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Reddick v. Metropolitan Life Insurance Co.

United States District Court, S.D. California

March 23, 2017

THOMAS REDDICK, Plaintiff,
v.
METROPOLITAN LIFE INSURANCE COMPANY, et al., Defendant.

          ORDER (1) GRANTING IN PART AND DENYING IN PART PLAINTIFF'S MOTIONS [DOCS. 40, 47] TO AUGMENT THE ADMINISTRATIVE RECORD AND (2) SETTING TRIAL DATES

          Hon. M. James Lorenz United States District Judge

         Pending before the Court is Plaintiff Thomas Reddick's (“Reddick”) motions to augment the administrative record. The Court decides the matter on the papers submitted and without oral argument. See Civ. L. R. 7.1 (d)(1). For the reasons stated below, the Court GRANTS IN PART and DENIES IN PART Reddick's motions.

         I. Background

         This case concerns the termination of Plaintiff Reddick's long term disability benefits. Reddick previously worked as a financial advisor for Morgan Stanley, a mostly sedentary job that requires long hours of sitting and mental concentration. In March 2008, Reddick injured himself when he slipped and fell while performing yard work at his home. As a result, Reddick underwent procedures including spinal surgery, epidural steroid injections, and was placed on various medications that may affect his cognitive abilities. Prior to sustaining this injury, Reddick enrolled in a long-term disability insurance plan provided by his employer Morgan Stanley. Defendant Metropolitan Life Insurance Company (“MetLife”) is both the insurer and administrator of this plan (“the Plan”). Under the Plan, an insured is considered “disabled” (and therefore entitled to benefits) if “due to Sickness or as a direct result of accidental injury: [the insured is] receiving Appropriate Care and Treatment and complying with the requirements of such treatment; [the insured is]: unable to earn more than 80% of [his] Predisability Earnings at [his] Own Occupation from any employer in [his] Local Economy; and unable to perform each of the material duties of [his] Own Occupation.” (AR 1947.)

         Because of his injury, Reddick started drawing benefits on his MetLife policy in 2010. He continued to draw benefits through November 21, 2014, when MetLife terminated his benefits. Prior to benefit termination, MetLife faxed a form (“the Form” [Doc. 40-8 Ex. 1 p. 5]) to Dr. Mark A. Harris (“Dr. Harris”), one of Reddick's treating physicians. The Form asked Dr. Harris “[d]o you agree that [Reddick] has the functional ability to return to work with or without accommodations [yes or no].” Before faxing it back, Dr. Harris circled “yes” and “with” and wrote in “I believe RTW [return to work] is an essential part of spine rehab although in this case likely with accommodations.” MetLife notified Reddick of his benefit termination via letter. (Termination Letter [AR 336-338].) In the Termination Letter, MetLife informed Reddick of his right to appeal within 180 days and explained that he should submit evidence to support his appeal. The Termination Letter did not notify Reddick of the Form filled out by Dr. Harris, nor did MetLife otherwise inform Reddick of the Form's existence prior to his administrative appeal.

         MetLife denied Reddick's administrative appeal. (Appeal Denial [AR 11-17].) In doing so, MetLife relied on a variety of medical and administrative opinions. (Id.) Of special relevance to the present motions, MetLife relied on an administrative law judge's (“ALJ”) determination that Reddick was not sufficiently disabled to qualify for social security disability benefits. (See [Doc. 42] 5:2-5.) This decision was vacated on an appeal heard by Judge Moskowitz.

         MetLife also relied on the opinion of an independent physician consultant (“IPC”). In his report, the IPC concluded Reddick could lift up to 20lbs; sit for 8 hours in an 8hour work day provided he could change positions every 30 minutes; walk and stand; bend, stoop, and twist occasionally; and reach overhead, waist level, and below the waist without any restrictions. (AR 218.) Before stating this conclusion, the IPC's report referenced the ALJ's vacated decision, stating “on December 27, 2013, an administrative law judge denied disability and noted [Reddick] could lift and carry 10 pounds frequently. The administrative law judge noted he could lift 20 pounds occasionally, stand and walk for four out of eight hours a day, and sit for six out of eight hours a day.” (AR 216-17.) The IPC further stated that his conclusions were “based on [Reddick's] history of chronic pain syndrome and previous surgery … [as well as] the note from Dr. Harris of June 5, 2014 [the Form], noting that return to work is an essential part of spine rehabilitation.” (AR 219.)

         Reddick subsequently appealed the denial of his disability benefits to this Court. (See Compl. [Doc. 1].) Reddick now seeks to augment the administrative record with three items. The first item is a letter from Dr. Harris. (The Letter [Doc. 40-8 Ex. 1 pp. 2-4].) In the Letter, Dr. Harris provides an in depth explanation of Mr. Reddick's physical condition, an opinion on Reddick's disability status, and an explanation of what he meant to communicate when he filled out the Form. (Id.) The second item is an exhibit containing W2's and earnings statements which Reddick claims are relevant to determining his disability pay. (Earnings Records [Doc. 40-6 Ex. 4].) The third is a summary judgment order in which Judge Moskowitz vacated the ALJ's opinion and remanded the case. (MSJ Order [Doc. 47-5 Ex. 1].) MetLife opposes the admission of all of these exhibits. (See Opp'ns [Docs. 42, 48].)

         II. Legal Standard

         Consistent with governing law[1], the parties have stipulated that the proper standard of review for this ERISA governed improper denial of benefits claim is de novo. (See Joint Stipulation [Doc. 31]; May 24, 2016 Order [Doc. 41].) Under this standard, the Court's duty is to determine whether a denial of ERISA governed benefits was proper. Abatie v. Alta Health & Life Ins. Co., 458 F.3d 955, 963 (9th Cir. 2006). In making this determination, a Court should generally consider only materials that were a part of the administrative record considered by the plan administrator. Mongeluzo v. Baxter Travenol Long Term Disability Ben. Plan, 46 F.3d 938, 943-44 (9th Cir. 1995). However, a district court, in its discretion, may consider evidence extrinsic to the administrative record when necessary to conduct an adequate de novo review. Id. A non-exhaustive list of circumstances in which extrinsic evidence can thus be “necessary” include those involving (1) potential conflicts of interest presented where the administrator is the payor and (2) relevant evidence that a claimant could not have presented during the administrative review process. Opeta v. Northwest Airlines Pension Plan for Contract Emps, 484 F.3d 1211, 1217 (9th Cir. 2007) (quoting Quesinberry v. Life Ins. Co. of N. Am., 987 F.2d 1017, 1025 (4th Cir. 1993).

         III. Dr. Harris' Letter

         Reddick seeks to admit a letter from Dr. Harris in which Dr. Harris explains what he meant when he filled out the Form stating that Reddick could return to work with accommodation and that a return to work was essential to spine rehab. (The Letter.) Because the Letter was not part of the administrative record, admission is proper only if necessary to conduct an adequate de novo review. Mongeluzo, 46 F.3d at 943-44. Broadly speaking, Reddick argues the Letter is necessary because (1) MetLife based their denial of benefits decision, at least in part, on the Form; (2) the Form is ambiguous; and (3) The Letter shows that Metlife resolved the ambiguity in a manner that is inconsistent with the actual opinion Dr. Harris intended to communicate when he filled out the Form.

         In support of this argument, Reddick cites to Williams v. Sun Life Assurance Co. of Canada, 2009 WL 604942 (C.D. Cal. 2009). In Williams, ERISA claimant Williams appealed the denial of her benefits. In denying Williams' administrative appeal, Defendant Sun Live, the insurer and claims administrator, relied on the opinion of a doctor who reviewed Williams' medical records and prepared a report essentially stating that she was not medically disabled from returning to her work. In reaching this conclusion, the reviewing doctor relied on a form that Sun Live created and sent to Williams' attending physician. The form listed three categories of activity: stand / walk, sit, and drive. Next to each activity were boxes for the attending physician to check off, indicating how much, if any, of the activity she believed Williams could undertake in a given day. Williams' attending physician checked “1-4 hours” for stand/walk, “1-3 hours” for sit, and “1-3 hours” for drive. In so doing, the attending physician meant to communicate her opinion that Williams could intermittently sit for a total of 1-3 hours in a day, whether driving or doing something else while seated. However, the reviewing doctor hired by Sun Live added the maximum number under sit with the maximum number under drive and concluded that Williams could sit for six hours in a given day and therefore was not disabled from performing her work.

         In appealing the denial of her claim to the district court, Williams sought to augment the administrative record with a declaration from her attending physician explaining that Sun Live interpreted the form her attending physician filled out in a manner inconsistent with the information her attending physician intended to communicate. The court granted Williams' motion to augment, emphasizing that (1) the form was ambiguous; (2) Sun Live created the ambiguity in drafting the form; (3) Sun Live, as both insurer and claims administrator, resolved the ambiguity in a manner that ...


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