The opinion of the court was delivered by: Hon. Jeffrey T. Miller United States District Judge
ORDER REGARDING SCOPE OF REVIEW MOTIONS TO DETERMINE Doc. Nos. 34 & 35
Plaintiff John Paul Micha filed the instant lawsuit seeking review of Defendants' decision to deny his claim for disability benefits. (Doc. No. 5, "Complaint.") Defendant Sun Life Assurance Company of Canada ("Sun Life") now brings a motion requesting the court to determine the proper scope of its review. (Doc. No. 34.) Plaintiff has filed a cross-motion requesting the same, in which he is joined by Defendant and Cross-Claimant Group Disability Benefits Plan for Gynecologic Oncology Associates Partners, LLC ("Group Disability Plan"). (Doc. Nos. 35-42, collectively "Cross-Motion"; Doc. No. 50)
Pursuant to CivLR 7.1(d)(1), the court has determined that this matter is appropriate for resolution without oral argument. For the reasons set forth below, the court DENIES Sun Life's motion and GRANTS IN PART and DENIES IN PART Plaintiff's and Group Disability Plan's motion.
Plaintiff is a board-certified gynecologic oncology cancer surgeon employed by Gynecologic Oncology Associates Partners, LLC ("GOA") in Newport Beach, California. (Complaint ¶¶ 4 & 9.) GOA maintains a welfare benefit plan for its employees through Defendant/Cross-Claimant Group Disability Plan. (Id. ¶ 6.) On or around June 1, 2006, Group Disability Plan purchased an insurance policy (the "Policy") from Defendant Sun Life for purposes of funding its plan. (Id. ¶¶ 6 & 11; Doc. No. 14, "Cross-Claim," ¶ 149.) Prior to that, the plan had been covered by various other insurance providers. (Complaint ¶ 11.) The Group Disability Plan provides benefits to GOA employees deemed totally or partially disabled and "unable to perform the [m]aterial and [s]ubstantial [d]uties" of their specific occupation. (Id. ¶ 20-21.) Sun Life has the sole authority to determine whether claimants are eligible for these benefits. (Cross-Claim ¶ 150.)
A. Plaintiff's Medical History
On February 6, 2006, Plaintiff took a leave of absence from his work at GOA to undergo a total arthroplasty on his right hip at Hoag Memorial Hospital. (Complaint ¶ 34.) He was discharged for a two-month convalescent period, and returned to work on April 1, 2006. (Id. ¶¶ 34-35.) Although Plaintiff did not immediately resume his pre-surgery workload, he claims that he steadily increased the amount of work he took on in the subsequent months until he returned to his normal level of productivity in July 2006. (Id. ¶ 36.)
On July 22, 2006, Plaintiff suffered a sudden acute anterior wall myocardial infarction ("MI"). (Id. ¶ 39.) Plaintiff's regular cardiologist, Dr. Richard J. Haskell, performed an emergent angiography and angioplasty on Plaintiff with stenting to the left anterior descending artery times three to prevent further damage to the heart. (Id. ¶¶ 38-39.) Before discharging Plaintiff from the hospital, Dr. Haskell placed him on multiple medications, including a beta blocker, an ace inhibitor, a statin, and a platelet drug. (Id. ¶ 39.)
After his MI, Plaintiff began to experience a variety of symptoms, including shortness of breath, dizziness, muscle weakness, fatigue, chest pain, and nausea. (Id. ¶¶ 41-42.) He underwent a series of tests and evaluations, and some of his medications were discontinued and new medications substituted several times in an attempt to alleviate some of the problems. (Id. ¶¶ 41-45, 47 & 49.) Upon returning to work, Plaintiff was initially limited to performing office duties part-time without any surgeries. (Id. ¶ 46.) In August 2006, Plaintiff began seeing a psychiatrist, Dr. Robert Johnson, for treatment of the depression he was experiencing as a result of his inability to perform surgeries and the side effects from his medication. (Id. ¶ 48.) Beginning in October, Plaintiff once again began performing relatively easy surgeries, and by November was operating 30 hours per week (compared to his normal pre-MI level of 90 hours per week). (Id. ¶ 49.) However, he continued to complain of "significant fatigue and trouble focusing, muscle weakness, and dizziness" through December, particularly during longer surgeries. (Id. ¶ 49.)
On January 15, 2007, Plaintiff was performing a surgery when he was overcome by extreme dizziness and fatigue. (Id. ¶ 52.) Although he ultimately was able to complete the procedure, he immediately canceled the six other surgeries he had scheduled for that week. (Id.) Following the incident, GOA and Dr. Haskell determined that Plaintiff was no longer able to safely perform surgery, and Plaintiff was limited to seeing only non-surgical patients thereafter. (Id. ¶ 53.) As a result of his reduced workload, Plaintiff's monthly earnings dropped significantly. (Id. ¶ 55.)
B. Plaintiff's Original Claim to Sun Life
Shortly after the January 15 incident, Plaintiff submitted a long-term disability claim to Sun Life, citing the symptoms of his disability, including "easily fatigued/severe fatigue, trouble focusing, muscle weakness, dizziness, chest pain and inability to multitask required during surgery." (Id. ¶ 57 (internal quotation marks omitted).) GOA and Dr. Haskell also submitted documents to Sun Life in connection with Plaintiff's claim. (Id. ¶ 58; Doc. No. 35-1 p. 6.) Specifically, Dr. Haskell completed an "Attending Physician Statement" ("APS") form provided by Sun Life in which he described Plaintiff's "[d]iagnosis and complications" as "[a]cute MI, fatigue, muscle weakness, [and] dizziness." (Complaint ¶ 58.) Dr. Haskell also speculated that these symptoms might be related to side effects from some of the medications Plaintiff was taking for his heart condition as well as possible depression. (Id. ¶¶ 59-62.)
In order to aid Sun Life's investigation of his claim, Plaintiff signed several release forms authorizing Sun Life to obtain any relevant medical, occupational, or earnings information from GOA, his physicians, and any other disability insurance companies that had provided Plaintiff with coverage during this time. (Id. at ¶ 64.) Plaintiff also participated in a 1.3-hour in-person interview with a representative from Archangel Investigations, an investigation service retained by Sun Life, on February 12, 2007, and submitted multiple financial documents, including quarterly profit and loss statements and tax returns, to Sun Life at its request. (Id. ¶¶ 66 & 69.) In addition, Plaintiff informed Sun Life on April 18, 2007 that two of his individual disability insurers had made findings of total disability and begun payments of full monthly disability benefits to Plaintiff under their policies with him. (Id. ¶ 71.) At no time during its review process did Sun Life request any additional examinations or testing to be performed on Plaintiff. (Id. ¶ 68.)
C. Sun Life's First Denial of Plaintiff's Claim
On May 23, 2007, a Sun Life agent informed Plaintiff's wife telephonically that Sun Life was denying Plaintiff's claim "due to the contractual provisions as noted in the [Policy]." (Id. ¶ 72.) Plaintiff subsequently received a letter of denial from Sun Life dated May 31, 2007, in which Sun Life purportedly explained the basis for its decision. (Id. ¶ 75; Cross-Motion at Exh. E, hereafter "Claim File," pp. 1424-32, hereafter "Original Denial.") In it, Sun Life stated generally that Plaintiff did not qualify for long-term disability benefits under the Policy, and went on to lay out its analysis in greater detail. (Id.) First, Sun Life indicated that it was "first notified of [Plaintiff's] claim for [long-term disability] benefits on January 23, 2007," despite the Policy term which requires that "written notice of claim must be given to Sun Life no later than 30 days before the end of the applicable Elimination Period"-January 18, 2007, in Plaintiff's case. (Original Denial at p.1.) The letter also went on to cite to several other provisions from the Policy, including the definitions of "total disability" and "partial disability," but did not explain the specific relevance of these provisions to the denial. (Id. at pp. 2-3.)
Sun Life then provided an overview of Plaintiff's "Claim History" and both a "Financial Review" and an "Occupational Review," summarizing its interpretation of the relevant facts in Plaintiff's case and the steps Sun Life took to review Plaintiff's claim. (Id. at pp. 3-6.) Included in this portion of the letter was the analysis of a vocational billing code reviewer asked by Sun Life to review Plaintiff's record of past procedures, who concluded that "[a]fter hip surgery in February 2006, [Plaintiff] never attained the level of productivity as a surgeon compared to 2005." (Id. at p.5.)
The letter then set forth the medical and psychiatric reviews of Plaintiff's condition conducted by Sun Life. (Id. at pp. 6-7.) Sun Life stated that it had forwarded Plaintiff's medical files to an orthopedist, a cardiologist, and a psychiatrist, each of whom provided his own medical opinion based on the information contained therein. (Id.) All three specialists concluded that there was no medical basis for Plaintiff's current inability to resume surgeries at his original pace and workload. (Id.) The orthopedist stated that Plaintiff's "treatment appears appropriate" with regard to his hip replacement surgery, and that there were "limited additional office notes reflecting any ongoing treatment . . . that would have precluded [Plaintiff] from returning to normal [work] capacity." (Id. at p.6.) The cardiologist opined that Plaintiff "has no evidence of any functional cardiac impairments," and that Plaintiff "has intact heart function and excellent functional capacity" such that Plaintiff should be able "to return to all of his usual pre-MI level of activity." (Id.) The cardiologist further concluded that "[t]he kinds of symptoms [Plaintiff] has are not likely due to his medicines," and that he "d[id] not feel these symptoms are directly related to any cardiac impairment." (Id.) Finally, the psychiatrist found that Plaintiff's condition was merely an emotional response to his MI, and not based on any diagnosed psychiatric condition. (Id. at p.7.)
Sun Life concluded that Plaintiff was not eligible for either total or partial disability benefits under the Policy because "any loss of income appears to be as a result of a life-style choice to stop working for your Employer and not as a result of any restrictions and limitations that would prevent you from performing a sedentary occupation." (Id.) However, the letter also appeared to intimate that Plaintiff might be disabled as a result of his February 2006 hip surgery, stating that "there is insufficient objective evidence to that [sic] after your February 6, 2006 total hip replacement surgery that [sic] you recovered completely and continued to perform similar surgeries at the same capacity that you were performing prior to February 2006," and that "there was a significant change in your medical condition in February 2006 causing you the inability of [sic] regaining the same productivity level." (Id. at pp. 7-8.) Sun Life further suggested that Plaintiff's disability resulting from the February 2006 surgery might be covered under a prior carrier's plan, since Sun Life's coverage did not become effective until June 1, 2006. (Id. at p.7.) The letter ended with a notice of Plaintiff's right to appeal Sun Life's denial within 180 days. (Id. at p.8.) The notice also stated that Plaintiff could "submit written comments, document, records or other information relating to [his] claim for benefits" in support of his appeal, and that Plaintiff was entitled receive "free of charge copies of all documents, records, and other information relevant to [his] claim for benefits." (Id.) However, the notice did not specify what additional information Plaintiff could provide on appeal to perfect his claim.
D. Plaintiff's Appeal to Sun Life
On June 8, 2007, Plaintiff requested a copy of all documents in his file from Sun Life; however, the file that Sun Life sent back was incomplete, omitting certain records including the reports of the medical specialists retained by Sun Life. (Complaint ¶¶ 88-89.) Plaintiff nevertheless submitted his appeal on October 16, 2007. (Id. ¶ 92.) Included in his appeal were a letter from his colleague, Dr. Mark Rettenmaier, discussing the specific occupational demands of gynecologic oncology surgeons and his own observations of Plaintiff's job performance following his MI; letters from Connie L. Birk, a registered nurse at GOA, and Plaintiff's wife, also describing their observations of Plaintiff's recent condition; a report from Plaintiff's neurologist Dr. Janet M. Chance, dated September 27, 2007, in which Dr. Chance diagnosed Plaintiff with vertigo and ordered a series of tests to determine its cause; and a second opinion report of another cardiologist, Dr. Marvin Appel, in which Dr. Appel explained the side effects of Plaintiff's medications and concluded that Plaintiff was "unfit to perform surgery." (Id.)
E. Sun Life's Final Denial of Plaintiff's Claim
As part of its review of Plaintiff's appeal, Sun Life sent requests for updated medical records to both Dr. Chance and Dr. Johnson. (Claim File at pp. 1490-91.) In addition, Sun Life forwarded Plaintiff's file to several new medical specialists for reassessment. (Complaint ¶ 98.) Sun Life thereafter issued a final decision confirming its original denial of Plaintiff's claim. (Id. ¶ 108.)
In a letter dated December 28, 2007, Sun Life explained that its decision was based on three medical and psychiatric reviews of Plaintiff's record. (Claim File at pp. 1541-46, hereafter "Final Denial.") First, Dr. Paul W. Sweeney, a cardiologist, examined Plaintiff's medical history and concluded that "[t]here is no direct cardiac cause of [Plaintiff's] current symptoms and perceived limitations." (Final Denial at p.2.) In Dr. Sweeney's opinion, Plaintiff's reported symptoms of "fatigue, dizziness, and lack of focus are not symptoms typically seen as a result of a small to moderate myocardial infarction"; rather, Dr. Sweeney speculated that they could "represent reactive depression or be in part secondary to medication." (Id. at pp. 2-3.) In particular, Dr. Sweeney suggested experimenting with alternative beta blockers and statins in order to determine if a better combination of medications was available for Plaintiff. (Id. at 3.) Second, Sun Life submitted Plaintiff's records to a neurologist, Dr. Alan Neuren, who concluded that "[t]here is no neurological basis for [Plaintiff's] complaints." (Id.) Instead, Dr. Neuren hypothesized that "[i]n all probability [Plaintiff's] somatic complaints are a manifestation of his emotional reaction to his heart attack." (Id.) He added that Plaintiff's symptoms of "[f]atigue and difficulty concentrating are common manifestations of depression/anxiety or dysthymia." Finally, a psychiatrist, Dr. Mark Schroeder, also examined Plaintiff's records and concluded that they "did not demonstrate impairment likely due to a psychiatric disorder severe enough to lead to restrictions and limitations." (Id. at p.4.) Dr. Schroeder found that Plaintiff's file did not support a finding of dysthymic disorder, but rather was "potentially consistent with a diagnosis of adjustment disorder with depressed mood or depressive disorder NOS." (Id. at p.3.) However, because Dr. Johnson's records did not provide sufficient objective findings, as through "a detailed cognitive mental status examination or neuropsychological testing," it was difficult to ascertain Plaintiff's true level of functional impairment. (Id.) Although Dr. Schroeder also noted that "[n]europsychological testing with validity scales could be helpful in assessing potential cognitive impairment due to [cardiac] medication or other causes," he explicitly stated that he was "not specifically recommending that such testing be done." (Id. at p.5.)
Based on the updated reviews of Plaintiff's records conducted by Drs. Sweeney, Neuren, and Schroeder, Sun Life determined that it was "unable to identify any medical or psychiatric condition which would reasonable [sic] render [Plaintiff] unable to perform the Material and Substantial Duties of [his] Own Occupation" under the Policy. (Id.) The letter concluded by informing Plaintiff that "[a]ll administrative remedies have been exhausted," but that he "ha[d] the right to bring a civil action under the Employee Retirement Income Security Act of 1974 (ERISA), §502(a)." (Id.)
On December 9, 2009, Plaintiff commenced the instant action against Defendants Group Disability Plan and Sun Life, seeking to recover unpaid disability benefits and enforce his right to future benefits under the Policy pursuant to 29 U.S.C. § 1132(a)(1)(B). (Doc. No. 5.) In its response to Plaintiff's complaint, Group Disability Plan filed an answer admitting substantially all of Plaintiff's allegations, along with a cross-claim against Sun Life for a declaration of comparative fault and indemnification. (Doc. No. 14.)
Sun Life now brings a motion requesting that the court issue an order restricting the scope of its review to the administrative record in this case. (Doc. No. 34.) Plaintiff in turn brings a cross-motion requesting an order admitting certain items of evidence not in the underlying administrative record. (Doc. No. 35.) Group Disability Plan has filed a joinder to Plaintiff's cross-motion. (Doc. No. 50.)
The Employment Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. § 1001 et seq., was enacted by Congress to protect the interests of both participants in employee benefit plans as well as their beneficiaries "by setting out substantive regulatory requirements for employee benefit plans and . . . 'provid[ing] for appropriate remedies, sanctions, and ready access to the Federal courts.'" Aetna Health Inc. v. Davila, 542 U.S. 200, 209 (2004) (quoting 29 U.S.C. § 1001(b)). To this end, the Act has been described as serving "competing congressional purposes": on the one hand, Congress sought "to offer employees enhanced protection for their benefits"; on the other, it also wished to avoid "creat[ing] a system . . . so complex that administrative costs, or litigation expenses, unduly discourage employers from offering welfare benefit plans in the first place." Varity Corp. v. Howe, 516 U.S. 489, 497 (1996).
29 U.S.C. § 1132(a)(1)(B) empowers an employee benefit plan participant to bring a civil action "to recover benefits due to him under the terms of his plan, to enforce his rights under the terms of the plan, or to clarify his rights to future benefits under the terms of the plan." "[A] denial of benefits challenged under § 1132(a)(1)(B) is to be reviewed under a de novo standard unless the benefit plan gives the administrator or fiduciary discretionary authority to determine eligibility for benefits or to construe the terms of the plan." Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989).
In 1995, the Ninth Circuit addressed the question of whether a district court can consider evidence outside of the administrative record upon de novo review of a plan administrator's decision. Mongeluzo v. Baxtor Travenol Disability Benefit Plan, 46 F.3d 938 (9th Cir. 1995). The Mongeluzo Court decided to follow the approach adopted by several other circuits, holding that "new evidence may be considered under certain circumstances to enable the full exercise of informed and independent judgment." Id. at 943 (emphasis added). The Court further noted that the decision to allow such evidence was within the district court's discretion; however, it also emphasized that [t]he district court should exercise its discretion . . . only when circumstances clearly establish that additional evidence is necessary to conduct an adequate de novo review of the benefit decision. In most cases, where additional evidence is not necessary for adequate review of the benefits decision, the district court should only look at the evidence that was before the plan administrator . . . at the time of the determination.
Id. at 944 (quoting Quesinberry v. Life Ins. Co. of N. Am., 987 F.2d 1017, 1025 (4th Cir. 1993)) (emphasis added). Thus, only under exceptional circumstances should consideration of extra-record evidence be permitted. The Mongeluzo Court went on to find that such circumstances were present in the situation before it because of an intervening Ninth Circuit decision that narrowed the definition of mental illness, thereby "chang[ing] the legal posture of [the] case." Id. Because "the original hearing was conducted under a misconception of the law," the ...