TOMLINSON v. METROPOLITAN LIFE, et al.

COMPLAINT – Case No. 17-cv-540 1

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Joseph A. Creitz, CBN 169552

joe@creitzserebin.com

Lisa S. Serebin, CBN 146312

lisa@creitzserebin.com

250 Montgomery Street, Suite 1410

San Francisco, CA 94104

415.466.3090 (tel)

415.513.4475 (fax)

Law Offices of Jeffrey C. Metzger

Jeffrey C. Metzger, CBN 

5120 Campus Drive, Suite 150

Newport Beach, CA 92660

949.756.1196 (tel)

949.756.0830 (fax)

Attorneys for Plaintiff

IN THE UNITED STATES DISTRICT COURT

FOR THE NORTHERN DISTRICT OF CALIFORNIA

OAKLAND DIVISION

KAREN TOMLINSON, an individual,

 Plaintiff,

vs.

METROPOLITAN LIFE INSURANCE 

COMPANY, a New York corporation 

in its capacities as a fiduciary and 

claims administrator of the ERISAregulated KAISER FOUNDATION 

HEALTH PLAN, INC. LONG-TERM 

DISABILITY PLAN, and the KAISER 

FOUNDATION HEALTH PLAN, 

INC. LONG-TERM DISABILITY 

PLAN,

 Defendants.

Case No.: 17-cv-540

COMPLAINT FOR BENEFITS 

AND FOR VIOLATIONS OF THE 

EMPLOYEE RETIREMENT 

INCOME SECURITY ACT OF 1974

(ERISA)

Case 4:17-cv-00540-DMR Document 1 Filed 02/02/17 Page 1 of 9
TOMLINSON v. METROPOLITAN LIFE, et al.

COMPLAINT – Case No. 17-cv-540 2

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JURISDICTION

1. Jurisdiction of this Court is based on the Employee Retirement 

Income Security Act of 1974, as amended (“ERISA”), and in particular, ERISA §§ 

502(e)(1) and (f), 29 U.S.C. §§ 1132(e)(1) and (f). Those provisions give the district 

courts jurisdiction to hear civil actions brought to recover benefits due under the 

terms of an employee welfare benefit plan. In addition, this action may be 

brought before this Court pursuant to 28 U.S.C. § 1331, which gives the district 

courts jurisdiction over actions that arise under the laws of the United States. 

Pursuant to ERISA § 502(h), a copy of this Complaint has been served upon the 

United States Secretary of Labor, and the United States Secretary of the Treasury.

VENUE

2. Venue is proper under ERISA § 502(e)(2), 29 U.S.C. §1132(e)(2), in 

that the employee benefit plan that is the subject of Plaintiff’s claims is 

administered in this District and/or the breaches described below occurred 

within the territorial limits of this District and/or a defendant may be found 

within the territorial limits of this District.

PARTIES

3. Karen Tomlinson (hereinafter “Ms. Tomlinson” and/or “Plaintiff”) 

is, and at all times mentioned herein was, a participant, within the meaning of 

ERISA § 3(7), 29 U.S.C. § 1002(7), in the Kaiser Foundation Health Plan, Inc. Long 

Term Disability Plan (the “Plan”). Plaintiff is, and at all times mentioned herein 

was, a California resident, residing in Concord, California. 

4. The Plan is, and at all times mentioned herein was, an employee 

welfare benefit plan within the meaning of ERISA § 3(1), 29 U.S.C. § 1002(1), 

administered in Oakland, California. The Plan is named as a defendant in this 

action solely to ensure complete relief.

Case 4:17-cv-00540-DMR Document 1 Filed 02/02/17 Page 2 of 9
TOMLINSON v. METROPOLITAN LIFE, et al.

COMPLAINT – Case No. 17-cv-540 3

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5. Plaintiff is informed and believes that Defendant METROPOLITAN

LIFE INSURANCE COMPANY (“MetLife”) is, and at all times mentioned herein 

was, a corporation formed under the laws of the state of New York, with its 

principal place of business in New York, New York; licensed by the California 

Department of Insurance to do business in California, and doing business 

throughout the state of California. At all times relevant herein, the Plan 

provided long-term disability (“LTD”) benefits to employees of Kaiser 

Permanente Health Plan, Inc., including Plaintiff, funded by a group policy 

insurance contract with MetLife. MetLife is a claim fiduciary responsible for 

paying benefits under the Plan and making decisions regarding eligibility for 

benefits under the Plan. As such, MetLife is a plan administrator within the 

meaning of ERISA § 3(16)(A), 29 U.S.C. § 1002(16)(A). As plan administrator, 

and as an entity that exercised discretion over Plan administration and assets, 

MetLife is, and at all times mentioned herein was, a fiduciary within the meaning 

of ERISA § 3(21)(A), 29 U.S.C. § 1002(21)(A). As a fiduciary that makes benefit 

determinations and funds those same benefits, MetLife operates under an 

inherent structural conflict of interest.

FACTUAL ALLEGATIONS

6. Ms. Tomlinson was employed by Kaiser Permanente Health Plan,

Inc. (“Kaiser”) as a registered Nurse. On her last day of work, September 15, 

2014, she held the position of Staff Nurse II/Advice Nurse for Kaiser’s hospice 

skilled nursing facility. Her position required focused, complex decisionmaking, 

frequently in urgent and emergent circumstances, arising from the complications 

of end-of-life care. She is now and at all times relevant hereto has been suffering 

from an active, ongoing, disabling infectious process diagnosed as chronic Lyme 

Disease and/or Chronic Fatigue Syndrome. As a result of her illness, Ms. 

Case 4:17-cv-00540-DMR Document 1 Filed 02/02/17 Page 3 of 9
TOMLINSON v. METROPOLITAN LIFE, et al.

COMPLAINT – Case No. 17-cv-540 4

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Tomlinson suffers constant and debilitating pain and chronic fatigue, 

necessitating a daily cocktail of potent painkillers and other medications. Her 

daily life is characterized by crippling pain, severe fatigue, overwhelming 

cognitive dysfunction, persistent depression, anxiety, excruciating headaches, 

frequent nausea and insomnia. Ms. Tomlinson’s symptoms are erratic and 

unpredictable in both onset and severity. Her immune system is significantly 

weakened and thus, her condition prevents her from engaging in virtually any 

social interaction. Ms. Tomlinson is fully disabled and unable to perform any of 

the functions of her own occupation or any other occupation.

7. Ms. Tomlinson filed a claim for long-term disability benefits and a 

life insurance waiver of premium under the Plan. On July 27, 2015, MetLife

exercised its fiduciary discretion over the Plan’s administration and denied her

long-term disability benefits. On September 29, 2015, MetLife exercised its 

fiduciary discretion over the Plan’s administration and denied Ms. Tomlinson’s

life insurance waiver of premium. 

8. Subsequent to MetLife’s denial of her long-term disability benefits

and life insurance waiver of premium, Ms. Tomlinson applied for and was 

awarded Social Security disability benefits based upon the Social Security 

Administration’s finding that she was completely disabled from performing any 

occupation in the national economy. Ms. Tomlinson provided notice of her 

favorable Social Security determination to MetLife on April 24, 2016. MetLife

promised to evaluate the Social Security award and reconsider MetLife’s denial 

of Ms. Tomlinson’s benefits in light of the social security disability benefits 

award, but MetLife never followed through or did so.

9. MetLife’s denials of Ms. Tomlinson’s long-term disability benefits

and life insurance waiver of premium were made without sufficient investigation 

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TOMLINSON v. METROPOLITAN LIFE, et al.

COMPLAINT – Case No. 17-cv-540 5

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of the claims, or any request for additional information. Although the Plan gave 

MetLife the right to an in-person examination of Ms. Tomlinson to better 

investigate her claims, MetLife failed to do so. MetLife’s denials failed to 

articulate what specific additional information Ms. Tomlinson could have or 

should have provided in order to perfect her claims. Ms. Tomlinson submitted a 

timely administrative appeals of MetLife’s denial of her long-term disability 

benefits and life insurance waiver of premium, but MetLife affirmed its adverse 

benefit determination and its denial of life insurance waiver of premium on 

appeal.

10. Ms. Tomlinson has exhausted her administrative appeals, and 

satisfied all other conditions precedent to suit.

11. Whether Ms. Tomlinson is eligible for long-term disability benefits

and a life insurance waiver of premium under the Plan shall be decided by the 

court on de novo review. De novo review is applicable because the Plan does not 

properly confer discretionary authority to MetLife to decide questions or 

eligibility for long-term disability benefits, and even if it did California Insurance 

Code Section 10110.6 renders such discretionary authority void as a matter of 

California law.

FIRST CAUSE OF ACTION

(Claim for Long-Term Disability Benefits and for Clarification of Rights to 

Future Benefits Under the Terms of the Plan pursuant to 

ERISA § 502(a)(1)(B))

12. Ms. Tomlinson realleges and incorporates by reference all 

allegations contained in paragraphs 1 through 11, as if fully stated herein.

13. ERISA § 503, 29 U.S.C. § 1133, and 29 C.F.R. § 2560.503-1 require 

every employee benefit plan, including an employee welfare benefit plan, to 

follow certain minimum procedures pertaining to claims for benefits and to 

Case 4:17-cv-00540-DMR Document 1 Filed 02/02/17 Page 5 of 9
TOMLINSON v. METROPOLITAN LIFE, et al.

COMPLAINT – Case No. 17-cv-540 6

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provide “adequate notice in writing” to participants whose claims for benefits 

under a plan have been denied. 29 C.F.R. § 2560.503-1(b)(5) requires that claims 

procedures contain administrative processes and safeguards designed to ensure 

and verify that benefit claim determinations are made in accordance with 

governing plan documents and that, where appropriate, plan provisions have 

been applied consistently with respect to similarly situated claimants. 

14. Employee benefit plans must further afford a reasonable 

opportunity for participants to receive a “full and fair review” after a claim for 

benefits has been denied. ERISA’s claims regulation, 29 C.F.R. § 2560.503.1-(g) 

requires that communications denying benefits must be clear and presented in 

language that an ordinary participant can understand, and further requires plan 

administrators to inform participants in such communications what additional 

information they could should have provided in order to perfect their claim.

15. In committing the acts and omissions herein alleged, Defendants 

have violated ERISA § 503, 29 U.S.C. § 1133 and 29 C.F.R. § 2560.503-1. 

16. Ms. Tomlinson is informed and believes, and thereon alleges, that 

Defendants have also violated 29 C.F.R. § 2560.503-1(b)(5) by providing benefits 

to other participants under circumstances similar to those of the Ms. Tomlinson.

17. Defendant MetLife’s adverse benefit determinations are contrary to 

the documents and instruments governing the Plan, and are also inconsistent 

with the reasonable expectations of Ms. Tomlinson to receive long-term 

disability benefits and a life insurance waiver of premium under the Plan based 

upon her total disability. 

18. As a result of the violations of ERISA by MetLife, and the Plan’s 

failure to pay benefits to which Ms. Tomlinson is entitled, Ms. Tomlinson is 

entitled to recovery pursuant to ERISA § 502(a)(1)(B), 29 U.S.C. § 1132(a)(1)(B), 

Case 4:17-cv-00540-DMR Document 1 Filed 02/02/17 Page 6 of 9
TOMLINSON v. METROPOLITAN LIFE, et al.

COMPLAINT – Case No. 17-cv-540 7

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which permits recovery of benefits due under the terms of an employee benefit 

plan. 

19. Ms. Tomlinson is further entitled to a clarification of her rights to 

future benefits under the terms of the Plan pursuant to ERISA § 502(a)(1)(B), 29 

U.S.C. § 1132(a)(1)(B).

SECOND CAUSE OF ACTION

(Breaches of Fiduciary Duty Under ERISA § 502(a)(3))

20. Ms. Tomlinson realleges and incorporates by reference all 

allegations contained in paragraphs 1 through 19, as if fully stated herein.

21. ERISA § 404(a)(1)(A), 29 U.S.C. § 1104(a)(1)(A), requires fiduciaries 

to discharge their duties solely in the interests of employee benefit plan 

participants and beneficiaries and for the exclusive purpose of providing 

benefits and defraying reasonable expenses of administering the plan.

22. ERISA § 404(a)(1)(B), 29 U.S.C. § 1104(a)(1)(B), requires fiduciaries 

to discharge their duties with the care, skill, prudence, and diligence under the 

circumstances then prevailing that a prudent man acting in like capacity and 

familiar with such matters would use in the conduct of an enterprise of a like 

character and with like aims. 

23. ERISA § 404(a)(1)(D), 29 U.S.C. § 1104(a)(1)(D), requires fiduciaries 

to discharge their duties in accordance with the documents and instruments 

governing the plan insofar as such documents and instruments are consistent 

with the provisions of ERISA.

24. In committing the acts and omissions herein alleged, MetLife

breached its fiduciary duties in violation of ERISA §§ 404(a)(1)(A), (B) and (D), 

29 U.S.C. §§ 1104(a)(1)(A)(B) and (D).

25. Ms. Tomlinson is informed and believes, and thereon alleges, that 

Case 4:17-cv-00540-DMR Document 1 Filed 02/02/17 Page 7 of 9
TOMLINSON v. METROPOLITAN LIFE, et al.

COMPLAINT – Case No. 17-cv-540 8

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MetLife has awarded long-term disability or other comparable benefits to other 

participants under circumstances similar to those of the Ms. Tomlinson. The 

failure to provide long-term disability benefits to Ms. Tomlinson as it has done 

so for other Plan participants in similar circumstances constitutes a breach of its 

fiduciary duties in violation of ERISA §§ 404(a)(1)(A) and (B), 29 U.S.C. §§ 

1104(a)(1)(A) and (B), wherefore Ms. Tomlinson is entitled to appropriate 

equitable relief including but not limited to injunction and surcharge.

PRAYER FOR RELIEF

WHEREFORE, Ms. Tomlinson prays judgment as follows:

A. For long-term disability benefits under the Plan pursuant to ERISA 

§ 502(a)(1)(B), 29 U.S.C. § 1132(a)(1)(B);

B. For an award of benefits and an order clarifying Plaintiff’s right to 

future benefits pursuant to ERISA § 502(a)(1)(B), 29 U.S.C. § 1132(a)(1)(B), 

including but not limited to long-term disability benefits and the restoration of 

her life insurance premium waiver benefit;

C. For appropriate equitable relief pursuant to ERISA § 502(a)(3), 29 

U.S.C. § 1132(a)(3), including but not limited to a declaration of her rights 

hereunder with respect to Defendant MetLife; an injunction against further 

failure to provide her benefits, and surcharge for any pecuniary injuries Ms. 

Tomlinson has suffered as a consequence of Defendant MetLife’s breaches of its 

ERISA fiduciary duties; 

D. For reasonable attorneys’ fees and costs incurred by Plaintiff in the 

prosecution of this action pursuant to ERISA § 502(g), 29 U.S.C. § 1132(g);

E. For pre-judgment interest and post-judgment interest on any and all 

amounts awarded to Ms. Tomlinson; and

F. For all such other relief as the Court deems appropriate and 

Case 4:17-cv-00540-DMR Document 1 Filed 02/02/17 Page 8 of 9
TOMLINSON v. METROPOLITAN LIFE, et al.

COMPLAINT – Case No. 17-cv-540 9

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equitable.

DATED this 2nd day of February, 2017.

By /s/ Lisa S. Serebin

Lisa S. Serebin

Attorneys for Plaintiff Karen 

Tomlinson

LAW OFFICES OF JEFFREY C. METZGER

By /s/ Jeffrey C. Metzger

Jeffrey C. Metzger

Attorneys for Plaintiff Karen 

Tomlinson

Case 4:17-cv-00540-DMR Document 1 Filed 02/02/17 Page 9 of 9