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Proof v. Intel Corporation Long Term Disability Plan

August 11, 2010

SHELLEY PROOF, PLAINTIFF,
v.
INTEL CORPORATION LONG TERM DISABILITY PLAN, DEFENDANT.



The opinion of the court was delivered by: Garland E. Burrell, Jr. United States District Judge

ORDER DENYING DEFENDANT'S MOTION FOR SUMMARY JUDGMENT AND REMANDING PLAINTIFF'S CLAIM FOR LONG TERM DISABILITY BENEFITS TO THE CLAIMS ADMINISTRATOR

Defendant Intel Corporation Long Term Disability Plan ("Defendant") seeks summary judgment on Plaintiff's claim for long term disability ("LTD") benefits, to which Plaintiff alleges she is entitled under the Employee Retirement Income Security Act of 1974, 29 U.S.C. § 1132 (a)(1)(b) ("ERISA"). However, the summary judgment record reveals that Plaintiff prevails on an issue even though Plaintiff is not a movant. "Even when a party has not cross moved for summary judgment, the Court may enter summary judgment in its favor if[, as here,] the other party has had a 'full and fair opportunity to ventilate the issues involved in the matter.'" Manyak v. Blackrock, Inc., 2010 WL 1927733, at *3 (W.D. Wash. 2010) (ERISA case) (quoting Cool Fuel, Inc. v. Connett, 685 F.2d 309, 312 (9th Cir. 1982)).

It is undisputed in this case that the review standard applicable to Plaintiff's LTD claim is the abuse of discretion standard. (SUF ¶ 5; Def.'s Mot. for Summ. J. 10:24-25; Plt.'s Opp'n 11:10-11.) Abuse of discretion review applies to a plan that "confer[s] discretionary authority on the administrator [of the plan]... to construe the terms of the plan." Abatie v. Alta Health & Life Ins. Co., 458 F.3d 955, 965 (9th Cir. 2006) (en banc). "Where the decision to grant or deny [ERISA] benefits is reviewed for abuse of discretion, a motion for summary judgment is merely the conduit to bring the legal question before the district court and the usual tests of summary judgment... do not apply." Bendixen v. Standard Ins. Co., 185 F.3d 939, 942 (9th Cir. 1999), abrogated on other grounds by Abatie, 458 F.3d at 965, 966-67, as recognized in Montour v. Hartford Life & Accident Ins. Co., 588 F.3d 623, 631 (9th Cir. 2009).

I. Background

Plaintiff worked at Intel as a Project Manager and was a participant in Intel's short-term and LTD plans. The LTD Plan (the "Plan") grants discretion to the Plan administrator to make factual determinations and to interpret the terms of the Plan. Beginning in 2005, Intel delegated its responsibility for administration of the Plan to Broadspire Services, Inc., an independent third party, which subsequently transferred its responsibility for claims administration to Aetna Life Insurance Company ("Aetna"). (Statement of Undisputed Facts ("SUF") ¶ 6.) If a participant is denied benefits under the Plan, "the participant can appeal the denial to the Aetna Appeal Committee ('Appeal Committee')." (Id. ¶ 7.)

On January 3, 2008, Plaintiff applied for and received short-term disability benefits. Aetna sent Plaintiff a "LTD Packet" in October 2008, "a few months" before her short-term disability benefits were scheduled to expire. (SUF ¶ 14.) The Packet explained the LTD Plan, provided information regarding the Plan, including Plan definitions of "Disability" and "Objective Medical Findings", and requested Plaintiff to complete and return the forms included with the LTD Packet. (Id. ¶ 15.)

Under the Plan terms, disability is defined as "any illness or injury that is substantiated by Objective Medical Findings and which renders a Participant incapable of performing work." (SUF ¶ 4; Administrative Record ("AR") 0001.) The Plan defines an "Objective Medical Finding" as "a measurable, independently-observable abnormality which is evidenced by one or more standard medical diagnostic procedures... that support the presence of a disability or indicate a functional limitation." (AR 0004.)

Plaintiff returned the forms included in the LTD Packet on October 18, 2008. Plaintiff wrote under the section in the forms entitled "Duties You Now Cannot Perform": "Due to the nausea, vomiting, and weakness attributed to my disability, I am no longer able to perform any job duties." (AR 0268.) Plaintiff also identified in her response Doctors Mark Redor, Amar Al-Juburi, and Lin Soe as her treating physicians. (SUF ¶ 22; AR 0270.) Aetna requested and received medical records from these physicians. (SUF ¶ 27.) Before receiving the requested medical records, Aetna sent Plaintiff a letter dated November 19, 2008 in which Aetna denied her claim because "there [were] no objective medical findings to substantiate [her] inability to perform her own occupation." (AR 0055.) Plaintiff's physician Dr. Redor submitted to Aetna his Attending Physician Statement form on November 17, 2009. (SUF ¶ 21.) Dr. Redor listed on this form "diabetic gastroparesis" as Plaintiff's "primary diagnosis" and attached reports of two gastric emptying studies dated November 13, 2006 and May 8, 2008, and two esophagogastroduodenoscopies dated February 1, 2007 and May 16, 2008. (AR 544-554.) Dr. Redor also listed Plaintiff's symptoms as "chronic nausea and vomiting" and checked the box "No ability to work." (Id. 0545.) Aetna again rejected Plaintiff's claim for LTD benefits in a letter dated November 26, 2008, stating "please refer to the initial denial letter." (AR 0057.)

Aetna sent Plaintiff's medical records to Aetna Review Consulting Services ("ARCS") on December 26, 2008, for review by a specialist in gastroenterology. (SUF ¶ 28.) ARCS referred the records to Doctor Jack Cohen, "an independent physician certified by the American Board of Gastroenterology." (Id. ¶ 29.) Dr. Cohen reviewed the medical records and conducted a peer-to-peer consultation with Dr. Redor, during which Dr. Redor stated Plaintiff had gastroparesis and "that the limiting factor in [Plaintiff's] returning to work was nausea." (AR 0163.) However, Dr. Cohen stated in his "Physician Review" form that Dr. Redor "agrees that [nausea] is a totally subjective symptom." (AR 0163.) Dr. Cohen also noted that Plaintiff "has not lost any weight," "has no electrolyte abnormalities, and she shows no signs of malnutrition." (AR 0164.) Dr. Cohen concluded "[t]he objective medical findings do not substantiate that the claimant is unable to perform the duties of her own occupation." (AR 0165; SUF ¶ 30.)

Aetna relied upon Dr. Cohen's review and notified Plaintiff that her application for LTD benefits had been denied in a letter dated January 14, 2009, which stated:

The review of your file indicated that there are no objective medical findings to substantiate your inability to perform your own occupation. You[r] diagnosis of gastroparesis is secondary to your [Insulin-Dependent Diabetes Mellitus]. You indicate symptoms of constant nausea with intermittent vomiting. Despite this diagnosis, you have maintained your weight. You have not had any problems with electrolyte imbalance or dehydration. Laboratory data failed to reveal any nutritional deficits secondary to your nausea and vomiting. Your symptomatology is not of an intensity or severity that it would impact upon your performing job related activities of a light physical demand rating.

Additionally, we contacted Dr. Redor to discuss your case. Dr. Redor indicated that the limiting factor in your returning to work was nausea. Dr. Redor agreed that this is a totally subjective symptom. Dr. Redor also agreed that despite that gastroparesis, nausea and intermittent vomiting you have not lost any weight. You have no electrolyte abnormalities and show no signs of malnutrition. It is again our determination that to date, your file does not include objective medical findings to substantiate you are incapable of performing work on a full time basis at this point or in the future. Under the terms of your contract objective medical findings do not include physicians' opinions or other third party opinions based on the acceptance of subjective complaints. (AR 0059.)

Plaintiff appealed Aetna's denial of her LTD benefits claim on February 19, 2009. (SUF ΒΆ 34.) The Appeal was assigned to Ana Molina ("Molina"), a Senior Appeal Specialist. Molina sent Plaintiff's medical records to ARCS for review by a gastroenterologist and an endocrinologist in March 2009. The Appeal Committee completed its review of Plaintiff's appeal on April 24, 2009, and notified Plaintiff in a letter dated April 24, 2009 ...


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