Document ID: s3://data.kl3m.ai/documents/govinfo/USCOURTS/USCOURTS-caed-2_14-cv-00235/USCOURTS-caed-2_14-cv-00235-1/pdf.json

Parties Involved:
Vlasia Hantakas
Plaintiff
Metropolitan Life Insurance Company
Defendant

Document Text:

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UNITED STATES DISTRICT COURT

EASTERN DISTRICT OF CALIFORNIA

VLASIA HANTAKAS,

Plaintiff,

v.

METROPOLITAN LIFE INSURANCE 

COMPANY,

Defendant.

No. 2:14-cv-00235-TLN-KJN

ORDER GRANTING IN PART AND 

DENYING IN PART PLAINTIFF’S 

MOTION FOR PARTIAL SUMMARY

JUDGMENT; GRANTING DEFENDANT’S 

MOTION FOR REMAND

This matter is before the Court pursuant to Plaintiff Vlasia Hantakas’ (“Plaintiff”) Motion 

for Partial Summary Judgment. (ECF No. 13.) Defendant Metropolitan Life Insurance Company

(“Defendant” or “MetLife”) opposes Plaintiff’s motion. (ECF No. 21.) Defendant subsequently

filed a related Motion for Remand of Plaintiff’s claim for long-term disability (“LTD”) benefits 

back to MetLife. (ECF No. 17.) Both parties have filed Oppositions (ECF Nos. 21 & 18) and 

Replies to the Oppositions (ECF Nos. 22 & 23). The Court has carefully considered the 

arguments raised by both parties. For the reasons set forth below, Plaintiff’s Motion for 

Summary Judgment is GRANTED in part and DENIED in part. Defendant’s Motion for Remand 

is GRANTED with the stipulations set forth below.

//

//

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I. FACTUAL & PROCEDURAL HISTORY

Plaintiff brought this action under the Employee Retirement Income Security Act of 1974 

(“ERISA”), 29 U.S.C. § 1001 et. seq. As part of her employment, Plaintiff was a participant in 

the Kaiser Permanente Flexible Benefits Plan (“the Plan”), an “employee welfare benefit plan” 

under 29 U.S.C. § 1002(1). (Compl., ECF No. 2 at ¶¶ 4–8.) MetLife issued the insurance policy 

funding the benefits, Group Policy Number 95910-1-G,

1

and served as the Plan administrator for 

all LTD claims. (ECF No. 17-2 at 10, 63–64.)

Plaintiff became an employee of Kaiser Permanente on or about April 3, 2006. (ECF No. 

2 at ¶ 9.) Plaintiff last worked as Assistant Director of Imaging in the Radiology Department of 

Kaiser Permanente Hayward, until May 26, 2010. (Mem. P. & A. Supp. Mot. for Summ. J., ECF 

No. 14 at 6.) As of May 27, 2010, Plaintiff was unable to perform the material duties of her job 

and submitted a claim with MetLife for LTD benefits on October 21, 2010. (Administrative R.

(“AR”) 902.)

2

 Plaintiff stated in her initial claim forms that she could not perform her job duties 

due to severe pain and sciatica when sitting, standing or lying in the same position. (AR 815.) 

She also claimed to have right knee and shoulder pain. (AR 815.) After a review of Plaintiff’s

medical records, MetLife approved Plaintiff’s claim for LTD benefits on March 29, 2011. (AR 

660–662.) Benefits of $3,755.27 were payable as of November 23, 2010 (following the 180 day 

“waiting period” required by the Plan from the date of eligibility of May 27, 2010). (AR 660–

662.)

In their March 29, 2011, benefits approval letter, MetLife also advised Plaintiff of the 

Plan’s two different disability definitions, noting that:

 

1 Two sets of “Plan” documents were submitted to the Court. The 2004 Plan document was originally submitted as 

part of the Administrative Record filed under seal. (ECF No. 12-5 at 113–155.) Subsequently the 2010 Plan 

document was filed by Defendant as Exhibit B to their Motion for Remand. (ECF No. 17-2 at 7–66.) According to 

MetLife’s Declaration by Litigation Specialist Cindy Broadwater, “The 2010 Plan document is the applicable Plan 

document for Plaintiff’s claim based on the claimant’s date of disability and is the Plan document that was used in the 

administration of Plaintiff’s claim.” (ECF No. 17-2 at 2–3.) As the Plaintiff did not dispute the new 2010 Plan 

document in her reply brief, the Court has used the 2010 Plan document for applicable definitions and all references 

to the Plan refer to the 2010 Plan document.

2 Defendants lodged the administrative record under seal on October 6, 2014, document bates labeled MET-HAN 001 

through MET-HAN 1370. Since the parties use the administrative record page numbers in their briefing, the Court 

has maintained this reference rather than the corresponding ECF page number.

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Disabled or disability means that, due to sickness, pregnancy or 

accidental injury you are receiving Appropriate Care and Treatment 

from a Doctor on a continuing basis; and 

1. during your Elimination period and the next 24 month period, 

you are unable to earn more than 80% of your Predisability 

Earning or Indexed Predisability Earnings at your Own 

Occupation for any employer in your Local Economy; or 

2. after the 24 month period, you are unable to earn more than 

80% of your Indexed Predisability Earnings from any employer 

in your Local Economy at any gainful occupation for which you 

are reasonably qualified taking into account your training, 

education, experience and Predisability Earnings.

(AR 660.) MetLife further noted that benefits would continue only as long as Plaintiff continued 

to meet the definitions of “disabled,” that in any case benefits under the Plaintiff’s 24-month 

“own occupation” period would end on November 22, 2012, and that in order for benefits to 

continue on or beyond November 23, 2012, (i.e., upon expiration of the 24-month “own

occupation” period) she must be disabled from performing “any occupation” as defined by the 

Plan. (AR 660–662.) The letter also informed Plaintiff that she was required to apply for Social 

Security disability benefits if she expected her disability to continue for at least one year, and that 

any recovery would offset her MetLife LTD award. (AR 662.)

Plaintiff timely applied for Social Security disability benefits and was awarded benefits in 

a letter dated September 4, 2011. (AR 499–505). On September 18, 2011, after the favorable 

Social Security Disability Award, MetLife sent Plaintiff a letter to recover the overpayment of 

benefits due to the required offset. (AR 495–496). Plaintiff sent MetLife a check for the benefit 

overpayment in the requested amount of $10,652.83. (AR 489.) 

Plaintiff continued to receive LTD benefits from MetLife up to and including November, 

13, 2012, nine days short of the full 24-month “own occupation” period. (AR 223–227.) On 

October 1, 2012, Dr. Veena Vani, MetLife Medical Director, conducted a Physician File Review 

of Plaintiff’s file and determined that Plaintiff had “no objective exam findings to show ongoing 

impairment to preclude from sedentary work.” (AR 246–247.) MetLife sent the Medical 

Director’s finding and report to Plaintiff’s treating physician, Dr. Larry Marianella for response. 

(AR 242.) On October 19, 2012, Dr. Marianella replied to MetLife stating that he disagreed with

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their conclusions and Plaintiff remained disabled and unable to work. (AR 236.) Nevertheless, 

on November 13, 2012 MetLife sent Plaintiff a letter informing her that the her claim for LTD 

benefits were terminated as of November 13, 2012 because the MetLife Medical Director’s 

review concluded that she was “able to perform your sedentary Usual and Customary occupation 

of an Assistant Facilities Director.” (AR 223–227.) 

On April 9, 2013, Plaintiff’s attorney submitted a “formal appeal” letter to MetLife, 

challenging the benefits denial. (AR 116.) On April 15, 2013, MetLife acknowledged receipt of 

Plaintiff’s timely appeal and informed Plaintiff that they would evaluate the documentation and 

advise her of their determination within 45 days, but under special circumstances could require up 

to an additional 45 days and would notify her in writing if this was necessary. (AR 115.) On 

May 14, 2013, MetLife informed Plaintiff her file was under review but they would require an 

additional 45 days to render a decision on the appeal. (AR 98.) On July 18, 2013, Plaintiff’s 

attorney sent a faxed request to MetLife for a status update. (AR 97.) On July 23, 2013, MetLife 

informed Plaintiff that her “entire file [had] been referred to an independent physician consultant 

for review” and she would be notified when they received the report. (AR 96.) On July 26, 

2013, Plaintiff acknowledged receipt of MetLife’s July 23, 2013 letter and again requested “a 

definitive response as to when MetLife [would] make a decision on the case.” (AR 82–84.) 

On September 9, 2013, MetLife informed Plaintiff that their review was ongoing and that 

they had submitted the results of the Independent Physician Consultant’s review to several of 

Plaintiff’s physicians. (AR 68.) Included in this communication was a copy of the May 2, 2013 

Independent Peer Review from Robert Lee Waltrip, M.D. (AR 69–78), along with Dr. Waltrip’s 

July 23, 2013 addendum supporting the original recommendation. (AR 79–81). MetLife 

informed Plaintiff that a response from Plaintiff’s physician was required within 14 days. (AR 

68.) On September 20, 2013, Plaintiff replied to MetLife’s request, including letters from two of 

Plaintiff’s physicians stating that Plaintiff could not return to work. (AR 36–48.)

On October 17, 2013, MetLife informed Plaintiff that a signed authorization form was 

needed by one of Plaintiff’s physicians, Dr. Nazeri, in order to respond to MetLife’s request. (AR 

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17.) Plaintiff’s attorney sent further inquiries to MetLife for a status update/claim decision on

October 18, 2013 (AR 7–15), November 13, 2013 (AR 5–6), and November 25, 2013 (AR 3-4). 

On December 9, 2013, Plaintiff’s attorney informed MetLife that if no benefit determination was 

received before December 31, 2013 Plaintiff would proceed with a federal lawsuit for benefits. 

(AR 1–2.) The Administrative Record (filed under Seal) and filings suggest there was no further 

communication between MetLife and the Plaintiff, or her attorney, until after this lawsuit was 

filed on January 27, 2014.3 

On January 27, 2014, Plaintiff filed the instant Complaint pleading three causes of action: 

(1) benefits under 29 U.S.C section 1132(a)(1)(B); (2) equitable relief under 29 U.S.C. 

1132(a)(3); and (3) declaratory relief. (ECF No. 2 at 6–7.) Plaintiff seeks the following relief: 

(1) judgment awarding Plaintiff past benefits owed; (2) judgment reinstating Plaintiff’s long term 

disability benefits; (3) attorney’s fees pursuant to 29 U.S.C. 1132(g); (4) prejudgment interest 

pursuant to 29 U.S.C. 1132(a)(1)(B); (5) cost of suit; (6) an accounting and establishment of a 

constructive trust to include disgorgement of profits made by Defendant; (7) judicial 

determination of the rights and duties of Plaintiff and defendant with regard to the contract of 

insurance issued by MetLife to Kaiser Foundation Health plan, as well as a determination of the 

past, present and future benefits to which Plaintiff is entitled; and (8) for such other and further 

relief as the Court may deem just and proper. (ECF No. 2 at 8–9.) 

As required by the Court’s Pretrial Scheduling Order (ECF No. 9), MetLife submitted the 

Administrative Record on October 1, 2014. (ECF No. 12.) On October 2, 2014, Defendants 

counsel, Jenny H. Yang, called Plaintiff’s counsel, Daniel Glass, and orally communicated 

MetLife’s willingness to pay Plaintiff benefits for the remaining 9 days of the 24-month “usual 

occupation” period, along with reasonable attorney’s fees that the Plaintiff incurred in this 

litigation up to that point in time. (Supplemental Decl. of Jenny H. Wang in Supp. Def.’s Mot.

Remand, ECF No. 23-1 at ¶ 2.) 

On October 9, 2014, Plaintiff submitted the instant Motion for Partial Summary 

 

3

Since the Court reached its decision on other grounds, the Court has not closely examined, provided a factual 

review of, or reached conclusions about the Plaintiff’s medical conditions as supported by the administrative record. 

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Judgment. (ECF No. 13.) On October 20, 2014 MetLife filed a Motion for Remand (ECF No. 

17) and also informed Plaintiff and her attorney via letter that they had completed the appeal 

review of Plaintiff’s termination of LTD benefits. (ECF No. 17-2 at 5.) Based on that review, 

MetLife reversed their termination decision and approved LTD benefits through November 22, 

2012, finding that “Ms. Hantakas continued to have restrictions and limitations that rendered her 

unable to perform her Usual Occupation as an Assistant Facilities Director of Imaging Services 

through November 22, 2012.” (ECF No. 17-2 at 5–6.) MetLife sent Plaintiff a check for 9 days 

of unemployment (11/14/2012 to 11/22/2012) in the amount of $1812.08. (Decl. of Daniel S. 

Glass in Opp. MetLife’s Mot. Remand, ECF No. 19 at 16.) MetLife also agreed to pay Plaintiff’s 

attorney $13,500 in fees. (ECF No. 19 at 3.) MetLife further informed Plaintiff that they would 

still need to make a determination about Plaintiff’s eligibility for benefits under the “‘any 

occupation’ definition of Total Disability under the Plan” and that they would be in touch to 

schedule an “independent medical examination” to assist with that decision. (ECF 17-2 at 5–6). 

On November 6, 2014, Plaintiff filed an Opposition to Defendant’s Motion to Remand 

(ECF No. 18), and Defendant filed an Opposition to Plaintiff’s Motion for Summary Judgment 

(ECF No. 21). Replies by both parties were filed on November 13, 2014. (ECF Nos. 22 & 23.) 

II. STANDARD OF LAW

Summary judgment is appropriate when the moving party demonstrates no genuine issue 

as to any material fact exists, and therefore, the moving party is entitled to judgment as a matter 

of law. Fed. R. Civ. P. 56 (c); Adickes v. S.H. Kress & Co., 398 U.S. 144, 157 (1970). Under 

summary judgment practice, the moving party always bears the initial responsibility of informing 

the district court of the basis of its motion, and identifying those portions of “the pleadings, 

depositions, answers to interrogatories, and admissions on file together with affidavits, if any,” 

which it believes demonstrate the absence of a genuine issue of material fact. Celotex Corp. v. 

Catrett, 477 U.S. 317, 323 (1986). “[W]here the nonmoving party will bear the burden of proof 

at trial on a dispositive issue, a summary judgment motion may properly be made in reliance 

solely on the pleadings, depositions, answers to interrogatories, and admissions on file.” Id. at 

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324 (internal quotations omitted). Indeed, summary judgment should be entered against a party 

who does not make a showing sufficient to establish the existence of an element essential to that 

party’s case, and on which that party will bear the burden of proof at trial.

If the moving party meets its initial responsibility, the burden then shifts to the opposing 

party to establish that a genuine issue as to any material fact actually does exist. Matsushita Elec. 

Indus. Co. v. Zenith Radio Corp., 475 U.S. 574, 585–87 (1986); First Nat’l Bank v. Cities Serv. 

Co., 391 U.S. 253, 288–89 (1968). In attempting to establish the existence of this factual dispute,

the opposing party may not rely upon the denials of its pleadings, but is required to tender 

evidence of specific facts in the form of affidavits, and/or admissible discovery material, in 

support of its contention that the dispute exists. Fed. R. Civ. P. 56(c). The opposing party must 

demonstrate that the fact in contention is material, i.e., a fact that might affect the outcome of the 

suit under the governing law, Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 248 (1986), and that 

the dispute is genuine, i.e., the evidence is such that a reasonable jury could return a verdict for 

the nonmoving party. Id. at 251–52.

In the endeavor to establish the existence of a factual dispute, the opposing party need not 

establish a material issue of fact conclusively in its favor. It is sufficient that “the claimed factual 

dispute be shown to require a jury or judge to resolve the parties’ differing versions of the truth at 

trial.” First Nat’l Bank, 391 U.S. at 288–89. Thus, the “purpose of summary judgment is to 

‘pierce the pleadings and to assess the proof in order to see whether there is a genuine need for 

trial.’” Matsushita, 475 U.S. at 587 (quoting Rule 56(e) advisory committee’s note on 1963 

amendments).

In resolving the summary judgment motion, the court examines the pleadings, depositions, 

answers to interrogatories, and admissions on file, together with any applicable affidavits. Fed. 

R. Civ. P. 56(c); SEC v. Seaboard Corp., 677 F.2d 1301, 1305–06 (9th Cir. 1982). The evidence 

of the opposing party is to be believed, and all reasonable inferences that may be drawn from the 

facts pleaded before the court must be drawn in favor of the opposing party. Anderson, 477 U.S. 

at 255. Nevertheless, inferences are not drawn out of the air, and it is the opposing party’s 

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obligation to produce a factual predicate from which the inference may be drawn. Richards v. 

Nielsen Freight Lines, 602 F. Supp. 1224, 1244–45 (E.D. Cal. 1985), aff’d, 810 F.2d 898 (9th Cir. 

1987). Finally, to demonstrate a genuine issue that necessitates a jury trial, the opposing party 

“must do more than simply show that there is some metaphysical doubt as to the material facts.” 

Matsushita, 475 U.S. at 586. “Where the record taken as a whole could not lead a rational trier of 

fact to find for the nonmoving party, there is no ‘genuine issue for trial.’” Id. at 587.

III. ANALYSIS4

Plaintiff requests awards to date.5 (ECF No. 14 at 24 (“Plaintiff requests . . . she be 

awarded 24.3 months of disability benefits . . . ”); ECF No. 22 at 11 (“Plaintiff respectfully 

requests . . . that she be awarded benefits from November 23, 2012 to the present, and that her 

monthly benefits continue through any further investigation MetLife now wants to undertake to 

decide if Ms. Hantakas remains disabled from ‘any occupation.’”).) According to the applicable 

MetLife Plan documents, an insured is considered totally disabled if:

During the Elimination Period and the next 24 months, You are 

unable to perform with reasonable continuity the Substantial and

Material Acts necessary to pursue Your Usual Occupation in the 

usual and customary way.

After such period, You are not able to engage with reasonable 

continuity in any occupation in which You could reasonably be

expected to perform satisfactorily in light of Your:

 age;

 education;

 training;

 experience;

 station in life; and

 physical and mental capacity

 

4

Plaintiff argues for a de novo standard of review under ERISA. (ECF No. 14 at 16–17.) Defendant argues that any 

need for review is now moot and therefore requests remand and does not address the standard of review in their 

Opposition or Motion for Remand. (ECF No. 17.) The Court has decided the instant motion on other grounds and 

thus does not address the appropriate ERISA standard of review or the applicability of California Insurance Code 

section 10110.6 at this time.

5

Plaintiff’s motion is labeled as “Partial Summary Judgment,” however, the Plaintiff is unclear in the briefing as to 

which causes of action are excluded from the summary judgment request. Accordingly, after careful review of the 

motion, the Court construes Plaintiff’s “Motion for Partial Summary Judgment” as a motion for complete summary 

judgment as to all causes of action plead. The Complaint brings three causes of action: (1) benefits under 29 U.S.C 

section 1132(a)(1)(B); (2) equitable relief under 29 U.S.C. 1132(a)(3); and (3) declaratory relief. For the purposes of 

this motion the underlying legal analysis is the same for all three counts and therefore the Court will address all

counts simultaneously.

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that exists within any of the following locations:

 a reasonable distance or travel time from Your residence in 

light of the commuting practices of Your community;

 a distance of travel time equivalent to the distance or travel 

time You traveled to work before becoming disabled; or

 the regional labor market, if You reside or resided prior to

becoming disabled in a metropolitan area.

Elimination Period means the period of Your Disability during 

which We do not pay benefits. The Elimination Period begins on 

the day You become Disabled and continues for the period shown 

in the SCHEDULE OF BENEFITS [180 days].

(ECF No. 17-2 at 28, 31.) 

Accordingly, pursuant to the Plan provisions, in order to qualify as “disabled” during the 

first 24 months following the elimination period, Plaintiff must be unable to perform the 

substantial and material acts necessary to pursue her usual occupation. (ECF No. 21 at 8.) That 

is typically referred to as the “own occupation” period. (ECF No. 21 at 8.) After that, Plaintiff 

qualifies as “disabled” as defined by the Plan only if she is unable to engage in any occupation

she could be reasonably expected to perform satisfactorily taking into account her age, education, 

training, experience, station in life and physical and mental capacity. (ECF No. 21 at 8.) That is 

typically called the “any occupation” period. (ECF No. 21 at 8.) Awarding benefits up to the 

present date would require the Court to find that Plaintiff’s benefits were wrongly terminated 

under the “own occupation” definition of disability, and also a finding that Plaintiff qualifies for 

benefits under the “any occupation” definition of disability.

A. “Own (usual) occupation” period

Plaintiff received benefits under the Plan’s “own occupation” definition of disability from 

November 23, 2010, (following the 180 day “elimination period” required by the Plan from the 

May 27, 2010 date of eligibility) (AR 660–662) until November 13, 2012, nine days short of the 

full 24-month “own occupation” period. (AR 223–227.) As of November 13, 2012, Plaintiff was 

denied continued benefits on the basis of an October 1, 2012 Physician File Review by MetLife 

Medical Director Dr. Vani that concluded Plaintiff had “no objective exam findings to show 

ongoing impairment to preclude from sedentary work.” (AR 223–227, 246–247.) Plaintiff timely 

appealed the denial on April 9, 2013. (AR 116.) Despite MetLife’s promise to make a 

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determination within a maximum time period of 90 days (AR 115), a decision on the appeal was 

not reached until October 20, 2014, approximately 15 months past the allotted review time, and 

only after Plaintiff filed this lawsuit. (ECF No. 17-2 at 5–6.) 

Despite the unreasonable delay, MetLife has recently decided that “the claim file supports 

that Ms. Hantakas continued to have restrictions and limitations that rendered her unable to 

perform her Usual Occupation as an Assistant Facilities Director of Imaging Services through 

November 22, 2012.” (ECF No. 17-2 at 5–6.) Given MetLife’s October 20, 2014, decision to 

reverse termination of Plaintiff’s LTD benefits for the remainder of her “own occupation” period,

there are no material facts in question as to Plaintiff’s eligibility for benefits for the remainder of 

the “own occupation” period. Therefore, the Court hereby GRANTS Plaintiff’s Motion for

Partial Summary Judgment as to LTD benefits for the remainder of Plaintiff’s “own occupation” 

period (November 14, 2012 through November 22, 2012). 

B. “Any occupation” period

Plaintiff also requests the Court award her benefits on the basis of the “any occupation” 

definition under the Plan. (ECF No. 14 at 24; ECF No. 22 at 11.) MetLife argues they have not 

yet made a determination about Plaintiff’s eligibility for benefits under the “any occupation” 

definition and requests that the Court remand the action back to MetLife to determine whether 

Plaintiff is disabled under the more expansive definition of “any occupation.” (ECF No. 17.) 

Plaintiff argues that remand is not appropriate as this Court can decide Plaintiff’s eligibility for 

benefits based on the administrative record. (ECF No. 18.)

Clearly established Ninth Circuit precedent holds that determinations of entitlement to 

ERISA-governed benefits are to be made in the first instance by the claim administrator, not by a 

court sitting in review thereof. Taft v. Equitable Life Assurance Soc’y of the U.S., 9 F.3d 1469, 

1472 (9th Cir. 1993). In Taft, the Ninth Circuit noted that if district courts were to conduct an 

expanded review of administrative decisions by examining evidence outside the administrative 

record, it 

would impede an important purpose of the federal statute under 

which district courts have jurisdiction to review these 

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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 parties that was not 

presented to the plan administrator would seriously impair the 

achievement of that goal. Nothing in the legislative history suggests 

that Congress intended that federal district courts would function as 

substitute plan administrators, a role they would inevitably assume 

if they received and considered evidence not presented to 

administrators concerning an employee's entitlement to benefits. 

Such a procedure would frustrate the goal of prompt resolution of 

claims by the fiduciary under the ERISA scheme.

Id. (quoting Sandoval v. Aetna Life & Casualty Ins. Co., 967 F.2d 377, 380 (10th Cir.1992)

(quoting Perry v. Simplicity Eng’g, 900 F.2d 963, 967 (6th Cir.1990)).

In Saffle, the Ninth Circuit found remand appropriate where “the district court erred by 

ordering benefit payments beyond the initial 24–month disability period because Saffle never 

applied for general disability payments and her eligibility for the second-tier benefits has never 

been considered by the Benefit Committee.” Saffle v. Sierra Pac. Power Co. Bargaining Unit 

Long Term Disability Income Plan, 85 F.3d 455, 460 (9th Cir. 1996). The Court noted that:

there is nothing in the administrative record about general 

disability. Of course it is the case, as Saffle contends, that she could 

not have applied for general disability since she first must have 

been awarded occupational disability benefits; but that affords no 

basis upon which to uphold an order to pay benefits from the date 

of onset to the present. Therefore, to the extent the district court 

ordered payments beyond the initial 24–month disability period, it 

was error to do so.

Id. The Court concluded that:

[u]nlike other instances where an ERISA plan administrator abuses 

its discretion (for example, rendering a decision without 

explanation, or relying on clearly erroneous findings of fact, Taft, 9 

F.3d at 1472), the Sierra Pacific Benefit Committee has not yet had 

the opportunity of applying the Plan, properly construed, to Saffle’s 

application for benefits. It should be up to the administrator, not the 

courts, to make that call in the first instance.

Id. 

After careful review of the entire administrative record, the Court agrees with MetLife 

that no decision has been reached about Plaintiff’s eligibility for benefits under the “any 

occupation” definition. All communications with Plaintiff have been about her eligibility for 

benefits during the initial 24 month “own occupation” period. Similar to Saffle, because her 

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benefits were denied short of the full “own occupation” period, Plaintiff never applied for and 

MetLife never considered Plaintiff’s eligibility under the more stringent “any occupation” 

standard for extended benefits. Accordingly, the Court finds that remand is appropriate in order 

for MetLife to make a determination as to Plaintiff’s eligibility under the “any occupation” 

standard. It is the Court’s job to review the administrator’s decision, not make the determination 

in the administrator’s stead. Until MetLife has rendered a decision regarding Plaintiff’s eligibility 

for benefits under the “any occupation” standard, there is nothing for this Court to review. 

Plaintiff proffers several different arguments to counter this conclusion. First, Plaintiff’s 

comparison to the facts in Lavino v. Metro. Life Ins. Co., 779 F.Supp.2d 1095 (C.D. Cal. 2011) 

(“Lavino II”) are unavailing. While the Plaintiff is correct that the ultimate outcome in Lavino II

was an award of benefits to the Plaintiff under the “any occupation” standard, the Court initially 

remanded the determination of Lavino’s eligibility for benefits under the “any occupation”

standard back to MetLife. Lavino v. Metro. Life Ins. Co., 2010 U.S. Dist. LEXIS 2510, *38 (C.D. 

Cal. Jan. 13, 2010) (“Lavino I”) (Because MetLife improperly terminated Plaintiffs’ benefits, 

reinstatement of the terminated benefits is appropriate. However, because MetLife has never had 

an opportunity to decide Plaintiff’s case under the “any occupation” standard, Plaintiff’s request 

for “any occupation” benefits is not an appropriate subject of this action. This Court is not the 

proper forum to submit an “any occupation” claim in the first instance. Remand is proper with 

respect to the any-occupation standard. See Saffle, 85 F. 3d at 461; accord Pakovich v. 

Broadspire Services, Inc., 535 F.3d 601, 605, 607 (7th Cir. 2008)). At this stage, the facts here 

are similar to the facts in Lavino I and remand is appropriate as to the “any occupation” standard. 

Plaintiff’s reliance on the ultimate decision in Lavino II is misplaced. 

Second, Plaintiff argues that “[Plaintiff’s] inability to perform her own ‘sedentary’ 

occupation is exactly the same as being unable to perform ‘any occupation.’” (ECF No. 14 at 

10.) More specifically, Plaintiff contends “there is absolutely no distinction to be made between 

the ‘any occupation’ definition of disability which attaches to a ‘sedentary’ occupation in the 

general economy and the purported ‘sedentary’ occupation [Plaintiff] last worked at in May, 

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2010.” (ECF No. 18 at 5–6; ECF No. 14 at 10–11.) The basis of Plaintiff’s contention is that the 

physical exertion category6attached to her “own occupation” (ie., her last job) was “sedentary”

and “no jobs in the national economy are recognized to require less physical exertion than 

‘sedentary.’” (ECF No. 14 at 10.) Therefore, Plaintiff contends that MetLife must reach the 

conclusion that Plaintiff is unable to perform “any occupation” since the same sedentary rating 

applies to this determination as it did to the “own occupation” standard.

Plaintiff has provided no case law to support the argument that a beneficiary’s sedentary 

job rating renders both LTD benefit standards equivalent. The plain language of the Plan as noted 

in III.A, supra, makes it clear that there are two different standards of disability. MetLife was 

also clear in their communications with Plaintiff that she would be required to meet a different 

definition of disability after 24 months. (AR 660–662.) Whether the sedentary rating of 

Plaintiff’s jobs renders the “own occupation” and “any occupation” standards equivalent is one 

for the claim administrator, MetLife, to determine in the first instance. It is possible there is a 

sedentary job that Plaintiff could perform meeting the more expansive “any occupation” 

definition. That is a fact specific inquiry to be conducted by the claim administrator based on the 

extent of Plaintiff’s disability and the factors outlined in the plan, including: age; education; 

training; experience; station in life; physical and mental capacity; and location of her residence 

with respect to the distance or travel time to available work. As no decision about the 

equivalency of the ratings has been made by MetLife, there is no determination for the Court to 

review at this time.

Third, Plaintiff asserts that MetLife’s November 13, 2012, denial letter (AR 228-232) 

“muddied the waters” as to what benefits were being denied by using improper terms. (ECF No. 

18 at 6.) The denial letter states that benefits were being terminated “because you are able to 

perform your sedentary Usual and Customary occupation of an Assistant Facilities Director.” 

(AR 228.) Plaintiff contends that “MetLife’s policy never uses the term “your sedentary usual 

 

6

20 C.F.R. section 404.1567 provides definitions for the physical exertion requirements of work in the national 

economy, used by the Social Security Administration to evaluate claims for Social Security Disability. Jobs are

classified as sedentary, light, medium, heavy, and very heavy. 

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and customary occupation.” (ECF No. 18 at 6.) Rather, the Plan refers only to “‘Your Usual 

Occupation’ or ‘any occupation.’” (ECF No. 18 at 6.) Plaintiff argues that the use of the term 

“sedentary job” was confusing and led Plaintiff to believe the denial was related to the “any 

occupation” benefit. Plaintiff further argues that the discussion in the denial letter of available 

benefits after 24 months would have no relevance if benefits were only being denied for the “own 

occupation” period. (ECF No. 18 at 6.) The Court disagrees. The Plaintiff is essentially 

contending that the additions of the words “sedentary” and “customary occupation” were added to 

cause purposeful confusion. The Plan language defines “Totally Disabled” or Total Disability” 

as: “During the Elimination Period and the next 24 months, You are unable to perform with 

reasonable continuity the Substantial and Material Acts necessary to pursue Your Usual 

Occupation in the usual and customary way.” (ECF No. 17-2 at 31.) The word “customary” is 

clearly part of this definition. The only word not in this definition is “sedentary” and it quite 

obviously refers to the Plaintiff’s own job which was determined to be sedentary when her claim 

was approved. (AR 660–662.) Further, MetLife was clear in all their communication with 

Plaintiff that two levels of benefits existed. It seems obvious that denial of benefits during the 

first level of benefits would relate to benefits only during that period. The reference to the two 

levels of benefits in the November 13, 2012, denial letter seems to clarify rather than confuse and 

is consistent with all the other communications Plaintiff received from MetLife. The Plaintiff 

does not make a compelling argument that MetLife intentionally attempted to confuse Plaintiff 

into believing her “any occupation” benefits were being denied.

Fourth, Plaintiff alleges that MetLife has not processed her appeal of the denial of LTD 

benefits in a timely fashion, resulting in a de facto denial of benefits. The crux of Plaintiff’s

argument here seems to be that “MetLife flagrantly and repeatedly violated its policy and 

ERISA’s Claims procedures found at 29 CFR 2560.503-1.” (ECF No. 18 at 8.) 

29 C.F.R. § 2560.503-1(f)(3) provides: 

In the case of a claim for disability benefits, the plan administrator 

shall notify the claimant, in accordance with paragraph (g) of this 

section, of the plan’s adverse benefit determination within a 

reasonable period of time, but not later than 45 days after receipt of 

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the claim by the plan.

The regulation provides that this period may be extended for up to two 30-day periods, but only if 

the plan administrator both determines that such an extension is 

necessary due to matters beyond the control of the plan and notifies 

the claimant, prior to the expiration of the initial 45-day period, of 

the circumstances requiring the extension of time and the date by 

which the plan expects to render a decision.

29 C.F.R. § 2560.503-1(f)(3). The regulation clarifies that:

[the time period] within which a benefit determination is required to 

be made shall begin at the time a claim is filed in accordance with 

the reasonable procedures of a plan, without regard to whether all 

the information necessary to make a benefit determination 

accompanies the filing.

29 C.F.R. § 2560.503-1(f)(4). If a plan fails to follow these claims procedures, 

a claimant shall be deemed to have exhausted the administrative 

remedies available under the plan and shall be entitled to pursue 

any available remedies under section 502(a) of the Act on the basis 

that the plan has failed to provide a reasonable claims procedure 

that would yield a decision on the merits of the claim.

29 C.F.R. § 2560.503-1(l). The Court agrees that MetLife failed to follow appropriate claim 

procedures as to Plaintiff’s appeal of the denial of her “own occupation” benefits. However, 

failure to follow ERISA claim procedures for the initial appeal does not impute to MetLife’s 

decision under the “any occupation” standard. Plaintiff’s reference to Kroll v. Kaiser Found. 

Health Plan Long Term Disability Plan, 2012 U.S. Dist. LEXIS 25063 (N.D. Cal. Feb. 10, 2012)

is unavailing. As the Plaintiff correctly points out, in Kroll “[a]fter a lawsuit and summary 

judgment, benefits were awarded by the court [for the own occupation period] and [the case was] 

remanded for an ‘any occupation’ determination.” (ECF No. 18 at 10.) Similar to Kroll, remand 

is appropriate here for a determination of benefit eligibility under the “any occupation” standard, 

despite the improper handling of the benefits termination under the “own occupation” standard. 

While the Plaintiff is correct that eventually the Kroll court found the defendant had failed to 

comply with ERISA’s claim procedures with respect to the “any occupation” standard, that 

decision was reached after the initial remand. Upon remand, the defendant in Kroll did nothing to 

evaluate the plaintiff’s “any occupation” claim for four months, and then requested a medical 

exam which the plaintiff’s opposed. Kroll, 2012 U.S. Dist. LEXIS 25063 at *6. That is not the 

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stage we are currently in. As in Kroll, MetLife should be given an opportunity to determine 

Plaintiff’s eligibility for benefits under the “any occupation” standard, following the ERISA claim 

procedures. Should MetLife fail to do so, then the Plaintiff can file another motion with the 

Court. 

Fifth, Plaintiff argues that because the Social Security Administration (“SSA”) approved 

her claim for benefits under the Social Security Act, MetLife must ipso facto approve her claim 

for benefits under the Plan’s “any occupation” definition of disability. Plaintiff is incorrect. The 

Ninth Circuit has long held that the SSA’s approval of benefits under the Social Security Act is 

not binding on a plan administrator in an ERISA case. Madden v. ITT Long Term Disability Plan 

for Salaried Employees, 914 F.2d 1279, 1286 (9th Cir. 1990), cert. denied, 498 U.S. 1087 (1991).

Moreover, if Madden’s argument [that he is eligible for ERISAgoverned disability benefits because he received a social security 

disability award] were correct, ERISA fiduciaries would be stripped 

of all administrative discretion, as they would be required to follow 

the Department of Health and Human Services’ decisions regarding 

social security benefits, even where the Plan determines benefits 

under different standards or the medical evidence presented is to the 

contrary. 

Id. The standards for determining disability as defined by the SSA are different from those 

applicable to ERISA-governed LTD plans. Specifically, the SSA must afford great weight to a 

claimant’s treating physicians, whereas ERISA claim administrators are not required to defer to 

treating physicians. Black & Decker Disability Plan v. Nord, 538 U.S. 822, 832–34 (2003). The 

SSA’s finding of disability can conflict with an ERISA claim administrator’s decision to deny a 

claim based upon the same condition because the “treating physician rule” does not apply to the 

ERISA-governed claim, whereas it does apply to the claim for benefits under the SSA. Chadwick 

v. Metropolitan Life Ins. Co., 2007 U.S. Dist. LEXIS 53688 (E.D. Cal. July 25, 2007). 

Accordingly, Plaintiff’s argument is unavailing since the favorable SSA award received by 

Plaintiff does not by law require MetLife to reach a favorable decision regarding Plaintiff’s 

eligibility for LTD benefits under the “any occupation” standard.

Finally, Plaintiff asserts that denial of her claim just short of the end of her “own 

occupation” period is a “stunt” that has allowed MetLife a “two year stall” in making a claim

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decision. (ECF No. 18 at 2–3.) Plaintiff cites several cases to suggest that “MetLife appears to 

be the ‘poster child’ for ‘parsimonious claims handling.’” (ECF No. 18 at 8.) According to 

Plaintiff, the improper denial of benefits in this case is “business as usual” for MetLife and this 

“requires the court to give very little credence to MetLife’s determination.” (ECF No. 14 at17.) 

The Court reminds Plaintiff that MetLife’s prior actions are not the subject of this case. As this is 

not a class action lawsuit, the Court considers only MetLife’s actions with respect to this Plaintiff 

in rendering a decision about whether MetLife’s benefit determination is proper. However, the 

Court agrees that MetLife’s conduct in this matter reeks of gamesmanship. The Court is 

unimpressed with MetLife’s admittedly wrongful termination of Plaintiff’s benefits under the 

“own occupation” period, the unreasonable delay in processing Plaintiff’s appeal, and the 

handling of Plaintiff’s current claim for benefits under the “any occupation” standard. MetLife 

has blatantly failed to follow its own claim procedures and those required under ERISA. While 

MetLife argues it has not acted in bad faith, it has certainly mishandled Plaintiff’s claim. 

However, because the claim administrator has not had the opportunity to consider whether 

Plaintiff is disabled under its definition for “any occupation,” the Court agrees that remand is 

appropriate despite MetLife’s conduct. See, Sullivan v. Prudential Ins. Co. of Am., No. 2:12-CV01173-TLN-DA, 2014 WL 3529974 at *36 (E.D. Cal. July 15, 2014). 

Nevertheless, the Court is sensitive to Plaintiff’s worry about further delays in claim 

processing. Therefore, MetLife must file a realistic and expedient timeline for their decision of 

Plaintiff’s LTD claim under the “any occupation” standard. While MetLife is correct that 

Plaintiff’s motion for summary judgement could be rendered moot by their benefit determination 

regarding Plaintiff’s “any occupation” eligibility, the Court will stay this case pending that

decision in order to prevent any further prejudice to the Plaintiff. 

IV. CONCLUSION

For the foregoing reasons, Plaintiff’s Motion for Partial Summary Judgment is 

GRANTED in part and DENIED in part. The Court orders as follows: 

1. Plaintiff’s Motion for Partial Summary Judgement is GRANTED for the “own 

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occupation” period up to and including November 22, 2012. 

2. Plaintiff’s Motion for Partial Summary Judgment is DENIED for the “any occupation” 

period, beginning November 23, 2012 to date.

Defendant’s Motion for Remand is GRANTED with the following stipulation:

1. Within fourteen days of this Order Defendant must file a realistic and expedient 

timeline for their decision of Plaintiff’s LTD claim under the “any occupation”

standard. 

This case is stayed pending decision of Plaintiff’s claim under the “any occupation” 

standard. 

Dated: January 29, 2016

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