level of skepticism with which a court reviews a conflicted administrator’s decision

may be low if a structural conflict of interest is unaccompanied, for example, by any

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

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

inconsistent reasons for denial, fails adequately to investigate a claim or ask the plaintiff

for necessary evidence, fails to credit a claimant’s reliable evidence, or has repeatedly

denied benefits to deserving participants by interpreting plan terms incorrectly or by

making decisions against the weight of the evidence in the record.

Id. at 968-69 (internal citations and quotations omitted). The court recognized that abuse of discretion

review with any conflict weighed as a factor is “indefinite,” but stated that trial courts “are familiar with

the process of weighing a conflict of interest.” Id. at 969. “What the district court is doing in an ERISA

benefits denial case is making something akin to a credibility determination about the insurance

company’s or plan administrator’s reason for denying coverage under a particular plan and a particular

set of medical and other records.” Id. 

In adopting a “careful, case-by-case approach,” the Ninth Circuit overruled its decision in

Atwood v. Newmont Gold Company, 45 F.3d 1317 (9th Cir. 1995). Atwood required a plan participant

to present “material, probative evidence, beyond the mere fact of the apparent conflict, tending to show

that the fiduciary’s self-interest caused a breach of the administrator’s fiduciary obligations to the

beneficiary.” Id. at 1323. The Abatie court held that Atwood was inconsistent with Supreme Court

precedent, and that Atwood placed an unreasonable burden on ERISA plaintiffs. “If the plaintiff could

not make that threshold showing [as required in Atwood], we would uphold an administrator’s decision

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so long as it was ‘grounded on any reasonable basis.’” Abatie, 458 F.3d at 969 (quoting Jordan v.

Northrop Grumman Corp. Welfare Benefit Plan, 370 F.3d 869, 875 (9th Cir. 2004)). “Going forward,

plaintiffs will have the benefit of an abuse of discretion review that always considers the inherent

conflict when a plan administrator is also the fiduciary.” Id. 

The Abatie court also clarified the standard of review when a plan administrator has exercised

discretion but, in doing so, has made procedural errors such as failing to adhere to various procedures

for giving notice, reporting, and claims processing. The court instructed, 

A procedural irregularity, like a conflict of interest, is a matter to be weighed in deciding

whether an administrator’s decision was an abuse of discretion. When an administrator

can show that it has engaged in an ongoing, good faith exchange of information between

the administrator and the claimant, the court should give the administrator’s decision

broad deference notwithstanding a minor irregularity. A more serious procedural

irregularity may weigh more heavily.

Id. at 972 (internal citations and quotations omitted).

II. Standard of review in this case

The parties agree that an abuse of discretion standard applies, and that there is a structural

conflict of interest. The parties dispute whether MetLife committed any procedural violations. The

Ninth Circuit instructed this Court to make factual findings regarding any procedural violations because

whether such violations occurred affects this Court’s review of the denial of benefits.

Plaintiff asserts that MetLife committed three procedural violations: (1) failing to specify what

additional material or information MetLife required in order for plaintiff to perfect her claim; (2) failing

to provide plaintiff with a copy of her file; and (3) making a final decision on plaintiff’s administrative

appeal without waiting to see if plaintiff was going to submit additional evidence.

A. Not telling what “objective evidence” required

ERISA regulations require that when a plan administrator denies a claim, the notification must

provide “a description of any additional material or information necessary for the claimant to perfect

the claim and an explanation of why such material or information is necessary.” 29 C.F.R.

§ 2560.503(g)(iii). Here, MetLife informed plaintiff that her medical records did not contain “objective”

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or “compelling” evidence to support a disability finding based on fibromyalgia or chronic fatigue

syndrome. In its January 9, 2003 letter approving long term disability benefits based on depression, but

denying based on fibromyalgia and chronic fatigue syndrome, MetLife informed plaintiff that “[y]our

medical records provided no objective evidence that either fibromyalgia or chronic fatigue syndrome

causes a functional impairment severe enough to prevent the performance of your job duties.”

EPI00088. When MetLife terminated plaintiff’s disability benefits, it informed plaintiff that a Board

certified rheumatologist found that “[t]here is no compelling evidence in the records reviewed to

indicate that the claimant would not be able to perform sedentary to light duties.” EPI00196.

Defendant contends that it complied with the ERISA regulations by informing plaintiff that there

was no “objective evidence” to support her claim of disability due to fibromyalgia or chronic fatigue

syndrome. Plaintiff contends that if there were in fact tests that MetLife thought plaintiff should have

undergone, MetLife was required to so inform plaintiff. Plaintiff notes that both in connection with the

original summary judgment briefing before Judge Conti, and in the briefing on remand, MetLife has

asserted that plaintiff could have submitted results of a Mental Status Exam or a Mini-Mental Status

Exam or of neuropsychological testing. See, e.g., Defendant’s Opening Brief at 9:6-7. 

The Court finds that MetLife violated 29 C.F.R. § 2560.503(g)(iii) by failing to provide “a

description of any additional material or information necessary for the claimant to perfect the claim and

an explanation of why such material or information is necessary.” The plain language of that regulation

requires a plan to provide a “description” of additional material or information necessary to perfect a

claim, and an “explanation” of why such information is necessary. As the Ninth Circuit has stated

regarding this regulation, 

In simple English, what [29 C.F.R. § 2560.503] calls for is a meaningful dialogue

between ERISA plan administrators and their beneficiaries. If benefits are denied in

whole or in part, the reason for the denial must be stated in reasonably clear language,

with specific reference to the plan provisions that form the basis for the denial; if the

plan administrators believe that more information is needed to make a reasoned

decision, they must ask for it. There is nothing extraordinary about this; it’s how

civilized people communicate with each other regarding important matters.

Booton v. Lockheed, 110 F.3d 1461, 1463 (9th Cir. 1997). It is insufficient to simply inform a claimant

that there is no “objective” evidence to support a disability claim without specifying what type of

“objective” evidence would substantiate a claim. MetLife’s statement in its August 29, 2003

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 These notes are a computer generated, chronological diary report that documents the activities

and events related to MetLife’s review of and determinations on plaintiff’s claim. The notes contained

in the administrative record are found at EPI00066-88. The upper right hand corner of these documents

states the date the page was printed “Jun 15, 2004” and the page number of the document, e.g. “Page

1 of 23.” The administrative record is missing pages “20 of 23” and “22 of 23”; these are the two pages

attached to the Broadwater Declaration. 

9

termination letter that there was no “compelling” evidence to support plaintiff’s claim is even more

vague and problematic. See Cheng v. UNUM, 291 F. Supp. 2d 717, 721 (N.D. Ill. 2003) (finding

violation of 29 C.F.R. § 2650.503 when plan informed claimant that if he had any “new, additional

information to support [his] request for disability benefits,” he should send it to plan); Cf. Boyd v. Aetna,

438 F. Supp. 2d 1134, 1154 (C.D. Cal. 2006) (holding, pre-Abatie, that plan engaged in significant

procedural irregularity warranting de novo review when plan repeatedly informed claimant that there

was “no objective evidence” to support claim but failed to specify what evidence was necessary or

provide forms that would have elicited necessary information). 

B. Providing file

ERISA regulations required MetLife to provide “upon request and free of charge, reasonable

access to, and copies of, all documents, records, and other information relevant to the claimant’s claim

for benefits.” 29 C.F.R. § 2560.503-1(h)(2)(iii). When plaintiff appealed the termination of her

benefits, she requested a copy of her claim file. EPI00087. The parties dispute whether MetLife

provided the file.

MetLife states, on remand, that in investigating plaintiff’s allegation that MetLife failed to

provide her with a copy of her claim file, “MetLife discovered an inadvertent error that occurred in the

production of the Administrative Record that unfortunately has escaped both parties up until now.”

Defendant’s Reply at 4-5. Defendant states that two pages from the “Real Time diary notes”5

 were

inadvertently omitted during the preparation of the Administrative Record; those pages contain a

notation that a copy of the claim file was sent to the “EE” (employee) on September 30, 2003. See

Broadwater Decl. Ex. A. 

Plaintiff has filed a supplemental reply brief addressing the production of these two pages.

Plaintiff accuses MetLife of lying and fabricating the two missing pages, and plaintiff’s counsel cites

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 Plaintiff argues that because she had 180 days from the date of the adverse determination to

file an appeal, see 29 C.F.R. § 2560.503-1(h)(4), MetLife should have accepted and reviewed the

medical information that plaintiff submitted in February 2004, after the appeal was denied but within

180 days of the adverse determination. This argument lacks merit, however, because it ignores the

applicable regulations which provide that plan administrators must act on an appeal no later than 45

days after receipt of the claimant’s request. Plaintiff’s February 2004 submission fell outside of the 45

day period.

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other cases in which MetLife has “played with the facts.” See Jagielski v. MetLife, 2007 WL 2458139

(W.D. Pa. Aug. 24, 2007) (repeatedly noting that MetLife’s counsel – different from counsel here – was

“cagey” and engaged in “repeated and flagrant obfuscation, smoke screens and ‘clever’ couching of its

statements of fact”); see also Fleishman Ex. A (declarations in Hawkins-Dean v. MetLife, (C.D. Cal.)

in which MetLife employee retracts former sworn statement regarding late-produced document not in

administrative record). Plaintiff has also submitted a declaration stating that she never received a copy

of her claim file. See Volynskaya Decl. In any event, plaintiff also argues that, if nothing else, the fact

that MetLife “lost” documents for over three years that should have been part of the administrative

record is evidence that should heighten the standard of review under Abatie.

Based on the record, the Court is unable to determine why MetLife did not originally provide

the two missing pages from the Administrative Record. While the Court cannot conclude that MetLife

engaged in any misconduct as plaintiff alleges, the Court does find that at the very least, the peculiar

circumstances under which MetLife has produced the two documents is another factor that heightens

the Court’s skepticism under Abatie.

C. Making final decision before waiting to see if plaintiff was going to submit

additional records

ERISA regulations require that when claimants appeal an adverse determination, benefit plans

must “[p]rovide claimants the opportunity to submit written comments, documents, records, and other

information relating to the claim.” 29 C.F.R. § 2560.503-1(h)(2)(ii). ERISA regulations also provide

that plan administrators “shall notify a claimant . . . of the plan’s benefit determination on review within

a reasonable period of time,” but not later than 45 days after receipt of the claimant’s request for review

by the plan. 29 C.F.R. § 2650.503-1(i)(3)(i); 29 C.F.R. § 2650.503-1(i)(1)(i).6

Plaintiff contends that MetLife precipitously denied her appeal without allowing her the

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opportunity to submit additional medical documentation, despite the fact that she informed MetLife that

she was “communicating with my doctor about additional medical evaluation.” EPI00087. Plaintiff

notes that MetLife received her appeal letter on September 30, 2003, and denied her appeal 27 days later

by letter dated October 27, 2003. 

The Court cannot conclude that MetLife clearly violated the ERISA regulations concerning

plaintiff’s opportunity to submit additional materials, since MetLife was required to act on plaintiff’s

appeal within 45 days of receipt of the appeal. However, it would have been “reasonable” for MetLife

to inquire of plaintiff whether she was, in fact, going to provide additional medical documentation prior

to denying her claim. This is particularly so since MetLife had not, as discussed supra, told plaintiff

what additional medical documentation would be necessary to perfect her claim. 

III. MetLife abused its discretion

Accordingly, in light of the above discussion and as informed by Abatie, the Court reviews

MetLife’s benefits denial for abuse of discretion, while taking into account MetLife’s structural conflict

of interest and procedural violations. Plaintiff contends that MetLife abused its discretion because (1)

she met her initial burden of showing she was disabled under the plan, (2) MetLife’s doctor provided

an equivocal opinion at best because he opined only that most people with fibromyalgia can perform

sedentary work, and he did not opine that plaintiff can perform her own occupation, and (3) in reaching

his opinion, MetLife’s doctor looked for “compelling objective evidence,” despite the fact that the

policy does not require that disability be proven by “compelling objective evidence.” 

In connection with her claim for disability benefits, plaintiff submitted a May 9, 2003 report

from her treating physician. Under “Assessment,” Dr. Targoff wrote,

 Chronic fatigue/fibromyalgia with resolving repetitive stress syndrome. Ms. Volynskaya

does give a history that certainly suggests a diagnosis of chronic fatigue syndrome.

Currently, however, her findings are most consistent with fibromyalgia with diffuse

trigger points. She unquestionably has a sleep disorder and I am concerned that she

probably does have sleep apnea, which is potentially seriously aggravating her

underlying pain syndrome. . . . 

EPI00099. Plaintiff also submitted a “Long Term Disability Claim Form Attending Physician

Statement,” which was completed by Dr. Arkady Goldstein. Dr. Goldstein diagnosed plaintiff with a

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primary diagnosis of “overuse syndrome,” and a secondary diagnosis of fibromyalgia and chronic

fatigue syndrome. EPI00109. Dr. Goldstein found that plaintiff was able to work “0” hours per day,

that she could not sit, stand or walk for any hours per day, that plaintiff was not able to climb,

twist/bend/stoop, or reach above shoulder level, but that plaintiff could operate a motor vehicle. Id. Dr.

Goldstein also noted on the form that he advised plaintiff not to return to work. Id. Finally, plaintiff

submitted her own statement regarding her level of functioning, stating that she was unable to dress

herself, cook, clean, drive and shop. EPI00087. Plaintiff stated that she had someone else type her

appeal letter for her, that she could not sit for more than 5 minutes without being in pain and needing

to lie down, and that she was unable to focus and required frequent naps. Id.

The Court finds that the information provided by plaintiff, especially the material submitted by

Dr. Goldstein, shows that plaintiff met the plan’s definition of disability, namely that plaintiff was

receiving treatment from a physician on a continuing basis and that she was unable to earn more than

80% of her predisability earnings at her own occupation. EPI00030. In particular, Dr. Goldstein’s

opinion that plaintiff could not work any hours per day, and that she could not sit for any amount of

time, shows that she was disabled from performing her occupation. See also EPI00112-148 (medical

records submitted by Dr. Goldstein).

In processing plaintiff’s claim, MetLife did not dispute that plaintiff suffered from fibromyalgia

or chronic fatigue syndrome. Instead, MetLife concluded that plaintiff was not disabled from those

conditions. MetLife’s letter terminating benefits stated,

On 8-28-03, an IPC review was completed by a Board certified rheumatologist. His

findings were as follows: “There is no compelling evidence in the records reviewed to

indicate that the claimant would not be able to perform sedentary to light duties.

According to the NIH Consensus Report on fibromyalgia (Dr. Frederick Wolfe, 1997),

most patients with fibromyalgia should be able to perform the duties of a sedentary or

light occupation. Wrist actigraphy analysis has shown fibromyalgia patients to be

functional similar to control groups despite subjective complaints of pain. There is

nothing specific in the records which would indicate that this claimant was different

from typical patients with fibromyalgia.”

EPI00196. 

Plaintiff contends that MetLife abused its discretion because MetLife’s doctor did not analyze

whether plaintiff was disabled from performing her own occupation, as required by the plan, and instead

only opined generally that plaintiff could perform light or sedentary work. Plaintiff notes that in

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addition to being sedentary, her job required that be able to “interface with customers and prospective

customers for troubleshooting and other technical assistance,” “100% typing while talking on the phone

with customers,” and that she do so for 8 hours a day, 5 days a week. EPI00149.

The Court agrees. As an initial matter, the Court notes that plaintiff submitted evidence in the

form of medical documentation and her own statements showing that, in fact, she could not perform

sedentary work. However, even assuming that plaintiff could perform “sedentary work,” such a finding

is not equivalent to a finding that plaintiff could perform her own occupation and earn more than 80%

of her predisability earnings. See Sabatino v. Liberty Life Assurance Co. of Boston, 286 F. Supp. 2d

1221, 1231 (N.D. Cal. 2003) (“Plaintiff was employed as an engineer, which may be a sedentary

occupation, but one that requires careful thought and concentration. Simply being able to perform

sedentary work does not necessarily enable one to work as an engineer.”); see also Hawkins v. First

Union Corp. Long-Term Disability Plan, 326 F.3d 914, 919 (7th Cir. 2003) (holding denial of benefits

unreasonable and noting “[t]he fact that a majority of individuals suffering from fibromyalgia can work

is the weakest possible evidence that [a claimant] can.”). 

MetLife contends that its doctor was not required to determine whether plaintiff met the Plan’s

definition of disability, and that his role was only to assess plaintiff’s level of functioning. Instead,

MetLife argues that MetLife “decision makers” reviewed all of the evidence in the file and made the

ultimate decision that plaintiff was not disabled under the Plan. This is a distinction without a

difference. Here, the denial letter stated that the reason MetLife was denying plaintiff’s disability claim

was based on the IPC review; there is nothing in the record to show that any decision maker specifically

concluded that plaintiff was not disabled from performing her own occupation.

The Court also finds that MetLife abused its discretion by requiring “compelling objective”

evidence of disability. As plaintiff correctly notes, the Plan does not require that disability be proved

by “compelling objective” evidence. It is arbitrary to add new terms to the Plan, particularly when those

terms are both imprecise and impose a higher evidentiary burden on a claimant. See Saffle v. Sierra,

93 F.3d 600, 608 (9th Cir. 1996) (“Imposition of conditions outside the plan amounts to arbitrary and

capricious conduct.”) (quotation omitted); see also Saliamonas v. CNA, 127 F. Supp. 2d 997, 1000 (N.D.

Ill. 2001) (on de novo review, granting summary judgment in favor of the plaintiff because, inter alia,

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“CNA notified Mr. Saliamonas that it was denying his claim because of a lack of “objective medical

evidence” of disability. But nowhere in the Policy or the SPD does CNA indicate that its decisions will

be based only on “objective medical evidence” of disability. The Policy is a contract, and CNA cannot

simply add new terms.”). 

CONCLUSION

For the foregoing reasons and for good cause shown, the Court hereby enters summary judgment

in favor of plaintiff and against defendant. (Docket Nos. 45 and 46). The Court holds that MetLife

abused its discretion when it terminated plaintiff’s disability benefits on August 29, 2003, and that

plaintiff is entitled to disability benefits as a result of fibromyalgia and chronic fatigue syndrome

through that date. The Court REMANDS to the plan administrator to make determinations, consistent

with this order, regarding plaintiff’s eligibility for disability benefits after August 29, 2003. See Saffle

v. Sierra Pacific Power Co. Bargaining Unit Long Term Disability Income Plan, 85 F.3d 455, 460-61

(9th Cir. 1996). Plaintiff has requested that the Court award attorneys’ fees and costs. If plaintiff

wishes to recover fees and costs, plaintiff may file a motion. 

IT IS SO ORDERED.

Dated: October 16, 2007 

SUSAN ILLSTON

United States District Judge

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