The opinion of the court was delivered by: Trumbull, United States Magistrate Judge.
OPINION AND ORDER ON CROSS-MOTIONS FOR SUMMARY JUDGMENT
Dionida submitted a claim for disability benefits arising from back and
shoulder problems. Reliance initially approved Plaintiff's claim, but
shortly thereafter reviewed her claim and denied it based on a
Transferable Skills Analysis that identified eight "suitable occupations"
for Dionida. On Dionida's appeal of the denial, Reliance affirmed its
decision to deny her claim.
For the reasons discussed below, the court reviews de novo, rather than
for abuse of discretion, Reliance's decision to deny benefits. "The court
finds that under either standard of review, Reliance's decision was
erroneous because it applied an "any occupation" standard rather than the
"regular occupation" standard required by the LTD Plan. Based on the
fully developed record, the only possible conclusion is that Dionida is
unable to perform the duties of her regular occupation, and is thus
entitled to benefits.
On July 17, 1995, Dionida submitted to Reliance a statement of claim
for long term disability benefits under an insurance policy issued to her
employer, St. Lukes Hospital. In her statement of claim, she identified
her disability as "severe low back pain radiating to right leg, and right
shoulder." The LTD Plan's description of "Total Disability" requires that
during the first 66 months*fn1 of disability the claimant be unable to
perform the material duties of his or her "regular occupation." She
described her occupation as "Staff Registered Nurse."
The administrative file for Dionida's claim contains several supporting
records from her doctors. Prior to Reliance's initial approval of
Dionida's claim, the primary support for her claim came from her treating
physician, Cesar Ortiz, M.D. Dr. Ortiz completed a Physician's Statement
of Disability form supplied by Reliance. In it he identified the
diagnoses as: 1) Chronic Degenerative Change in Acromioclavicular Joint
with Encroachment on Rotation Cuff; 2) Degenerative Arthritis of Lumbar
Spine with Slipped of L4 on L5; and 3) Bilateral Radiculopathy. He
indicated that Dionida was totally disabled from her regular occupation
and from any occupation.
There are also several other Disability Certificates and Doctor's
Certificates in the administrative file that Dr. Ortiz apparently filled
out for submission to St. Lukes and California's Employment Development
Department ("EDD") in connection with Dionida's disability leave and
disability claims. The file also contains copies of Dr. Ortiz's records
and a Physical Capacities form he filled out at Reliance's request. On
the Physical Capacities form, he indicates that Dionida is capable of
lifting/carrying a maximum of ten pounds, which is characterized on the
form as "sedentary work." He also indicates restrictions on bending,
squatting, climbing, reaching above the shoulder, kneeling, crawling and
using foot controls. The administrative record also contains a few
records from other doctors that do not add materially to the information
"provided by Dr. Ortiz.
Reliance approved Dionida's claim on February 1, 1998. Six weeks after
approving Dionida's claim, Defendants decided to require Plaintiff to
submit to an independent medical examination ("IME").). The M.D. was
performed by Robert Branick, He stated in his report that:
"1) The results of the physical examination are
inconclusive in determining significant disability.
The objective studies that are available do document
disability related to impingement of the, right
shoulder as well as fairly mild degenerative changes
in the lumbar spine which will cause some restrictions
as mentioned above, that is, repetitive bending,
stooping, lifting, and carrying of weights in excess
of 25 pounds.
"5) This has been answered above. Barring appropriate
medical or surgical treatment, the patient will have
"6) The patient's limitations will interfere with the
ability to work as a registered nurse. Any other work
that could be carried out aside from that requiring
bending, lifting, and carrying would be permissible.
Sedentary work, keyboard work, work requiring
mobility, etc., would all be permissible."
Dr. Branick also completed a Physical Capacities form, on which he
indicates that Dionida was capable of lifting/carrying a maximum of 20
pounds (in his narrative report he says 25 pounds), which is characterized
on the form as "light work." He also indicates restrictions on bending,
climbing, and reaching above the shoulder.
Based on Dr. Branick's IME report and Physical Capacities form,
Reliance asked its Vocational Rehabilitation Consultant, Rabia Rosen, to
do a Transferable Skills Analysis ("TSA"). Rosen reported the results of
the TSA in a memorandum dated June 19, 1996. Rosen stated that "[b]ased
on her work history and her current capabilities and utilizing the OASYS
system,*fn2 a TSA was performed and eight suitable occupations were
identified for this claimant." Accompanying the memorandum is a computer
printout that contains: 1) a DOT occupation description for "Nurse,
General Duty"; 2) a ...