Document ID: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-caed-2_03-cv-01672/USCOURTS-caed-2_03-cv-01672-1/pdf.json

Parties Involved:
Elvira Cervantes
Plaintiff
Metropolitan Life Insurance Company
Defendant
Wells Fargo Bank
Defendant

Document Text:

1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

Both parties agree, and the Court concurs, that the 1

employee benefit plan at issue in this case is governed by ERISA.

1

UNITED STATES DISTRICT COURT

EASTERN DISTRICT OF CALIFORNIA

----oo0oo----

ELVIRA CERVANTES,

NO. CIV. S 03-1672 MCE PAN

Plaintiff,

v. MEMORANDUM AND ORDER

METROPOLITAN LIFE INSURANCE

COMPANY,

Defendant.

----oo0oo----

Through the present action, Plaintiff Elvira Cervantes

(“Plaintiff”) alleges that Metropolitan Life Insurance Company

(“MetLife”) violated the Employee Retirement Income

Security Act, 29 U.S.C. §§ 1001 et. seq. (“ERISA”), when it

denied her application for disability insurance benefits under

her employer’s group short term disability policy. MetLife now 1

moves for summary judgement as to Plaintiff’s claim. 

///

Case 2:03-cv-01672-MCE -PAN Document 48 Filed 07/18/05 Page 1 of 10
1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

A true and correct copy of the Wells Fargo & Company’s 2

Benefit Book and Short-Term Disability Benefit Plan Summary Plan

Description is attached as Exhibit A to the Declaration of Laura

Sullivan. 

2

For the reasons set forth below, Defendant’s summary judgment

motion is granted. 

BACKGROUND

At all times relevant to this action, Plaintiff was employed

as a personal banker for Wells Fargo Bank (“Wells Fargo”). As

part of Wells Fargo’s employee benefits package, Plaintiff was

entitled to participate in its group short term disability plan

(the “Plan”). 

2

Wells Fargo both sponsors the Plan and acts as Plan

Administrator. The Plan Administrator has full discretionary

authority to administer and interpret the Plan. (Undisputed Fact

No. 5). Wells Fargo has delegated its authority to receive,

process and administer benefit claims to MetLife as the Plan

Claims Administrator. (Undisputed Facts Nos. 5 & 6). 

The Plan provides for payments as a result of an insured’s

“...disabling injury or illness that is: Documented by disabling

signs and symptoms, as certified by approved care providers; and

Prevents [the insured] from performing some or all of [his or

her] regular job duties.” (Undisputed Fact No. 4).

On November 6, 2000, Plaintiff underwent surgery to remove

her ovaries. Plaintiff submitted a claim for short term

disability payments on November 27, 2000. Thereafter,

Plaintiff’s physician, Dr. Melba Berbano, advised MetLife by

telephone that Plaintiff would be capable of returning to work on

December 18, 2000. (Undisputed Fact No. 9). 

Case 2:03-cv-01672-MCE -PAN Document 48 Filed 07/18/05 Page 2 of 10
1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

3

By letter dated December 1, 2000, MetLife advised Plaintiff that

her application for benefits was approved from November 3, 2000,

through December 17, 2000. On or about December 14, 2000, Dr.

Berbano provided MetLife a fitness certification

(“Certification”) regarding Plaintiff’s then existing condition. 

(Undisputed Fact No. 13). The physical capabilities portion of

the Certification indicated that Plaintiff could intermittently

sit, stand and walk. The Certification also established that

Plaintiff could reach above shoulder level and operate a motor

vehicle. Dr. Berbano released Plaintiff to resume full time

duties with no restrictions but noted that the release was only

effective after Plaintiff’s period of disability was concluded. 

In the Certification’s additional comments section, Dr. Berbano

typed the following: “Extension of her disability. Due to post

op pain, headache, fatigue and hypertension. Pt will return to

work on 01/15/01.” (Undisputed Fact No. 14).

On or about January 31, 2001, MetLife referred Plaintiff’s

claim to a nurse consultant for review. The nurse consultant

concluded that Plaintiff was not disabled beyond December 17,

2000, and therefore not entitled to additional benefits. By

letter dated February 2, 2001, MetLife advised Plaintiff that her

claim for benefits beyond December 17, 2000, was being withdrawn

for failure to demonstrate continued severity of total

disability. (Undisputed Fact No. 18). That same letter

instructed that any request for review of MetLife’s decision

should be forwarded to: “Group Insurance Claim Review,

Metropolitan Life Insurance Company, P.O. Box 1088, Glastonbury,

CT 06033-6088.”

Case 2:03-cv-01672-MCE -PAN Document 48 Filed 07/18/05 Page 3 of 10
1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

4

On February 21, 2001, Dr. Berbano requested that MetLife

reexamine its decision to deny Plaintiff’s request for extended

benefits. Dr. Berbano’s request specified that Plaintiff was

unable to perform her regular work duties through January 16,

2001 due to “post-operative pain in lower abdomen with

fatigability, and headaches, as well as hypertension.” This

request was addressed to MetLife directly.

By letter dated March 19, 2001, MetLife answered Dr.

Berbano’s request as follows: “This letter is to confirm receipt

of your appeal request. Your file can not be referred for

independent claim review due to lack of office notes 12/18/00

through 01/16/01. Please submit requested medical by 04/02/01 or

claim will be referred for independent claim review as is.” 

Thereafter, neither Plaintiff nor her physician provided any

medical evidence substantiating Plaintiff’s disability. 

(Undisputed Fact No. 25). 

By letter dated April 27, 2001, MetLife upheld its denial of

benefits based in part on Plaintiff’s failure to tender

additional medical evidence as requested. In this letter,

MetLife instructed Plaintiff to direct any additional medical

information that would support her claim to: “Wells Fargo, Sixth

and Marquette, Minneapolis, MN 55479.”

STANDARD

Where the decision to grant or deny benefits is reviewed for

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

conduit to bring the legal question before the Court and the

usual tests of summary judgment, such as whether a genuine

dispute of material fact exists, do not apply. 

Case 2:03-cv-01672-MCE -PAN Document 48 Filed 07/18/05 Page 4 of 10
1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

5

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

The issue then becomes whether an abuse of discretion is the

proper standard of review in the present action. 

Plaintiff urges that a de novo standard of review is

applicable here. In support of this argument, Plaintiff quotes

Firestone Tire & Rubber Co. v. Bruch wherein the Supreme Court

held that “a denial of benefits challenged under [ERISA] is to be

reviewed under a de novo standard unless the benefit plan gives

the administrator or fiduciary discretionary authority to

determine eligibility for benefits or to construe the terms of

the plan.” 489 U.S. 101, 115 (U.S. 1989). In instances where

discretionary authority has been granted, case law is clear that

an abuse of discretion standard is proper. See Nord v. Black &

Decker Disability Plan, 356 F.3d 1008, 1010 (9th Cir. 2004). In

light of the Ninth Circuit’s teaching, this Court declines

Plaintiff’s request to apply a de novo standard of review because

discretionary authority has been granted pursuant to the terms of

the Plan. 

Plaintiff next argues that the existence of an actual

conflict of interest subjugates the less deferential de novo

standard. In fact, the Supreme Court expressly addressed this

issue and held that if a benefit plan gives discretion to an

administrator who is operating under a conflict of interest, that

conflict must be weighed as a "facto[r] in determining whether

there is an abuse of discretion." Firestone, 489 U.S. at 115. 

///

///

///

Case 2:03-cv-01672-MCE -PAN Document 48 Filed 07/18/05 Page 5 of 10
1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

6

Contrary to Plaintiff’s assertion, in the event of an actual

conflict of interest, the standard does not change but the Court

must weigh that conflict as a factor in determining whether there

was an abuse of discretion.

There is no evidence in the record tending to show that

MetLife was operating under an actual conflict of interest. 

However, even assuming, without deciding, that an apparent

conflict of interest exists, Plaintiff must put forth material,

probative evidence, beyond the mere fact of the apparent

conflict, tending to show that the fiduciary's self-interest

caused the breach. See Nord, 356 F.3d at 1010. Plaintiff failed

to provide any evidence beyond her bare assertion that MetLife

was operating under an actual or apparent conflict or that selfinterest caused a breach of its fiduciary duty as the Plan Claims

Administrator. Accordingly, the Court finds that an abuse of

discretion standard is applicable to the present action. 

ANALYSIS

1. Exhaustion of Administrative Remedies

MetLife argues that Plaintiff failed to exhaust her

administrative remedies before bringing the present action

entitling it to summary judgment. MetLife correctly points out

that under ERISA, employee benefit plans are required to provide

internal dispute resolution procedures for participants whose

claims have been denied. See 29 U.S. C. § 1133. The general

rule governing ERISA claims is that a claimant must avail himself

or herself of a plan's own internal review procedures before

bringing suit in federal court. Diaz v. United Agric. Employee

Welfare Benefit Plan & Trust, 50 F.3d 1478, 1483 (9th Cir. 1995). 

Case 2:03-cv-01672-MCE -PAN Document 48 Filed 07/18/05 Page 6 of 10
1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

7

 MetLife principally argues that Plaintiff’s request for

review fails to comply with the Plan’s internal appeals process

because the request came from Dr. Berbano rather than Plaintiff. 

Under the terms of the Plan, an “authorized representative” may

appeal an adverse benefits decision on behalf of an insured. 

Nothing in ERISA or in the applicable portions of the Code of

Federal Regulations defines "authorized representative" for the

purposes of communicating with a plan administrator. The Code of

Federal Regulations does, however, permit an ERISA plan to

establish reasonable procedures for determining whether an

individual has been authorized to act on behalf of an insured. 

See 29 CFR § 2560.503-1(4)(2005). Despite this express

authority, the Plan is silent on this issue. Since MetLife

failed to exercise its right to delimit who may qualify as a duly

authorized representative under the Plan, the Court finds that

Plaintiff was free to select Dr. Berbano as her personal

representative in connection with her disability. 

MetLife also contends that Plaintiff’s appeal was

insufficient because it was directed to MetLife rather than Wells

Fargo. MetLife, however, disregards the plain language of the

Plan. Specifically, the Summary of Material Modifications to the

2000 Benefits Book reads as follows: 

“Effective May 1, 2000, if your request for STD

benefits is denied, or you believe you should be

entitled to a different amount of STD benefits, or you

disagree with any determination that has been made

reflecting your benefits under the STD Plan, you may

present a claim in writing for review by the Claims

Administrator, MetLife within 60 days.” 

(Sullivan Decl. ¶2, Ex. A, MET 0078).

///

Case 2:03-cv-01672-MCE -PAN Document 48 Filed 07/18/05 Page 7 of 10
1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

The record is unclear regarding whether the nurse 3

consultant engaged by MetLife is a licensed medical professional. 

For purposes of this summary judgement motion, the Court assumes

MetLife’s consultant is not a licensed medical professional.

8

It is clear that an insured is to seek review of a benefit

determination with MetLife rather than with the Plan

Administrator, Wells Fargo. In addition, MetLife’s February 2,

2001, letter instructs Plaintiff to seek review of adverse

decisions from MetLife directly. While MetLife’s April 27, 2001,

letter instructed Plaintiff to forward supplemental medical

evidence to Wells Fargo, the plain language of the Plan together

with MetLife’s February 2, 2001, letter make clear that

Plaintiff’s request for review was correctly submitted.

Accordingly, the Court finds that Plaintiff has exhausted

her administrative remedies under the terms of the Plan.

2. The Court’s Review of MetLife’s Benefits Determination

MetLife’s benefits determination is subject to an abuse of

discretion review. Under this standard of review, the Court is

not seeking to resolve whether there is an issue of material

fact; instead, the Court is reviewing MetLife’s decision to

determine whether it is “so patently arbitrary and unreasonable

to lack foundation in factual basis.” Taft v. Equitable Life

Assurance Soc'y, 9 F.3d 1469, 1471 (9th Cir. 1993). 

Plaintiff argues at length that MetLife abused its

discretion because it sought review of Plaintiff’s claim from a

“nurse consultant” rather than a licensed medical professional.3

Plaintiff’s assertion, however, is wholly without merit. Neither

the terms of the Plan nor relevant case law provide any support

for Plaintiff’s argument. 

Case 2:03-cv-01672-MCE -PAN Document 48 Filed 07/18/05 Page 8 of 10
1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

9

In the absence of such authority, the Court declines to create a

requirement that a plan administrator or its fiduciary engage a

licensed medical professional to review its benefit

determinations. MetLife’s decision to engage a nurse consultant

to review Plaintiff’s claim was neither patently arbitrary nor

unreasonable. 

Plaintiff next contends that MetLife should have accorded

her treating physician’s opinions more weight than the opinions

of its nurse consultant. On the contrary, the Supreme Court has

expressly rejected the notion that the opinions of an insured’s

treating physician should be accorded more weight than other

objective medical evidence in the insured’s record. See Black &

Decker Disability Plan v. Nord, 538 U.S. 822 (2003). MetLife was

not required, nor should it have, accorded greater deference to

Dr. Berbano’s opinions than other evidence in the record before

it.

Finally, Plaintiff claims this Court must only find that

MetLife more likely than not abused its discretion in denying her

claim. Again, the law in this Circuit is contrary. The Ninth

Circuit has instructed that only when a plan administrator relies

on clearly erroneous findings of fact is it guilty of an abuse of

discretion. See Bendixen, 185 F.3d at 944. A finding is clearly

erroneous when “although there is evidence to support it, the

reviewing [body] on the entire evidence is left with the definite

and firm conviction that a mistake has been committed." Boyd v.

Bell, 2005 U.S. App. LEXIS 11057, 13-14 (9th Cir. 2005)(Internal

quotations and citations omitted). 

///

Case 2:03-cv-01672-MCE -PAN Document 48 Filed 07/18/05 Page 9 of 10
1

2

3

4

5

6

7

8

9

10

11

12

13

14

15

16

17

18

19

20

21

22

23

24

25

26

27

28

10

Here, MetLife had verbal authorization from Dr. Berbano that

Plaintiff could return to work on December 18, 2000. In

addition, Dr. Berbano submitted a physical certification

indicating that Plaintiff could perform a number of functions

relevant to her work including sitting, standing and driving a

car. Neither Plaintiff nor Dr. Berbano submitted any additional

medical evidence of Plaintiff’s condition beyond December 17,

2000, as specifically requested by MetLife. Although there are

facts in the record that could support a finding contrary to that

made by MetLife, this Court is not left with the definite and

firm conviction that a mistake has been committed. 

CONCLUSION

For the reasons more fully explained above, MetLife's motion

for summary judgment is GRANTED.

IT IS SO ORDERED.

DATED: July 18, 2005

_____________________________

MORRISON C. ENGLAND, JR

UNITED STATES DISTRICT JUDGE

Case 2:03-cv-01672-MCE -PAN Document 48 Filed 07/18/05 Page 10 of 10