United States District Court, N.D. California, San Jose Division
For Robert Gordon, Plaintiff: Charles J. Fleishman, A Professional Corporation, Woodland Hills, CA; Paul Amos Fleishman, The Fleishman Law Firm, Woodland Hills, CA.
For Metropolitan Life Insurance Company, Defendant: Rebecca A. Hull, LEAD ATTORNEY, Erin A. Cornell, Sedgwick LLP, San Francisco, CA.
ORDER DENYING PLAINTIFF'S MOTION FOR SUMMARY ADJUDICATION
Re: Dkt. No. 53
EDWARD J. DAVILA, United States District Judge.
In this action under the Employee Retirement Income Security Act of 1974 (" ERISA" ), 29 U.S.C. § 1132, Plaintiff Robert Gordon (" Plaintiff" ) seeks long term disability (" LTD" ) payments from Defendant Metropolitan Life Insurance Company (" Defendant" ) after Defendant denied his claim for that relief through his former employer's benefits plan. Presently before the court is Plaintiff's Motion for Summary Adjudication focused solely on the standard of review that should be applied to Defendant's benefits determination. See Docket Item No. 53. Defendant has filed written opposition to the motion. See Docket Item No. 54.
This matter was found suitable for decision without oral argument pursuant to Civil Local Rule 7-1(b). Having carefully considered the parties' arguments and evidence, the court has determined that Plaintiff's request for de novo review is unpersuasive. Thus, this motion will be denied, but with particular instructions regarding the appropriate level of scrutiny that will be applied to the decision on Plaintiff's claim.
I. FACTUAL AND PROCEDURAL BACKGROUND
Plaintiff alleges he began employment with Ashton-Tate in 1989 until it was purchased by Borland Software (" Borland" ) in 1991, at which time he began working for Borland. On or about April 19, 2002, Plaintiff commenced a period of short term disability. See Decl. of Paul Fleishman (" Fleishman Decl." ), Docket Item No. 53, at AR 001410-11. He returned to work on May 1, 2002, but was terminated that same day. Id. at AR 001412-13.
Although questioned initially, it appears undisputed at this point that Plaintiff became subject to Borland's Long Term Disability Employment Benefit Plan (the " Borland Plan" ) while he was an employee of the company. Id. at AR 000947. On October 22, 2009, Plaintiff submitted a claim for LTD benefits under the Borland Plan. Id. at AR 001440. He indicated on the claim form that he had suffered from " disabling back and neck pain from degenerative disc disease," " chronic migraine headaches," and " failed knee and shoulder surgery" from February, 2002. Id.
On May 7, 2010, Defendant notified Plaintiff that it lacked " required Employer information to complete the initial review" of Plaintiff's claim. Id. at AR 001079. Specifically, Defendant stated that it lacked " an Employer statement which provides verification and documentation of [Plaintiff's] LTD coverage and as an eligible employee with Borland Software Corporation." Id. Defendant further indicated that Plaintiff's claim would be closed " until required Employer information is received and reviewed to determine his eligibility for LTD coverage," but also stated Plaintiff could appeal the decision because the claim " was denied in whole or in part." Id.
Plaintiff appealed the May 7th decision on August 11, 2010. Id. at AR 001053. He then initiated this action on November 29, 2010. See Compl., Docket Item No. 1. At that time, Defendant had not yet issued a decision on Plaintiff's appeal.
On December 9, 2011, with this case still pending, Plaintiff and Defendant agreed to remand Plaintiff's LTD claim back to Defendant so that it could resolve the undecided appeal. See Docket Item No. 24. The court granted the parties' stipulation on January 24, 2012, and stayed the proceedings. See Docket Item No. 25.
Pursuant to the remand, Defendant determined on March 30, 2012, that Plaintiff had coverage under the Borland Plan through May 1, 2002. Id. at AR 000947. Plaintiff then faxed to Defendant on April 4, 2012, certain forms Defendant required to determine his eligibility for benefits. Id. at AR 000961. On August 3, 2012, Defendant informed Plaintiff that it sent copies of record review reports to three of Plaintiff's treating physicians and had given them two weeks to respond. Id. at AR 000917. These physicians, however, claimed not to have received any documents related to Plaintiff. Id. at AR 000813-15.
On December 7, 2012, Defendant notified Plaintiff his LTD claim was denied, this time because the information in the claim file did not support disability during the relevant time period. Id. at AR 000776. Plaintiff appealed from that decision on December 12, 2012. Id. at AR 000775. He provided to Defendant additional information in connection with the appeal on August 6, 2014, and requested that Defendant make a decision on the appeal on August 25, 2014. Id. at AR 000365; 000336-37. He again requested a ...