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JAMES v. EQUICOR

April 24, 1992

JANICE JAMES, Plaintiff,
v.
EQUICOR, INC., et al., Defendants.



The opinion of the court was delivered by: EDWARD A. INFANTE

 I. Introduction

 Plaintiff Janice James' complaint alleges a claim for relief under the Employee Retirement Income Security Act ("ERISA"), 29 U.S.C. Sections 1001 and 1132(a)(1)(B). Plaintiff alleges that defendant Equicor Inc. improperly terminated benefits due her under an employee benefits plan established under ERISA. Equicor Inc. is the plan administrator. Presently before the court is Equicor's motion for summary judgment.

 II. Background

 In 1962, plaintiff developed chronic mild lower back pain which was not severe or disabling. On October 4, 1988, plaintiff fell in a non-work-related incident. This caused a recurrence of her back pain which radiated down the posterior aspect of her lower extremities, extending to her ankles. Plaintiff continues to complain of back pain and tightness.

 At the time of this injury, plaintiff was employed full time as a preschool teacher at Syntex Corporation and was covered by Syntex's employee medical plan, a plan established under ERISA. The plan provides permanent disability benefits for participants who become totally disabled during the term for which they are covered by the plan. *fn1"

 Pursuant to the terms of the plan, plaintiff was considered totally disabled for two years (October 1988 - September 1990) and received benefits of $ 842.53 per month, as well as paid group medical and life insurance. On September 25, 1990, Equicor informed plaintiff that her long term disability benefits were terminated based on the medical records and reports provided by her treating physicians, Dr. Tillim and Dr. Conley, both neurosurgeons. Equicor further informed plaintiff that under the terms of the plan she had 60 days to appeal the decision.

 The next correspondence from plaintiff to Equicor was a letter dated December 27, 1990 from her attorney, Michael Kelly. On January 15, 1991 Equicor responded by sending Mr. Kelly copies of all "pertinent" medical information, and indicating that it would await the receipt of further medical evidence in support of plaintiff's appeal.

 On January 23, 1991 Equicor ordered an MNA Transferable Skills Evaluation. On March 8, 1991, in response to another letter from Mr. Kelly, Equicor informed him that it was still awaiting submission of plaintiff's additional medical evidence. On May 21, 1991, plaintiff submitted a further report of Dr. Tillim to Equicor. Thereafter, Dr. Bruce Raymond reviewed the entire claim file.

 On August 21, 1991 Equicor denied the appeal, but informed plaintiff that Equicor would keep the file open if plaintiff agreed to an independent medical exam ("IME"). Thereafter, plaintiff sent Equicor a document entitled "appeal", but never took Equicor up on its offer to have an IME performed. Instead, plaintiff filed this lawsuit.

 III. Summary Judgment Standard

 Rule 56(c) F.R.Civ.P. provides that upon motion, summary judgment shall be rendered:

 if the pleadings, depositions, answers to interrogatories, and admissions on file, together with the affidavits, if any, show that there is no genuine dispute as to material fact and that the moving party is entitled to judgment as a matter of law.

 Summary judgment is appropriate where there is no genuine issue of material fact and the only dispute is as to pure legal questions. Smith v. Califano, 597 F.2d 152 (9th Cir. 1979). There is no genuine dispute unless a reasonable fact finder could return a verdict for the non-moving party. Anderson v. Liberty Lobby Inc., 477 U.S. 242, 248, 91 L. Ed. 2d 202, 106 S. Ct. 2505 (1986).

 The questions presented by this motion for summary judgment are (1) what is the standard by which the court reviews the ERISA plan administrator's decision?, (2) regardless of the standard applied, does the court review only the record which the plan administrator had before it at the time the final decision to terminate plaintiff's long-term disability benefits was made, or may the court look outside the record at new or additional evidence when reviewing the ...


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