United States District Court, N.D. California
ORDER DENYING PLAINTIFF'S MOTION FOR PARTIAL SUMMARY JUDGMENT Re: Dkt. No. 31
WILLIAM H. ORRICK, District Judge.
Defendant Reliance Standard Life Insurance Company ("Reliance") denied plaintiff Marlon Montoya's claim for long term disability benefits under a plan covered by the Employee Retirement Income Security Act of 1974 ("ERISA"). At oral argument on defendants' motion for partial summary judgment on the question of exhaustion of administrative remedies, I granted leave for the parties to brief the issue of whether ERISA's procedural safeguards require that Reliance allow Montoya to review and respond to the independent medical examination (IME) reports before Reliance reaches a final decision on plaintiff's administrative appeal. Having considered the briefs submitted, I find that on the record before me Montoya has not shown that he is entitled to review the IME reports prior to Reliance issuing a final decision on Montoya's appeal.
Montoya is a beneficiary of an ERISA-covered long term disability insurance plan, for which Reliance is the plan fiduciary and claims administrator. See Order Denying Motion for Summary Judgment (Dkt. No. 35), 1-2. On April 20, 2013, Montoya filed a claim for benefits, which was denied on June 18, 2013. Id. at 2. On December 19, 2013, Montoya appealed the denial. Id. As part of its review of the appeal, Reliance arranged for Montoya to undergo two independent medical examinations ("IMEs"), one psychological and one physical. Id. Montoya appeared for the psychological IME, refused to attend the rescheduled physical IME because counsel was not allowed to be present, and simultaneously filed suit seeking declaratory relief as to his rights under ERISA. Id. Shortly after this lawsuit was filed, Reliance upheld its initial denial of Montoya's claim based on physical disability, citing his failure to cooperate with Reliance's physical IME request as a reason for the denial. Id. at 2-3. Later, Reliance upheld its denial of Montoya's claim based on psychological disability, relying on the results of the psychological IME. Id. at 3.
At the February 4, 2015, oral argument on defendants' motion for summary judgment on exhaustion of administrative remedies, the parties raised the additional issue of whether Reliance is required under ERISA to provide Montoya with a copy of the IME reports before it reaches a final decision on his appeal. Montoya contends that as a plan participant, he is entitled under ERISA to the opportunity to view and respond to the IME results. Plaintiff's First Amended Complaint ("FAC") (Dkt. No. 32) ¶¶ 14, 24. I granted leave for the parties to brief this issue and I treat that briefing as a motion for partial summary judgment.
Summary judgment is proper "if the movant shows that there is no genuine dispute as to any material fact and the movant is entitled to judgment as a matter of law." Fed.R.Civ.P. 56(a). The moving party bears the initial burden of demonstrating the absence of a genuine issue of material fact. Celotex Corp. v. Catrett, 477 U.S. 317, 323 (1986). The moving party, however, has no burden to disprove matters on which the non-moving party will have the burden of proof at trial. The moving party need only demonstrate to the court "that there is an absence of evidence to support the nonmoving party's case." Id. at 325.
Once the moving party has met its burden, the burden shifts to the non-moving party to "designate specific facts showing that there is a genuine issue for trial." Celotex, 477 U.S. at 324 (quotation marks omitted). To carry this burden, the non-moving party must "do more than simply show that there is some metaphysical doubt as to the material facts." Matsushita Elec. Indus. Co., Ltd. v. Zenith Radio Corp., 475 U.S. 574, 586 (1986). "The mere existence of a scintilla of evidence... will be insufficient; there must be evidence on which the jury could reasonably find for the [non-moving party]." Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 252 (1986).
In deciding a summary judgment motion, the court must view the evidence in the light most favorable to the non-moving party and draw all justifiable inferences in its favor. Anderson, 477 U.S. at 255. "Credibility determinations, the weighing of the evidence, and the drawing of legitimate inferences from the facts are jury functions, not those of a judge... ruling on a motion for summary judgment." Id.
Montoya argues that he is entitled to review and respond to the IME reports prior to a final determination on administrative appeal because ERISA regulations require a claimant to be provided with an opportunity for a "full and fair review" of the claim during the appeal.
I. "FULL AND FAIR REVIEW" UNDER ERISA
ERISA requires a plan administrator to provide a full and fair review of the plan participant's claim. 29 U.S.C. § 1133(2). The claims procedures of a plan "will not be deemed to provide a claimant with a reasonable opportunity for a full and fair review of a claim and adverse benefit determination unless the claims procedures [¶] [p]rovide that a claimant shall be provided, upon request and free of charge, reasonable access to, and copies of, all documents, records, and other information relevant to the claimant's claim for benefits." 29 C.F.R. § 2560.503-1(h)(2)(iii). A "relevant" document, record, or other information includes what was "submitted, considered, or ...