The opinion of the court was delivered by: WILLIAM HASKELL ALSUP, District Judge.
ORDER DENYING DEFENDANT'S MOTION FOR SUMMARY JUDGMENT AND
REMANDING MATTER TO PLAN ADMINISTRATOR
Plaintiff filed suit under 29 U.S.C. § 1132(a)(1)(B), the civil
enforcement provision of the Employee Retirement Income Security
Act of 1974 ("ERISA"), to recover benefits allegedly due.*fn1
order DENIES the motion for summary judgment of defendant
Jefferson Pilot Financial Insurance Company ("Jefferson Pilot")
and REMANDS the matter to the plan administrator for a
redetermination of plaintiff's eligibility for benefits.
Plaintiff worked as an assistant sales manager at Serramonte
Auto Plaza, an automobile dealership. Serramonte provided its
employees, including plaintiff, with disability insurance. A
group insurance policy issued by Guarantee Life Insurance Company
to Serramonte Auto Plaza set forth the terms of coverage (Maley
Plaintiff suffers from diabetic neuropathy and alleges that
this condition has rendered him unable to perform the main duties
of his job. In February 2001, plaintiff submitted a short-term
disability claim form to Guarantee Life Insurance (Maley Exh. 1).
Included with plaintiff's submission was an "Attending Physician
Statement," a Guarantee Life Insurance form signed on by Dr.
Aruna Chinnakotla, plaintiff's physician (ibid.). Dr. Chinnakotla
indicated on the form that plaintiff suffered from diabetes with
neuro/renal manifestations and was totally disabled from his
present occupation from February 5 through May 4, 2001 (ibid.).
The insurer's definition of total disability was printed on this
Jefferson Pilot, which administered the insurance plan,
concluded that there was not enough medical information to
support plaintiff's claim of disability (Maley Exh. 4). Jefferson
Pilot informed plaintiff of this assessment and requested
relevant medical records from Dr. Chinnakotla (Maley Exh. 5).
After reviewing the material submitted by Dr. Chinnakotla,
Jefferson Pilot denied
plaintiff's request for disability benefits (Maley Exh. 7). In a
letter dated April 4, 2001, Jefferson Pilot informed plaintiff of
its decision (ibid.). The letter stated in part (ibid.):
Benefits are being denied based on the following
"Total Disability" means the "Insured Person's
inability, due to Sickness or Injury, to perform each
of the material duties of his or her regular
occupation". A person engaging in employment for wage
or profit is not Totally Disabled.*fn2
The letter further explained that "there is not sufficient
medical information to support a severity of impairment, which
would render you, totally disabled from your occupation" (ibid.).
The letter noted that Dr. Chinnakotla characterized plaintiff's
condition as "under control" and that plaintiff's symptoms of
"burning, tingling and sometimes electrical shock sensation in
the feet, especially at nighttime" were to be treated by an
increased dosage of medication (ibid.). "Taking a medication
alone," the letter stated, "does not substantiate Total
Disability as defined above" (ibid.).
On May 5, 2001, plaintiff wrote to Jefferson Pilot requesting a
reconsideration of the decision to deny him benefits (Maley Exh.
8). He explained that his job in car sales required him to stand
on his feet for long periods of time and that his job and
diabetes were causing pain in his feet (ibid.). He further stated
that he was "unable to perform [his] job" because he was "unable
to stand for longer than half and [sic] hour" (ibid.). Plaintiff
enclosed a letter from a neurologist, Dr. Chi-Chen Mao,
confirming that plaintiff had difficulty performing work duties
because his diabetic neuropathy caused him to experience pain
while on his feet (ibid.). Also enclosed was a health-care
provider form noting that plaintiff's "peripheral neuropathy
. . . is aggravated by the weight bearing demands of his job" and
"[h]is condition would improve with a new job with less weight
bearing" (ibid.). Jefferson Pilot wrote to plaintiff on June 7,
2001, explaining that it was unable to overturn its decision
because plaintiff's submissions contained no new medical evidence
of total disability (Maley Decl. ¶ 11).
In November 2001, Jefferson Pilot received a letter from the
California Department of Insurance indicating that plaintiff had
requested assistance and asking Jefferson Pilot to reevaluate the
matter (Maley Exh. 9). Jefferson Pilot requested and received
additional medical information from Dr. Chinnakotla and Dr. Mao.
It then arranged for a third physician, licensed in California
and selected by a third-party vendor, to review plaintiff's
medical records. The third physician, Dr. Fred Nowroozi,
requested a job description for plaintiff's regular occupation,
which plaintiff's employer subsequently provided. The job
description indicated that plaintiff's duties as a car
salesperson required him to sit for three hours, stand for two
hours, and walk for three hours each workday, all with rest
(Maley Exh. 20). Furthermore, plaintiff's job occasionally
required him to bend, to squat, and to lift and carry loads of up
to ten pounds (ibid.). "Driving automotive equipment" was also
included among the activities the job involved (ibid.).
Dr. Nowroozi recommended that plaintiff undergo additional
testing to evaluate his ability to return to work (Maley Exh.
18). Another physician, Dr. David Discher, subsequently reviewed
plaintiff's medical records and examined him. Dr. Discher's
evaluation, dated July 20, 2002, included the following
conclusions (Maley Exh. 22):
Specific Limitations and Restrictions
Sitting limited to 30 minutes at a time. Standing
limited to 30 minutes at a time. Alternating between
both over an 8 hour work day is recommended. Walking
distance should be limited to 100 feet without uneven
terrain or stair climbing. Walking can be repeated
over the workday with the requirement of a sitting
rest of at least 30 minutes prior to a walk.
* * * * * *
Physical Capacity Findings
Is generally able to use his feet for standing and
walking alternating with appropriate sitting
intervals. Carrying light loads, lifting repetitively
light loads, and assuming mild bended or squatting
positions are all functionally safe within some
limits for repetitions. I do not recommend that this
person operate any vehicle.
Employer's Physical Requirements for Sales Person
With respect to [the requirements] listed by his
employer, I have interpreted that none of my
recommended limitations or restrictions are impacting
on job requirements, assuming that sitting and
standing/walking alternation can be worked out in the
details. These statements are limited to my
evaluation of his feet. The statements bear on
current abilities and functional capacities, not
Jefferson Pilot concluded from Dr. Discher's report that
plaintiff did not suffer from a sickness or injury that rendered
him unable to perform the main duties of his regular occupation
(Maley Exh. 24-25). Jefferson Pilot forwarded Dr. Discher's
report to plaintiff's treating physician, Dr. Chinnakotla, for
comment. As requested, Dr. Chinnakotla confirmed in writing that
she agreed with the Dr. Discher's findings (Maley Exh. 24).
Relying on the assessments by Dr. Discher and Dr. Chinnakotla,
Jefferson Pilot concluded that plaintiff was not totally disabled
within the meaning of the policy, and as a ...