Gordon v. Metropolitan Life Insurance Company et al
Filing
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ORDER denying 53 Motion for Summary Adjudication. Signed by Judge Edward J. Davila on 4/29/2015. (ejdlc1S, COURT STAFF) (Filed on 4/29/2015)
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UNITED STATES DISTRICT COURT
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NORTHERN DISTRICT OF CALIFORNIA
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SAN JOSE DIVISION
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ROBERT GORDON,
Case No. 5:10-cv-05399-EJD
Plaintiff,
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ORDER DENYING PLAINTIFF’S
MOTION FOR SUMMARY
ADJUDICATION
v.
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United States District Court
Northern District of California
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METROPOLITAN LIFE INSURANCE
COMPANY,
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Defendant.
Re: Dkt. No. 53
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In this action under the Employee Retirement Income Security Act of 1974 (“ERISA”), 29
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U.S.C. § 1132, Plaintiff Robert Gordon (“Plaintiff”) seeks long term disability (“LTD”) payments
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from Defendant Metropolitan Life Insurance Company (“Defendant”) after Defendant denied his
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claim for that relief through his former employer’s benefits plan. Presently before the court is
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Plaintiff’s Motion for Summary Adjudication focused solely on the standard of review that should
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be applied to Defendant’s benefits determination. See Docket Item No. 53. Defendant has filed
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written opposition to the motion. See Docket Item No. 54.
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This matter was found suitable for decision without oral argument pursuant to Civil Local
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Rule 7-1(b). Having carefully considered the parties’ arguments and evidence, the court has
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determined that Plaintiff’s request for de novo review is unpersuasive. Thus, this motion will be
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denied, but with particular instructions regarding the appropriate level of scrutiny that will be
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applied to the decision on Plaintiff’s claim.
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I.
FACTUAL AND PROCEDURAL BACKGROUND
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Plaintiff alleges he began employment with Ashton-Tate in 1989 until it was purchased by
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Borland Software (“Borland”) in 1991, at which time he began working for Borland. On or about
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Case No.: 5:10-cv-05399-EJD
ORDER DENYING PLAINTIFF’S MOTION FOR SUMMARY ADJUDICATION
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April 19, 2002, Plaintiff commenced a period of short term disability. See Decl. of Paul
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Fleishman (“Fleishman Decl.”), Docket Item No. 53, at AR 001410-11. He returned to work on
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May 1, 2002, but was terminated that same day. Id. at AR 001412-13.
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Although questioned initially, it appears undisputed at this point that Plaintiff became
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subject to Borland’s Long Term Disability Employment Benefit Plan (the “Borland Plan”) while
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he was an employee of the company. Id. at AR 000947. On October 22, 2009, Plaintiff submitted
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a claim for LTD benefits under the Borland Plan. Id. at AR 001440. He indicated on the claim
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form that he had suffered from “disabling back and neck pain from degenerative disc disease,”
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“chronic migraine headaches,” and “failed knee and shoulder surgery” from February, 2002. Id.
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On May 7, 2010, Defendant notified Plaintiff that it lacked “required Employer
United States District Court
Northern District of California
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information to complete the initial review” of Plaintiff’s claim. Id. at AR 001079. Specifically,
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Defendant stated that it lacked “an Employer statement which provides verification and
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documentation of [Plaintiff’s] LTD coverage and as an eligible employee with Borland Software
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Corporation.” Id. Defendant further indicated that Plaintiff’s claim would be closed “until
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required Employer information is received and reviewed to determine his eligibility for LTD
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coverage,” but also stated Plaintiff could appeal the decision because the claim “was denied in
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whole or in part.” Id.
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Plaintiff appealed the May 7th decision on August 11, 2010. Id. at AR 001053. He then
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initiated this action on November 29, 2010. See Compl., Docket Item No. 1. At that time,
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Defendant had not yet issued a decision on Plaintiff’s appeal.
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On December 9, 2011, with this case still pending, Plaintiff and Defendant agreed to
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remand Plaintiff’s LTD claim back to Defendant so that it could resolve the undecided appeal.
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See Docket Item No. 24. The court granted the parties’ stipulation on January 24, 2012, and
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stayed the proceedings. See Docket Item No. 25.
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Pursuant to the remand, Defendant determined on March 30, 2012, that Plaintiff had
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coverage under the Borland Plan through May 1, 2002. Id. at AR 000947. Plaintiff then faxed to
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Defendant on April 4, 2012, certain forms Defendant required to determine his eligibility for
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ORDER DENYING PLAINTIFF’S MOTION FOR SUMMARY ADJUDICATION
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benefits. Id. at AR 000961. On August 3, 2012, Defendant informed Plaintiff that it sent copies
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of record review reports to three of Plaintiff’s treating physicians and had given them two weeks
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to respond. Id. at AR 000917. These physicians, however, claimed not to have received any
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documents related to Plaintiff. Id. at AR 000813-15.
On December 7, 2012, Defendant notified Plaintiff his LTD claim was denied, this time
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because the information in the claim file did not support disability during the relevant time period.
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Id. at AR 000776. Plaintiff appealed from that decision on December 12, 2012. Id. at AR
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000775. He provided to Defendant additional information in connection with the appeal on
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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 decision on October 3rd and October 29,
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United States District Court
Northern District of California
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2014. Id. at AR 000334-35. Defendant, however, did not and still has not decided Plaintiff’s
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appeal.
The court lifted the stay and restored this case to active litigation on January 2, 2015. See
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Docket Item No. 48. The instant motion followed.
II.
LEGAL STANDARD
A motion for summary adjudication must meet the same standards as an ordinary motion
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for summary judgment under Federal Rule of Civil Procedure 56. See California v. Campbell,
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138 F.3d 772, 780 (9th Cir. 1998). A motion for summary judgment should be granted if “there is
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no genuine dispute as to any material fact and the movant is entitled to judgment as a matter of
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law.” Fed. R. Civ. P. 56(a); Addisu v. Fred Meyer, Inc., 198 F.3d 1130, 1134 (9th Cir.2000). The
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moving party bears the initial burden of informing the court of the basis for the motion and
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identifying the portions of the pleadings, depositions, answers to interrogatories, admissions, or
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affidavits that demonstrate the absence of a triable issue of material fact. Celotex Corp. v. Catrett,
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477 U.S. 317, 323 (1986). If the moving party meets this initial burden, the burden then shifts to
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the non-moving party to go beyond the pleadings and designate specific materials in the record to
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show that there is a genuinely disputed fact. Fed. R. Civ. P. 56(c); Celotex, 477 U.S. at 324. The
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court must draw all reasonable inferences in favor of the party against whom summary judgment
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is sought. Matsushita Elec. Indus. Co. v. Zenith Radio Corp., 475 U.S. 574, 587 (1986).
However, the mere suggestion that facts are in controversy, as well as conclusory or
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speculative testimony in affidavits and moving papers, is not sufficient to defeat summary
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judgment. See Thornhill Publ’g Co. v. GTE Corp., 594 F.2d 730, 738 (9th Cir.1979). Instead, the
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non-moving party must come forward with admissible evidence to satisfy the burden. Fed. R. Civ.
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P. 56(c); see Hal Roach Studios, Inc. v. Feiner & Co., Inc., 896 F.2d 1542, 1550 (9th Cir.1989).
A genuine issue for trial exists if the non-moving party presents evidence from which a
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reasonable jury, viewing the evidence in the light most favorable to that party, could resolve the
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material issue in his or her favor. Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 248-49 (1986);
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Barlow v. Ground, 943 F.2d 1132, 1134-36 (9th Cir. 1991). Conversely, summary judgment must
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United States District Court
Northern District of California
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be granted where a party “fails to make a showing sufficient to establish the existence of an
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element essential to that party’s case, on which that party will bear the burden of proof at trial.”
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Celotex, 477 U.S. at 322.
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III.
DISCUSSION
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Since the critical procedural facts are not in dispute, this motion presents one limited legal
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issue for resolution: the parties disagree on the standard this court will eventually apply to review
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the decision on Plaintiff’s application for LTD benefits. Plaintiff argues that standard should be
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de novo. Defendant argues it should be abuse of discretion. On this record, and notwithstanding
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Defendant’s unexplained and serious procedural violation, the court must agree with Defendant.
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Generally, “[a] denial of benefits challenged under § 1132(a)(1)(B) is to be reviewed under
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a de novo standard unless the benefit plan gives the administrator or fiduciary discretionary
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authority to determine eligibility for benefits or to construe the terms of the plan.” Firestone Tire
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& Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989). “[I]f the plan does confer discretionary
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authority as a matter of contractual agreement, then the standard of review shifts to abuse of
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discretion.” Abatie v. Alta Health & Life Ins. Co., 458 F.3d 955, 963 (9th Cir. 2006).
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Discretionary plan language, and in turn review for abuse of discretion, remains effective even in
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the face of a plan’s structural conflict of interest. Id. at 965.
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Case No.: 5:10-cv-05399-EJD
ORDER DENYING PLAINTIFF’S MOTION FOR SUMMARY ADJUDICATION
As to the Borland Plan, it is undisputed that the plan’s terms give Defendant, as the
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designated fiduciary, “discretionary authority to interpret the terms of the Plan and to determine
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eligibility for and entitlement to Plan benefits in accordance with the terms of the Plan.” See
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Fleishman Decl., at AR 001508. Accordingly, benefits decisions made by Defendant pursuant to
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the plan are presumptively subject to review under an abuse of discretion standard, “unless it can
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be shown that the interpretation or determination was arbitrary and capricious,” or absent some
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other development which would negate Defendant’s discretionary authority. Id.
In this motion, Plaintiff argues that Defendant has forfeited the benefit of discretionary
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review because of its alleged failure to observe ERISA’s procedural requirements. Specifically,
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Plaintiff contends that by neglecting to timely decide his appeals in accordance with 29 C.F.R. §
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United States District Court
Northern District of California
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2560.503-1(h),1 the court must now decide his LTD claim de novo.
Plaintiff is correct that quantity and quality of procedural violations can, under appropriate
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circumstances, modify the applicable standard of review from deferential to de novo. But these
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circumstances are rare, at least in this circuit. “[P]rocedural violations of ERISA do not alter the
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standard of review unless those violations are so flagrant as to alter the substantive relationship
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between the employer and employee, thereby causing the beneficiary substantive harm.” Gatti v.
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Reliance Standard Life Ins. Co., 415 F.3d 978, 985 (9th Cir. 2005). “When an administrator
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engages in wholesale and flagrant violations of the procedural requirements of ERISA, and thus
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acts in utter disregard of the underlying purpose of the plan as well, [the court] review[s] de novo
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the administrator’s decision to deny benefits.” Abatie, 458 F.3d at 971.
In addition, as Plaintiff emphasizes, de novo review may be applied in place of deferential
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review when the administrator fails to exercise discretion, such that a resulting default denial is
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“undeserving of deference under Firestone.” Jebian v. Hewlett-Packard Co. Emple. Benefits Org.
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Although Plaintiff references 29 C.F.R. § 2560.503(f) in the motion, the court will instead apply
§ 2560.503(h) since that section governs appeals of benefits decisions rather than initial
determinations. Under either section as well as under the Borland Plan, Defendant was obligated
to issue a decision within 45 days absent any notifications of extension. See Fleishman Decl., at
AR 001507.
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Income Prot. Plan, 349 F.3d 1098, 1106 (9th Cir. 2003). Indeed, courts “will not defer when a
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decision is, under the Plan, necessarily the mechanical result of a time expiration rather than an
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exercise of discretion.” Id. at 1105.
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Here, while Plaintiff’s frustration with Defendant’s inability to render a decision - for
reasons that remain unexplained - is understandable, he has not identified any substantive harm
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resulting from Defendant’s conduct such that the relationship between himself and his former
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employer has been altered. Thus, this case is distinguishable from cases in which such harm has
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been found, like Blau v. Del Monte Corporation, 748 F.2d 1348 (9th Cir. 1984), where the
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evidence showed that the administrator “failed to comply with virtually every applicable mandate
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of ERISA.” 748 F.2d at 1353. In this case, only ERISA’s timing requirements have been violated,
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United States District Court
Northern District of California
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albeit on more than one occasion.
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Furthermore, Plaintiff’s reliance on Jebian is misplaced because it does not govern this
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case. In Jebian, the Ninth Circuit held that “where, according to plan and regulatory language, a
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claim is ‘deemed . . . denied’ on review after the expiration of a given time period, there is no
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opportunity for the exercise of discretion and the denial is usually to be revewied de novo.”
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Jebian, 349 F.3d at 1103. Importantly, Jebian has since been explicitly limited to its particular
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facts; circumstances where the plan language at issue dictates a particular result for the
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administrator’s failure to act within a specified time. See Gatti, 415 F.3d at 982 (“The Jebian
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opinion discusses the time limits established by the plan and those imposed by regulation in
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tandem, but the court’s ultimate holding was based solely on the time limitation language in the
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plan. “). Such a refinement of the Jebian holding makes sense, since employers who include
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automatic denial provisions in their plan contracts do so knowing that any denial rendered as a
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result of that provision will not constitute an exercise of discretion worthy of any deference. See
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Abatie, 458 F.3d at 971 (“[U]nder Firestone, a plan administrator’s decision is entitled to
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deference only when the administrator exercises discretion that the plan grants as a matter of
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contract.”). But violations of regulatory violations, without a corresponding penalty for a
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contractual default, are something different. “Ordinarily, a claimant who suffers because of a
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Case No.: 5:10-cv-05399-EJD
ORDER DENYING PLAINTIFF’S MOTION FOR SUMMARY ADJUDICATION
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fiduciary’s failure to comply with ERISA’s procedural requirements is entitled to no substantive
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remedy.” Blau, 748 F.2d at 1353. Although these types of violations were discussed by the
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Jebian court, it did not actually decide the issue of whether regulatory violations are significant
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enough to alter the standard of review. Abatie, 458 F.3d at 971 (“The Jebian decision recognizes
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that there will be cases where benefits decisions are made in violation of the regulations alone, and
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explicitly leaves this issue open.”).
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Unlike Jebian, the Borland Plan does not call for any particular result, such as an automatic
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denial, when Defendant fails to decide an appeal within the plan’s specified timeframe. Thus, this
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court is not presented with a species of spontaneous decision obviously unentitled to any
deference. Defendant did issue a substantive decision on Plaintiff’s claim for benefits constituting
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United States District Court
Northern District of California
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an exercise of discretion – the denial on December 7, 2012. That decision is now considered
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capable of review by this court. See 29 C.F.R. § 2560.503-1(l); see also Gatti, 415 F.3d at 983
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(“Because a claimant must exhaust her plan’s administrative review procedures before she may
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bring suit in federal court, . . . a mechanism is necessary to allow claimants access to the courts in
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the event that their plan never makes a decision.”). And since a decision on the appeal is
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apparently not forthcoming, even after the court reopened this case while also providing an
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opportunity for one to issue, it is now time to proceed with the December 7th decision as
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Defendant’s final determination on the matter.
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Thus, for the reasons explained, this court concurs with those district courts holding that an
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administrator’s failure to timely decide a benefits appeal is not itself a basis to alter the standard of
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review when it does not also manifest substantive harm to the applicant. See, e.g., Hinz v. Hewlett
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Packard Co. Disability Plan, No. 10-CV-03633-LHK, 2011 U.S. Dist. LEXIS 386454, 2011 WL
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1230046 (N.D. Cal. Mar. 30, 2011).
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Consequently, the examination of the December 7th decision will not be a de novo one.
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Instead, the court will review it for abuse of discretion. But to be sure, this result is not some type
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of undeserved reward for Defendant since the court is mindful that “procedural violations of
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ERISA’s requirements are evidence of arbitrary and capricious decisionmaking.” Gatti, 415 F.3d
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ORDER DENYING PLAINTIFF’S MOTION FOR SUMMARY ADJUDICATION
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at 984; see also Abatie, 458 F.3d at 972 (“A procedural irregularity, like a conflict of interest, is a
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matter to be weighed in deciding whether an administrator’s decision was an abuse of
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discretion.”). In addition, as other courts have done under similar circumstances, the court will
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conduct the review “with a heightened degree of skepticism and will consider additional evidence
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submitted with Plaintiff’s notice of appeal.” Hinz, 2011 U.S. Dist. LEXIS 386454, at *24. The
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parties should arrange their summary judgment briefing accordingly.
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IV.
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ORDER
Based on the foregoing, Plaintiff’s Motion for Summary Adjudication (Docket Item No.
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53) is DENIED.
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United States District Court
Northern District of California
IT IS SO ORDERED.
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Dated: April 29, 2015
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______________________________________
EDWARD J. DAVILA
United States District Judge
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Case No.: 5:10-cv-05399-EJD
ORDER DENYING PLAINTIFF’S MOTION FOR SUMMARY ADJUDICATION
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