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Roach v. Kaiser Permanente Long Term Disability Plan

May 12, 2009

PATRICIA ROACH, PLAINTIFF,
v.
KAISER PERMANENTE LONG TERM DISABILITY PLAN; METROPOLITAN LIFE INSURANCE COMPANY, DEFENDANTS.



The opinion of the court was delivered by: John F. Walter United States District Judge

FINDINGS OF FACT AND CONCLUSIONS OF LAW

This action came on for court trial on April 14, 2009. Sara Smith Ray of Altman & Ray LLP appeared for Plaintiff Patricia Roach ("Plaintiff"). Rebecca A. Hull appeared for Defendants Kaiser Permanente Long Term Disability Plan and Metropolitan Life Insurance Company(collectively "Defendants").

After considering the evidence, briefs, and argument of counsel, the Court makes the following findings of fact and conclusions of law:

Findings Of Fact*fn1

I. Introduction

This is an action under the Employee Retirement Income Security Act of 1974, 29 U.S.C. § 1001, et seq. ("ERISA") for recovery of long term disability benefits under a group long term disability plan issued by Metropolitan Life Insurance Company("MetLife") to Kaiser Foundation Health Plan, Inc. for the benefit of employees of the Southern California Permanente Medical Group("SCPMG"). On July 18, 2008, Plaintiff filed a Complaint seeking review of Defendants' denial of Plaintiff's long term disability ("LTD") benefits under the Kaiser Permanente Long Term Disability Plan, insured by MetLife (the "Plan").

II. Facts

Plaintiff commenced her employment with SCPMG in 1975. As a benefit of her employment with SCPMG, Plaintiff was eligible for long term disability insurance under the Plan issued by MetLife. At all relevant times, Plaintiff was a participant in the Plan. Pursuant to the terms of the Plan, MetLife is the claims administrator for claims made under the Plan and is also a Plan fiduciary.

A. The Plan

After a 180 day Elimination Period (during which no benefits are paid), the Plan provides long term disability ("LTD") benefits if the participant became disabled while covered under the Plan. (AR 0024)

The Plan defines "disabled" or "disability" as follows: "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 Earnings 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 0025) "Own occupation" is defined as: the activity that you regularly perform, as determined by the Employer, and that serves as your source of income. . . .Own occupation is not limited to the specific position you held with your Employer. It may be a similar activity that could be performed with your Employer or any other Employer.

(AR 0025). If the participant is disabled "due to a Mental or Nervous Disorder or Disease," the Plan limits coverage to 36 months of disability, including the 180 day Elimination Period. (AR 0030) In effect, after accounting for the Elimination Period during which no benefits are payable, a participant who is disabled due to a Mental or Nervous Disorder or Disease is entitled to only 30 months of disability payments. "Mental or Nervous Disorder or Disease" means "a medical condition of sufficient severity to meet the diagnostic criteria established in the current Diagnostic And Statistical Manual of Mental Disorders. You must be receiving Appropriate Care and Treatment for your condition by a mental health Doctor." (AR 0030)

B. Plaintiff's Occupation and her Disability

Plaintiff began her employment with SCPMG on October 13, 1975, and held a number of positions during her approximately 30 years of employment with SCPMG. She began her most recent position as a Project Manager/Ambulatory Care Registered Nurse Manager in 2002. (AR 0098; 0203-206) Her responsibilities included overseeing the remodeling and building of a new facility, which required her to meet with architects and facility administrators regarding design. (AR 0259) She typically worked 12 to 14 hour days. (AR 0259) According to Plaintiff's supervisor, her position required overtime on a routine basis, and necessitated "frequent" stressful situations (34 to 66 percent of the time) and "continual" interpersonal relations with others (67 to 100 percent of the time). (AR 0108) Her position was not capable of being modified by her employer. (AR 0109)

In September 2004, Plaintiff awoke with intense chest pains that required her to be hospitalized from September 10 to 15, 2004. (AR 0129) After Plaintiff's hospital stay, she remained at home for two days, and then returned to work on September 20, 2004. (AR 0129) However, on November 4, 2004, Plaintiff's primary care physician, Sue Park, M.D. recommended that Plaintiff see a psychologist and that she take time off from work due to significant stress. (AR 0195; AR 0280) Plaintiff has not worked since then. (AR 0129)

On December 1, 2004, Dr. Park submitted a "Documentation of Medical Impairment (DMI)" form to Plaintiff's employer, stating that Plaintiff was completely unable to work for 60 days due to "anxiety/stress/phobic disorders." (AR 0275) Plaintiff's medical leave was thereafter extended by her physicians multiple times. (AR 0153, 0171, 0182, 0201, 0227, 0245)

On February 2, 2005, Plaintiff was examined by Jeffrey Hirsch, M.D., an internist, in connection with Plaintiff's application for workers' compensation. (AR 0258-266) He determined that Plaintiff suffered from occupational stress, multiple stress-driven physical complaints, temporomandibular joint syndrome ("TMJ") with bruxism, and musculoskeletal pain. (AR 0258; 0263) He opined that "[i]t is medically reasonably probable that Ms. Roach's underlying tendency toward hypertension has been 'lit up' due to her exposure to stress." (AR 0264) Dr. Hirsch concluded that Plaintiff was "temporarily totally ...


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