United States District Court, N.D. California, San Jose Division
ORDER DENYING PLAINTIFF'S MOTION FOR SUMMARY
JUDGMENT; GRANTING DEFENDANT'S MOTION FOR SUMMARY
JUDGMENT RE: DKT. NOS. 62, 64
J. DAVILA UNITED STATES DISTRICT JUDGE.
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.
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
“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;
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.
Record (“AR”) at 001470. The Plan contains the
following limitation for disabilities due to a mental or
nervous disorder or disease:
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:
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
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.
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.
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.
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.
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.
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).
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
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).
Standard of Review
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.
Defendant's Benefit Determination Was Not
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.
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.
Defendant's Medical Reviewers Conducted a Thorough Review