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Bosley v. Metropolitan Life Insurance Co.

United States District Court, N.D. California

June 13, 2017





         Plaintiff in this ERISA action contends that defendant insurer erred in denying his claim for long-term disability benefits. This order agrees in part based upon findings of fact and conclusions of law after a one-day bench trial, as set forth below.


         Plaintiff Robert Bosley worked for non-party Kaiser Permanente from 2006 to 2013. He enrolled in Kaiser's ERISA plan, which included a long-term disability insurance policy issued by defendant Metropolitan Life Insurance Company (“MetLife”). Bosley previously claimed, and MetLife approved, long-term disability benefits in 2009 and 2011. Benefits from those claims terminated in 2010 and 2012, respectively, when Bosley returned to work in less demanding positions. In 2014, Bosley submitted a third claim for long-term disability benefits based on chronic fatigue syndrome. MetLife denied that claim and Bosley's subsequent appeal.

         Bosley filed the instant action in January 2016. Both sides agreed to de novo review and moved for summary judgment. A prior order denied MetLife's motion because MetLife “failed to explain why it rejected Bosley's subjective complaints, ” noting that, “Ordinarily, it would be appropriate to remand this action to MetLife to reevaluate Bosley's claims, now directed to consider his subjective complaints and the assessments thereof” (Dkt. No. 38 at 7-8). Bosley, however, requested further discovery of his claim files from 2009 and 2011 to show that MetLife “paid the prior claims on essentially the same basis” as that asserted for his 2014 claim, to “provide additional evidence of inconsistent positions taken by MetLife . . . as well as further evidence of [his] disability, ” and to provide “evidence of MetLife's breach of fiduciary duty” (see Dkt. No. 34 at 3). The Court granted Bosley's request and held his motion for summary judgment in abeyance (Dkt. No. 38 at 8).

         After MetLife produced the 2009 and 2011 claim files, Bosley renewed his motion for summary judgment, urging against remand and suggesting a bench trial “[i]n the event the Court does not see its way clear to granting summary judgment” (Dkt. No. 39 at 7-8). A subsequent order denied Bosley's motion, noting that “there are significant differences between Bosley's 2009, 2011, and 2014 claims, ” and “Bosley was and remains wrong . . . in representing that MetLife previously approved his long-term disability claims based on the same medical record as in the 2014 claim” (Dkt. No. 54 at 3). That order agreed, however, that a bench trial was preferable to remand under these circumstances (id. at 5).

         Bosley had aged out of his eligibility for benefits as of July 29, 2016, effectively capping the amount of benefits at issue in this case (Dkt. Nos. 57 at 2; 65 at 10). Both sides therefore requested that the bench trial proceed solely on the “closed administrative record” (Dkt. No. 57 at 2). They disagreed, however, as to the scope of that record. When the Court tried to clarify the issue at the final pretrial conference, both sides reaffirmed their agreement that this case should be decided on the administrative record alone. Counsel for MetLife maintained that the prior claim files from 2009 and 2011 did not belong in the record but nevertheless agreed that the Court could review those files in making its decision. This case was thus submitted on a closed record consisting of Bosley's claim files from 2009, 2011, and 2014, except that both sides submitted a joint pretrial statement with stipulated facts, submitted separate proposed findings of fact and conclusions of law, and presented closing argument.[*]

Stipulated facts and any proposed finding of fact expressly agreed to by the opposing side at least in part shall be deemed adopted to the extent agreed upon, even if not expressly adopted herein. Citations to the record herein are provided only as to particulars that may assist the court of appeals. All declarative statements herein are factual findings.


         1. MetLife's policy provided in relevant part that a participant in Kaiser's ERISA plan is disabled if (AR 59):

(a) during the 90-day elimination period and the next 24 months, the participant is “unable to perform with reasonable continuity the Substantial and Material Acts necessary to pursue [their] Usual Occupation in the usual and customary way” (the “own occupation” provision), or
(b) after the elimination period plus 24 months, the participant is unable “to engage with reasonable continuity in any occupation in which [they] could reasonably be expected to perform satisfactorily in light of [their] age, education, training, experience, station in life, and physical and mental capacity” (the “any occupation” provision).

         The policy also defined “Substantial and Material Acts” as (AR 60):

[T]he important tasks, functions and operations generally required by employers from those engaged in [the participant's] Usual Occupation that cannot be reasonably omitted or modified. In determining what substantial and material acts are necessary to pursue [the participant's] Usual Occupation, [MetLife] will first look at the specific duties required by [the participant's] job. If [the participant is] unable to perform one or more of these duties with reasonable continuity, [MetLife] will then determine whether those duties are customarily required of other employees engaged in [the participant's] Usual Occupation.

         Finally, the policy defined “Usual Occupation” as (ibid.):

[A]ny employment, business, trade or profession and the Substantial and Material Acts of the occupation [the participant was] regularly performing for the employer when the Disability began. Usual Occupation is not necessarily limited to the specific job that [the participant] performed for the employer.

         2. In 2007, after an extensive work-up that ruled out many other diagnoses, the Veterans Administration diagnosed ...

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