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Gordon v. Metropolitan Life Insurance Co.

United States District Court, N.D. California, San Jose Division

September 7, 2017





         In this action under the Employee Retirement Income Security Act of 1974, 29 U.S.C. §1001, et seq. (“ERISA”), Plaintiff Robert Gordon (“Plaintiff”) seeks long term disability benefits from Defendant Metropolitan Life Insurance Company (“Defendant”). Presently before the Court are the parties' competing motions for summary judgment. The Court finds it appropriate to take the motions under submission for decision without oral argument pursuant to Civil Local Rule 7-1(b). For the reasons set forth below, the Court DENIES Plaintiff's motion for summary judgment and GRANTS Defendant's motion for summary judgment.


         Plaintiff worked as a Senior Staff Systems Programmer with Ashton-Tate starting in 1989. In 1991, Ashton-Tate was purchased by Borland Software (“Borland”) and Plaintiff worked for Borland until May 1, 2002. As a Borland employee, Plaintiff was eligible for LTD benefits through the Borland Software Corporation LTD Plan (“the Plan”), which is governed by ERISA. Defendant MetLife funded LTD benefits under the Plan and was also the claim administrator for the LTD claims. The Plan includes the following definition of “Disability, ” subject to all other Plan terms and conditions:

“Disabled” or “Disability” means that, due to sickness, pregnancy or accidental injury, you are receiving Appropriate Care and Treatment from a Doctor on a continuing basis; and
1. during your Elimination Period and the next 60 month period, you are unable to earn more than 80% of your Predisability Earnings or Indexed Predisability Earnings at your Own Occupation for any employer in your Local Economy; or
2. after the 60 month period, you are unable to earn more than 80% of your Indexed Predisability Earnings from any employer in your Local Economy at any gainful occupation for which you are reasonably qualified taking into account your training, education, experience and Predisability Earnings.
Your loss of earnings must be a direct result of your sickness, pregnancy or accidental injury. Economic factors such as, but not limited to, recession, job obsolescence, paycuts and job-sharing will not be considered in determining whether you meet the loss of earnings test.

         Administrative Record (“AR”) at 001470. The Plan contains the following limitation for disabilities due to a mental or nervous disorder or disease:

         Limitation For Disabilities Due to Particular Conditions

Monthly Benefits are limited to 24 months during your lifetime if you are Disabled due to a Mental or Nervous Disorder or Disease, unless the Disability results from:
1. schizophrenia;
2. bipolar disorder;
3. dementia; or
4. organic brain disease.
“Mental or Nervous Disorder or Disease” means a medical condition of sufficient severity to meet the diagnostic criteria established in the current Diagnostic And Statistical Manual of Mental Disorders. You must be receiving Appropriate Care and Treatment for your condition by a mental health Doctor.

         AR at 001485.

         On or about April 19, 2002, Plaintiff commenced a period of short term disability. He returned to work on May 1, 2002, but was terminated that same day due to performance issues and his behavior at a meeting with Human Resources about his performance issues. MetLife AR at 001412-13.

         On October 22, 2009, seven years after Plaintiff allegedly became disabled, Plaintiff submitted a claim for LTD benefits for a disability beginning April 19, 2002. AR at 001440. He indicated on the claim form that he suffered from the following conditions that prevented him from performing his job: arthritis in the spine and joints; severe insomnia; collapsed thoracic vertebra; very large spinal osteophytes; herniated vertebral discs; severe cervical foraminal stenosis; depression; chronically active viruses; anxiety; ADD; heart palpitations; impaired short-term memory; migraine headaches; chronic system inflammation; left knee surgery; cervical spine surgery; left shoulder surgery; Apico/jaw surgery; sinus surgery; thoracic and lumbar disc disease; chronic esophagitis; and chronic sinusitis. AR at 001440-41. Accompanying Plaintiff's claim form was a note from his treating physician, Dr. Resneck-Sannes, dated October 15, 2009, which indicated that the most recent date of treatment was October 15, 2009, and stated that Plaintiff had “disabling back & neck pain for degenerative disc disease, ” “chronic migraine headaches, ” and “failed knee and shoulder surgery” since February of 2002. Id.

         In May of 2010, Defendant notified Plaintiff that it lacked “required Employer information to complete the initial review” of Plaintiff's claim. AR at 001079. More specifically, Defendant stated that it lacked verification from Borland that Plaintiff was eligible for LTD coverage. Defendant further indicated that Plaintiff's claim would be closed until it received the employer verification, but also stated Plaintiff could appeal the decision because the claim “was denied in whole or in part.” AR at 001080. Plaintiff appealed Defendant's decision (AR at 001053), and initiated this action on November 29, 2010. See Compl., Docket Item No. 1.

         Pursuant to stipulation, the instant action was stayed while Defendant resolved Plaintiff's appeal. On March 30, 2012, Defendant determined that Plaintiff had coverage under the Borland Plan through May 1, 2002. AR at 000947. A few days later, Plaintiff faxed to Defendant certain forms Defendant required to determine his eligibility for benefits. AR at 000961.

         On December 7, 2012, Defendant notified Plaintiff his LTD claim was denied because the information in the claim file did not support a finding of disability within the meaning of the Plan. AR at 000776. On May 7, 2013, Plaintiff appealed Defendant's decision. Defendant has not issued a formal decision on Plaintiff's appeal.

         The court lifted the stay and restored this case to active litigation on January 2, 2015. See Docket Item No. 48. By Order dated April 29, 2015, this Court determined that Defendant's benefit decision is subject to review under an abuse of discretion standard. See Order Denying Plaintiff's Motion for Summary Adjudication. This Court noted, however, that procedural violations of ERISA's requirements are evidence of arbitrary and capricious decision making. Id. at 7:26-8:3 (citing Gatti v. Reliance Standard Life Ins. Co., 415 F.3d 978, 985 (9th Cir. 2005) and Abatie v. Alta Health & Life Ins. Co., 458 F.3d 955, 972 (9th Cir. 2006) (“A procedural irregularity, like a conflict of interest, is a matter to be weighed in deciding whether an administrator's decision was an abuse of discretion.”)). The Court also advised the parties that it would conduct a review of Defendant's benefit decision “with a heightened degree of skepticism and will consider additional evidence submitted with Plaintiff's notice of appeal.” Id. at 8:4-6. (citing Hinz v. Hewlett Packard Co. Disability Plan, No. 10-CV-03633-LHK, 2011 U.S. Dist. LEXIS 386454, at *24 (N.D. Cal. March 30, 2011).

         Plaintiff now moves for summary judgment, contending that he has been disabled within the meaning of the Plan since he stopped working on April 19, 2002. Defendant opposes Plaintiff's motion for summary judgment and also moves for summary judgment in its favor, contending that its determination was reasonable, supported by the evidence, and not an abuse of discretion.


         Ordinarily, a motion for summary judgment should be granted if “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); Addisu v. Fred Meyer, Inc., 198 F.3d 1130, 1134 (9th Cir. 2000). The moving party bears the initial burden of informing the court of the basis for the motion and identifying the portions of the pleadings, depositions, answers to interrogatories, admissions, or affidavits that demonstrate the absence of a triable issue of material fact. Celotex Corp. v. Catrett, 477 U.S. 317, 323 (1986). If the moving party meets this initial burden, the burden then shifts to the non-moving party to go beyond the pleadings and designate specific materials in the record to show that there is a genuinely disputed fact. Fed.R.Civ.P. 56(c); Celotex, 477 U.S. at 324. The court must draw all reasonable inferences in favor of the party against whom summary judgment is sought. Matsushita Elec. Indus. Co. v. Zenith Radio Corp., 475 U.S. 574, 587 (1986).


         A. Standard of Review

         Under the abuse of discretion standard of review, “the plan administrator's interpretation of the plan ‘will not be disturbed if reasonable.'” Day v. AT&T Disability Income Plan, 698 F.3d 1091, 1096 (9th Cir. 2012) (citing Conkright v. Frommert, 559 U.S. 506 (2010)). The test for abuse of discretion in a factual determination is whether “we are left with a definite and firm conviction that a mistake has been committed, ” and the court “may not merely substitute [its] view for that of the fact finder.” Salomaa v. Honda Long Term Disability Plan, 642 F.3d 666, 676 (9th Cir. 2011), citing United States v. Hinkson, 585 F.3d 1247, 1262 (9th Cir. 2009). “To do so, we consider whether application of a correct legal standard was (1) illogical, (2) implausible, or (3) without support in inferences that may be drawn from the facts in the record.” Id. at 676.

         B. Defendant's Benefit Determination Was Not Unreasonable

         The Administrative record shows that Plaintiff suffered mentally and emotionally as of April 19, 2002, and there is evidence that Plaintiff's condition was directly related to issues at his workplace and with his supervisor. There is also evidence that Plaintiff suffered from chronic pain. The issue before the court, however, is not whether Plaintiff suffered from these medical challenges. Instead, the proper inquiry is whether Defendant's disability determination was reasonable. Day, supra.

         The Administrative Record contains conflicting medical opinions regarding whether Plaintiff's mental condition and chronic pain rendered Plaintiff disabled within the meaning of the Plan as of April 19, 2002. Nevertheless, Defendant's determination that Plaintiff was not “disabled” within the meaning of the Plan cannot be characterized as illogical, implausible or without support in inferences that may be drawn from the record.

         1. Defendant's Medical Reviewers Conducted a Thorough Review ...

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