Baker v. The Hartford Financial Services Group, Inc.

Filing 35

MEMORANDUM DECISION AND ORDER. IT IS ORDERED: Plaintiff's Motion for Summary Judgment 25 is DENIED. Defendant's Motion for Summary Judgment 24 is GRANTED. Signed by Judge B. Lynn Winmill. (caused to be mailed to non Registered Participants at the addresses listed on the Notice of Electronic Filing (NEF) by (st)

UNITED STATES DISTRICT COURT
FOR THE DISTRICT OF IDAHO
CLAY SCOTT BAKER, an Idaho
Resident,

Case No. 4:14-cv-209-BLW

Plaintiff,

MEMORANDUM DECISION AND
ORDER

v.
HARTFORD LIFE AND ACCIDENT
INSURANCE COMPANY,
Defendant.

INTRODUCTION
Plaintiff Clay Scott Baker brings this action against Defendant Hartford Life and
Accident Insurance Company claiming wrongful denial of disability benefits under 29
U.S.C. § 1132(a)(1)(B). The parties have filed cross-motions for summary judgment.
The motions were argued on February 17, 2015, and taken under advisement. Having
considered the record and pleadings, the Court will grant Defendant’s Motion for
Summary Judgment and deny Plaintiff’s Motion for Summary Judgment.
BACKGROUND
This is an Employment and Retirement Income Security Act (“ERISA”) case.
Hartford Life and Accident Insurance Company issued a group long term disability
(“LTD”) Plan to Intermountain Medical Clinic. Admin. Rec. at 39, Dkt. 23-1. Baker is a
former dermatologist of Intermountain who submitted a claim for LTD benefits under the

MEMORANDUM DECISION AND ORDER - 1

Plan based on mycotoxicosis, which is exposure to mold toxins. Admin. Rec. at 1155-63,
1174-75, Dkt. 23-25. To be eligible for coverage, the Plan requires, in relevant part, that:
Your Disability must be the result of:
1) accidental bodily injury;
2) sickness; [or]
3) Mental Illness;
…
Mental Illness means a mental disorder as listed in the current
version of the Diagnostic and Statistical Manual of Mental
Disorders, published by the American Psychiatric
Association. A Mental Illness may be caused by biological
factors or result in physical symptoms or manifestations.
R., 30-31, Dkt. 23-1. However, the Plan limits benefits as follows:
Mental Illness And Substance Abuse Benefits: Are benefits
limited for Mental Illness? If You are Disabled because of:
1) Mental Illness that results from any cause; [or]
2) any condition that may result from Mental Illness;
…
then subject to all other provisions of The Policy, We will
limit the Maximum Duration of Benefits.
Benefits will be payable:
1) for as long as you are confined in a . . . place licensed to
provide medical care for the disabling condition; or
2) if not confined, or after you are discharged and still
Disabled, for a total of 24 month(s) for all such disabilities
during your lifetime.
Id. at 21.
Hartford engaged two of its medical professionals, a Medical Care Manager
(“MCM”) and a Behavioral Health Care Manager (“BHCM”), to evaluate Baker’s
medical records. Admin. Rec. at 86-87, Dkt. 23-2. The BHCM, after speaking with
Baker and his psychiatrist, Dr. Soofi, ordered an independent psychiatric review from the
third party vendor MES Solutions (“MES”). Id. at 77-79. Dr. Jean Dalpe, a psychiatrist

MEMORANDUM DECISION AND ORDER - 2

engaged by MES, determined that Baker’s disability was due to psychiatric conditions.
Admin. Rec. at 577, Dkt. 23-13. In Hartford’s denial letter, dated May 30, 2013, Hartford
indicated that it had reviewed records and reports from Drs. Soofi, Reichman, Sponangle,
Hooper, Kennedy, Dalpe, the MCM, and the BHCM, as well as lab reports, diagnostic
tests, medical records, and conversations with Dr. Soofi. Admin. Rec. at 126, Dkt. 23-3.
On July 16, 2013, Baker submitted additional materials from his providers.
Admin. Rec. at 545, 555, Dkts. 23-12, 23-13. Hartford reviewed the materials, again
denied coverage, and encouraged Baker to submit an appeal. Admin. Rec. at 122, Dkt.
23-3. Over the next three months, Baker appealed and submitted a neuropsychological
report by Dr. Didriksen, as well as records from Drs. Rea and Soofi. Admin. Rec. at 220,
252, Dkts. 23-5, 23-6. Upon receiving the additional documentation, Hartford engaged
the third party vendor University Disability Consortium (“UDC”) to review Baker’s file.
Admin. Rec. at 211-12, Dkt. 23-5. UDC assigned the review to three physicians with
different specialties: Dr. Ruffell (psychiatry), Dr. King (neurology), and Dr. Caruso
(occupational medicine). Admin. Rec. at 180, 194, 210, Dkts. 23-4, 23-5. Based upon his
review, Dr. Ruffell diagnosed Baker with Bipolar Affective Disorder. Admin. Rec. at
209, Dkt. 23-5. Dr. King found that Baker would not, from a neurological perspective,
be precluded from work.” Admin. Rec. at 193, Dkt. 23-4. And Dr. Caruso questioned the
accuracy of the testing and methods used to diagnose Baker with mycotoxicosis. See id.
at 169-76.

MEMORANDUM DECISION AND ORDER - 3

On November 26, 2013, Hartford concluded that Baker “meets the definition of
disability and is eligible for LTD benefits.” Admin. Rec. at 113, Dkt. 23-3. Two weeks
later, Hartford issued an appeal letter in which it found that “Dr. Baker was unable to
perform the Essential Duties of his occupation due to symptoms and impairment resulting
from Major Depression. The Appellate Review further shows there is no supported
Disability from a physical perspective.” Admin. Rec. at 108-10, Dkt. 23-3. Accordingly,
Hartford limited LTD benefits to the 24-month period set forth in the Plan. Id.
Baker submitted a second appeal on March 11, 2014, but failed to submit any new
medical evidence. Admin. Rec. at 161-62, Dkt. 23-4. In Hartford’s response to the
second appeal, it explained:
since we have determined that Dr. Baker was not physically
precluded from working and has already exhausted the
maximum duration of benefits payable due to any Mental
Illnesses he may suffer from, we are maintaining the prior
determination to terminate this [sic] LTD benefits as of
December 28, 2103. This determination regarding eligibility
for benefits as described in the above analysis represents our
final decision on this claim.
Admin. Rec. at 104, Dkt. 23-3.
Baker sued under 29 U.S.C. § 1132(a)(1)(B), the provision of ERISA allowing for
civil actions to recover benefits under an ERISA plan. The parties have filed crossmotions for summary judgment. See Dkts. 24, 25.
STANDARD FOR SUMMARY JUDGMENT
Summary judgment is appropriate where a party can show that, as to any claim or
defense, “there is no genuine dispute as to any material fact and the movant is entitled to

MEMORANDUM DECISION AND ORDER - 4

judgment as a matter of law.” Fed. R. Civ. P. 56(a). One of the principal purposes of the
summary judgment “is to isolate and dispose of factually unsupported claims.” Celotex
Corp. v. Catrett, 477 U.S. 317, 323-24 (1986). It is “not a disfavored procedural
shortcut,” but is instead the “principal tool[ ] by which factually insufficient claims or
defenses [can] be isolated and prevented from going to trial with the attendant
unwarranted consumption of public and private resources.” Id. at 327. “[T]he mere
existence of some alleged factual dispute between the parties will not defeat an otherwise
properly supported motion for summary judgment.” Anderson v. Liberty Lobby, Inc., 477
U.S. 242, 247-48 (1986). There must be a genuine dispute as to any material fact – a fact
“that may affect the outcome of the case.” Id. at 248. The Court must be “guided by the
substantive evidentiary standards that apply to the case.” Id. at 255.
When cross-motions for summary judgment are filed, the Court must
independently search the record for factual disputes. Fair Hous. Council of Riverside
Cnty., Inc. v. Riverside Two, 249 F.3d 1132, 1136 (9th Cir. 2001). The filing of crossmotions for summary judgment – where both parties essentially assert that there are no
material factual disputes – does not vitiate the court’s responsibility to determine whether
disputes as to material fact are present. Id.
ANALYSIS
1.

Hartford’s Decision is Reviewed under an Abuse of Discretion Standard.
“ERISA is a comprehensive statute designed to promote the interest of employees

and their beneficiaries in employee benefit plans.” Ingersoll–Rand Co. v. McClendon,

MEMORANDUM DECISION AND ORDER - 5

498 U.S. 133, 136 (1990) (quotation citation omitted). ERISA requires that a plan
fiduciary administer an ERISA plan for the purpose of “providing benefits to participants
and their beneficiaries” and “in accordance with the documents and instruments
governing the plan.” 29 U.S.C. § 1104(a)(1)(A)(i), (a)(1)(D). However, “[a]n ERISA
fiduciary is obligated to guard the assets of the [Plan] from improper claims, as well as to
pay legitimate claims.” Boyd v. Bell, 410 F.3d 1173, 1178 (9th Cir. 2005) (internal
quotation marks omitted).
In actions challenging denials of benefits pursuant to 29 U.S.C. § 1132(a)(1)(B),
the district court reviews de novo “unless the benefit plan gives the administrator or
fiduciary discretionary authority to determine eligibility for benefits or to construe the
terms of the plan.” Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989). If
the plan unambiguously confers discretionary authority, then the standard of review shifts
to an abuse of discretion standard. Id.
The first step of the analysis is to determine whether the Plan unambiguously
grants discretion to the administrator. The insurance policy provides, “[t]he Plan has
designated and named the Insurance Company as the claims fiduciary for benefits
provided under the policy. The Plan has granted the Insurance Company full discretion
and authority to determine eligibility for benefits and to construe and interpret all terms
and provisions of the Policy.” Admin. Rec. at 41, Dkt. 23-1.
The Ninth Circuit has repeatedly held that such plan language—granting the
power to interpret plan terms and to make final benefits determinations—confers

MEMORANDUM DECISION AND ORDER - 6

discretion on the plan administrator. See Abatie v. Alta Health & Life Ins. Co., 458 F.3d
955, 963 (9th Cir. 2006) (citing Bergt v. Ret. Plan for Pilots Employed by MarkAir,
Inc., 293 F.3d 1139, 1142 (9th Cir. 2002) and Grosz–Salomon v. Paul Revere Life Ins.
Co., 237 F.3d 1154, 1159 (9th Cir. 2001)). Therefore, the Plan unambiguously confers
on the administrator full discretion and authority to both interpret all terms and provisions
of the Plan and to determine eligibility for benefits. Accordingly, the Court will proceed
to review the Plan administrator's decision under the deferential abuse of discretion
standard.
2.

The Court’s Deference to the Administrator’s Decision is Tempered by

the Degree of the Severity of any Structural Conflict of Interest
In the absence of an internal conflict, an ERISA administrator abuses its discretion
only if the administrator “(1) renders a decision without explanation, (2) construes
provisions of the plan in a way that conflicts with the plain language of the plan, or (3)
relies on clearly erroneous findings of fact.” Boyd, 410 F.3d at 1178. However, a less
deferential standard is triggered when a structural conflict of interest exists. Firestone,
489 U.S. at 115. If the administrator or fiduciary having discretion is operating under a
conflict of interest, that conflict must be weighed as a “facto[r] in determining whether
there is an abuse of discretion.” Id. This language does not imply a change in the
standard of review, but merely instructs courts to “take account of several different
considerations of which a conflict of interest is one.” Metropolitan Life Ins. Co. v. Glenn,
554 U.S. 105, 117 (2008).

MEMORANDUM DECISION AND ORDER - 7

Stated another way, the Court’s review of the administrator’s decision will be
“tempered by skepticism” to the degree of the severity of the conflict. Abatie, 458 F.3d
at 959. A conflict of interest may be weighed “more heavily if, for example, the
administrator provides inconsistent reasons for denial, fails adequately to investigate a
claim or ask the plaintiff for necessary evidence, fails to credit a claimant's reliable
evidence, or has repeatedly denied benefits to deserving participants by interpreting plan
terms incorrectly or by making decisions against the weight of evidence in the record.”
Id. at 968-69.
In order to weigh a conflict of interest more heavily, the beneficiary must provide
“material, probative evidence, beyond the mere fact of the apparent conflict, tending to
show that the fiduciary's self-interest caused a breach of the administrator's fiduciary
obligations to the beneficiary.” Tremain v. Bell Indus., Inc., 196 F.3d 970, 976 (9th Cir.
1999). If the beneficiary meets this threshold burden, then a rebuttable presumption
arises in favor of the beneficiary. Id. The Plan then bears the burden of rebutting this
presumption by producing evidence that the conflict of interest did not affect its decision
to deny benefits. Id. If the Plan fails to carry this burden, then the Court will review the
denial of benefits de novo. Id.
It is undisputed that Hartford is operating under a conflict of interest by serving as
both claim administrator and payer of LTD benefits. Therefore, the Court proceeds to
determine the extent to which the conflict tempers its deference to Hartford’s decision.

MEMORANDUM DECISION AND ORDER - 8

A.

Hartford has taken steps to reduce potential bias

The Supreme Court recognized that a structural conflict “should prove less
important (perhaps to the vanishing point) where the administrator has taken active steps
to reduce potential bias and to promote accuracy, for example, by walling off claims
administrators from those interested in firm finances, or by imposing management checks
that penalize inaccurate decision-making irrespective of whom the inaccuracy benefits.”
Metropolitan Life Ins. Co., 554 U.S. at 117. As described in Hartford’s Response to
Baker’s Interrogatory No. 4:
Hartford’s claims personnel do not have access to or
knowledge of financial information regarding the
policyholder, nor are claims personnel provided with
information regarding claim reserves. Profitability and other
financial information do not weigh in to the claims decision.
…
[A]n examiner’s compensation is not determined by reference
to his or her record in denying claims. The claims personnel
are separate from and are not involved with those persons
responsible for Hartford’s financial operations and decisions.
Claims investigations and decisions are made separately
from, and without consideration of, the financial affairs of
Hartford.
…
The office of the Chief Financial Officer of Hartford and its
affiliate, subsidiary, or parent companies does not have any
involvement and does not participate in claim or appeal
determinations at any level.
…
Claims personnel are not reviewed or compensated based on
the outcome of their claim determinations. Hartford does not
establish numerical quotas requiring a certain number of
claim approvals versus denials, and does not evaluate its
employees on the number of claims approved versus denied.
Hartford compensates members of the claims department and
appeals unit in accordance with the terms of their individual

MEMORANDUM DECISION AND ORDER - 9

employment with Hartford. Claim personnel do not receive
benefits, bonuses, commissions, promotions, or any other
incentives, financial or otherwise, based on the number of
claims that they approve versus deny.
…
Hartford has a check against the arbitrary denial of claims and
promotes accuracy by maintaining a separate appeals unit for
the independent consideration of denied claims. Members of
the appeals unit are charged with making independent
assessments of the underlying claim decision based on all of
the evidence in the claim file. When a claim denial is
appealed, the entire claim file, including the appeal
investigation and the decision on which the appeal is based, is
assigned to an Appeals Specialist in the appeals unit who had
no involvement in the initial investigation and claim
determination. The Appeals Specialist investigating and
deciding the appeal has the sole authority to make the appeal
decision.
Decl. of Jack Englert, Ex. A at 6-7, Dkt. 24-3.
Clearly Hartford took active steps to reduce potential bias and promote accuracy.
Accordingly, the Court should give little weight to the conflict. Nevertheless, the Court
must consider all the circumstances surrounding the claim decision.
Baker points to three factors that he argues should result in a less deferential
review of Hartford’s decision: (1) Hartford took inconsistent positions throughout the
claim process; (2) Hartford failed to adequately investigate Baker’s claim; and (3)
Hartford’s findings were clearly erroneous. Pl.’s Br. at 5, Dkt. 26.
B.

Hartford did not take inconsistent positions throughout the claim process

Baker maintains that Hartford took inconsistent positions throughout the claims
process. First, on May 30, 2013, Hartford denied Baker’s LTD claim and concluded that
Baker did not suffer from a disability. Admin. Rec. at 122-28, Dkt. 23-3. Subsequent to

MEMORANDUM DECISION AND ORDER - 10

an appeal, on November 26, 2013, Hartford concluded that Baker “meets the definition of
disability and is eligible for LTD benefits.” Id. at 113. Two weeks later, on December
10, 2013, Hartford issued a detailed appeal letter in which it found that Baker’s disability
was the result of a mental illness and LTD benefits were limited to the 24-month period
set forth in the Plan. Id. at 108-10. Baker contends that these decisions and letters
illustrate that Hartford took inconsistent positions and that its position changed as a result
of “obtaining paid for conclusions from its experts.” Pl.’s Br. at 6, Dkt. 26.
However, the record reveals that Hartford did not take an inconsistent position
during the claims process and was not operating under a conflict of interest. After the
initial denial, Hartford informed Baker that he could appeal, should he choose to
challenge Hartford’s claim determination. Admin. Rec. at 122, 545, 555, Dkts. 23-3, 2312, 23-13. Upon receipt of the additional documentation, Hartford obtained independent
physician reviews and received reports from these physicians on November 20, 2013.
Admin. Rec. at 167, 184, 195, Dkt. 23-4. On November 26, 2013, Hartford sent a letter to
Baker indicating that “[b]ased on review of the documentation in Dr. Baker’s claim file
together with additional medical information obtained at the appeal level we have
determined that he meets the definition of disability and is eligible for LTD benefits.”
Admin. Rec. at 113, Dkt. 23-3.
The November 26 letter indicated that the review was “conducted separately from
the individual who made the original decision to deny benefits and without deference to
said decision.” Id. Moreover, the appeals determination considered additional medical

MEMORANDUM DECISION AND ORDER - 11

information provided by Baker and reports of the reviewing physicians. This is not
evidence of an inconsistent position due to a conflict of interest. Instead, it suggests that
the change in claim determination between the initial determination and the November 26
letter resulted from an appeals process which gave no deference to the initial claim
determination. Furthermore, Dr. Sponaugle admits that the “initial evaluation of
[Baker’s] disability claim is a moot point” because, in Dr. Sponaugle’s opinion, Baker
was not accurately diagnosed until April 2012. Admin. Rec. at 470, Dkt. 23-11.
The November 26 letter further indicated that “[b]ased on review of the
documentation in Dr. Baker’s claim file together with additional medical information
obtained at the appeal level we have determined that he meets the definition of disability
and is eligible for LTD benefits.” Admin. Rec. at 113, Dkt. 23-3. Notably, the November
26 letter does not indicate the nature of the disability or the term or value of the LTD
benefits. On December 10, 2013, Hartford issued a formal determination letter in which
it stated “[t]he Appellate Review completed for your client’s claim shows that Dr. Baker
was unable to perform the Essential Duties of his occupation due to symptoms and
impairment resulting from Major Depression. The Appellate Review further shows there
is no supported Disability from a physical perspective.” Id. at 109-110, Dkt. 23-3.
Additionally, the December 10 letter indicated that Hartford considered the November 20
physician reports in its determination before sending the November 26 letter. Id.
Consistent with the December 10 letter, Hartford’s internal file note dated
November 26, 2013, 1:45:37 PM states that the “appeal decision is to reverse denial and

MEMORANDUM DECISION AND ORDER - 12

pay benefits based on Dr. Baker’s psychiatric disorder.” Admin. Rec. at 61, Dkt. 23-2.
(emphasis added). As such, both the November 26 and December 10 letters were
premised on an award from Baker’s disability due to a psychiatric disorder. Accordingly,
Hartford has not offered inconsistent positions due to any structural conflict of interest.1
C.

Hartford adequately investigated Baker’s claim

When considering a claim for benefits, ERISA administrators have a duty to
adequately investigate the claim. Booton v. Lockheed Med. Ben. Plan, 110 F.3d 1461,
1463 (9th Cir. 1997). This requires that the plan administrator engage in “meaningful
dialogue” with the beneficiary. Id. If the administrator “believes more information is
needed to make a reasoned decision, they must ask for it.” Id.
When investigating Baker’s claim, Hartford interviewed Baker about his LTD
claim and reviewed the records provided by his health care providers. Admin. Rec. at 8693, Dkt. 23-2. Two of Hartford’s on-staff medical professionals, a Medical Care
Manager (“MCM”) and a Behavioral Health Care Manager (“BHCM”), evaluated
Baker’s medical records. Id. at 86-87. The BHCM, after speaking with Baker and his

1

Baker makes much of the fact that Hartford changed its position after “obtaining
paid for conclusions from its experts.” Pl.’s Br. at 6, Dkt. 26. This is a facetious
argument. A plan administrator is certainly permitted, and in light of its fiduciary
obligation to plan participants is probably obligated, to obtain opinions from physicians
other than the claimant’s own doctors. And, certainly those physicians will expect to be
compensated for their time in reviewing records, conducting interviews, examining the
claimant, and formulating an opinion.

MEMORANDUM DECISION AND ORDER - 13

psychiatrist, ordered an independent psychiatric review. Id. at 77-79. Psychiatrist Dr.
Jean Dalpe performed an independent review. Admin. Rec. at 577, Dkt. 23-13. In the
denial letter, dated May 30, 2013, Hartford indicated that it had reviewed records and
reports from Drs. Soofi, Reichman, Sponangle, Hooper, Kennedy, Dalpe, the MCM, and
the BHCM, as well as lab reports, diagnostic tests, and medical records. Admin. Rec. at
126, Dkt. 23-3.
On July 16, 2013, Baker submitted additional materials, which were reviewed by
Hartford. Admin. Rec. at 545, 555, Dkts. 23-11, 23-12. Baker filed an appeal and
submitted a neuropsychological report by Dr. Didriksen, as well as additional records
from Drs. Rea and Soofi. Admin. Rec. at 220, 252, Dkts. 23-5, 23-6. As part of its
independent review process, Hartford engaged UDC, which assigned the review to three
of its physicians. Admin. Rec. at 180, 194, 210, Dkts. 23-4, 23-5. In addition to
reviewing the record, UDC’s physicians consulted with Baker’s primary physicians. All
of UDC’s physicians summarized the record and created reports detailing their findings.
Although the UDC physicians criticized the disabling effects of the mycotoxicosis
diagnosis, Baker failed to provide evidence to the contrary when he filed his second
appeal on March 11, 2014. See Admin. Rec. at 158-59, Dkt. 23-4. It is significant that
Baker chose only to highlight records and reports that had been previously considered.
Among other concerns, Baker chose not to address an adverse article by The American
College of Occupational and Environmental Medicine, the position of the Society of
Nuclear Medicine Brain Imaging Council and the reviewing physicians regarding SPECT

MEMORANDUM DECISION AND ORDER - 14

scans, or alleged criticism of Dr. Rea’s standards by the Texas Board of Medicine and the
American Board of Allergy. Moreover, reports submitted after the second appeal
determination failed to address the same condemning information in the record.
The Court finds that Hartford conducted a more than adequate investigation of
Baker’s claim. Hartford and the reviewing physicians engaged in “meaningful dialogue”
with Baker and his physicians, requested additional documents, and gave Baker ample
opportunity to supplement their investigation with additional evidence. Further, Hartford
used independent physicians who gave no deference to the initial claim determination
when reviewing Baker’s claims.
D.

Hartford findings were not clearly erroneous

Baker maintains that “Hartford’s denial was clearly erroneous because “several
medical providers… all concluded that Dr. Baker was disabled due to mold and chemical
exposure.” Pl. Br. at 7, Dkt. 26. “A finding is 'clearly erroneous' when, although there is
evidence to support it, the reviewing [body] on the entire evidence is left with the definite
and firm conviction that a mistake has been committed.” Concrete Pipe and Prods. of
Cal., Inc. v. Constr. Laborers Pension Trust for S. Cal., 508 U.S. 602, 622
(1993) (emphasis added). Moreover, “that the plan administrator's decision is directly
contrary to some evidence in the record does not show that the decision is clearly
erroneous.” Snow v. Standard Ins. Co., 87 F.3d 327, 331 (9th Cir. 1996), overruled on
other grounds by Kearney v. Standard Ins. Co., 175 F.3d 1084 (9th Cir.1999) (en banc).

MEMORANDUM DECISION AND ORDER - 15

As a result of the abuse of discretion standard, courts “have generally limited the
record for judicial review to the administrative record compiled during internal review.”
Heimeshoff v. Hartford Life & Accident Ins. Co., 134 S. Ct. 604, 613 (2013).
Accordingly, the Court will limit its review to the administrative record created during
the initial determination and appeals process.
Baker claims the record supports disability due to a physical condition—
mycotoxicosis or chemical sensitivity—while Hartford’s claim determination points to a
psychiatric disorder. There appears to be conflicting reports as to what caused Baker’s
disability. Baker’s psychiatrist, Dr. Soofi, indicated a secondary diagnosis of
mycotoxicosis in her Attending Physician’s Statement of Disability. Admin. Rec. at 248,
Dkt. 23-5. However, in her medical notes, Dr. Soofi stated, “I basically have minimal
knowledge of how mold toxin can look like [in] somebody who has bipolar disorder,
panic disorder, attention deficit-hyperactivity disorder basically most of the psychiatric
major diagnoses. Nevertheless, I have been supportive and [am] keeping an open mind.”
Admin. Rec. at 637, Dkt. 23-14. In a conversation with Dr. Ruffell, she qualified that it
would “be extremely difficult for [Baker] to buy into [his illness] being psychiatric.”
Admin. Rec. at 206, Dkt. 23-5. As further evidence of Dr. Soofi’s skepticism, she wrote
in her patient notes that “[Baker] still is in the process of testing his theory that his
primary problem is [mycotoxicosis],” “[Baker] continued to research literature on mold
toxicity and found a physician in Texas,” “he wants to test his theory of immunotherapy,”
“he except[s] my opinion that he has a depressive disorder,” and “he feels that he's not

MEMORANDUM DECISION AND ORDER - 16

[in] ‘denial’ however he is quite convinced with the data that he has been gathering on his
own health.” Admin. Rec. at 462-63, Dkt. 23-11. Thus, it is clear that Dr. Soofi was
highly skeptical that Baker’s condition could be attributed to mycotoxicosis.
The opinions of Drs. Didriksen, Rea, Hooper, and Sponaugle all support the
existence of mycotoxins in Baker’s system. However, Dr. Ruffell noted that Baker was
referred to Dr. Didriksen by Dr. Rea with a bias toward a diagnosis of “toxic exposure.”
Admin. Rec. at 208, Dkt. 23-5. Additionally, Dr. Rea’s diagnosis of mycotoxins relied, at
least partly, on “significant testing done prior to coming to our clinic… by Dr. Hooper.”
R. 267. Thus, much of the mycotoxin results stem from the tests performed by Drs.
Hooper and Sponaugle. The record also supports the finding that Baker sought out these
doctors because of their focus on mycotoxins. It was Dr. Ruffell’s opinion that it is more
likely that the “findings are clue to a much more common and well-recognized syndrome
– Bipolar Affective Disorder.” Id. at 209.
Dr. Caruso’s report disagrees with the methods and tests administered, from which
Drs. Sponaugle, Rea, and Didriksen “drew unvalidated conclusions of clinically
significant environmental toxicity.” Admin. Rec. at 176, Dkt. 23-4. Particularly, Dr.
Caruso disagreed with the methodology of Dr. Didriksen. See Admin. Rec. at 174, Dkt.
23-4. For example, Dr. Didriksen administered a WAIS-III rather than WAIS-IV test,
focused on individual scores when most overall scores were within normal limits,
administered a non-standard psychological test, and validated her assertions with
“research in this office” without any reference to peer-reviewed studies. Id. As a result

MEMORANDUM DECISION AND ORDER - 17

of his review, Dr. Caruso determined that “within a reasonable degree of medical
certainty, Dr. Baker’s primary medical problem was psychiatric in nature.” Id. at 175.
Dr. Caruso also relied on a position paper of the American College of
Occupational and Environmental Medicine, which concluded that “[c]urrent scientific
evidence does not support the existence of a causal relationship between inhaled
mycotoxins in home, school, or office environments and adverse health effects.” Id. at
176. It appears from the record that mycotoxicosis is a controversial diagnosis that is not
widely recognized in the medical field. Drs. Rea and Sponaugle appear to be among the
very small group of physicians who have embraced the diagnosis. For example, Dr.
Sponaugle refers to “mycotoxin-mediated human disease [as] grossly under-recognized
in the U.S.” Admin. Rec. at 471, Dkt. 23-11. He also refers to this as an “emerging
disease” with “a high likelihood that your physician consultants have never heard of it.”
Id.
Baker’s neurologist, Dr. Kennedy, indicated in his Attending Physician’s
Statement of Disability that Baker had “subacute encephalopathy,” but that it was of
unknown etiology. Admin. Rec. at 246, Dkt. 23-5. In a phone conference with Dr. King,
Dr. Kennedy said that “he thought that [Baker’s] greatest problems were psychiatric in
nature and if he had neurocognitive dysfunction that it would probably be from his
psychiatric issues.” Admin. Rec. at 190, Dkt. 23-4.
Baker contends that Hartford failed to credit the objective testing supporting
Baker’s mycotoxicosis and chemical sensitivity diagnoses as the basis of his disability.

MEMORANDUM DECISION AND ORDER - 18

Admittedly, that testing conducted by Drs. Didriksen, Rea, Hooper, and/or Sponaugle
shows that Dr. Baker has experienced high levels of mycotoxins. However, there is no
evidence in the record, apart from those doctors’ unsupported conclusions, that such
toxicity can cause the symptoms which Baker has experienced. While “plan
administrators may not arbitrarily refuse to credit reliable evidence, including the
opinions of a treating physicians… courts have no warrant to require administrators
automatically to accord special weight to the opinions of a claimant’s physician.” Black
& Decker Disability Plan v. Nord, 538 U.S. 822, 834 (2003). Likewise, this Court has
held that “[a] plan administrator does not have to be swayed by the sheer amount of
evidence or the source of the evidence.” Wirries v. Reliance Standard Ins. Co., No. CV
01-565-E-MHW, 2005 WL 2138682, at *7 (D. Idaho Sept. 1, 2005) aff'd sub nom.
Wirries v. Reliance Standard Life Ins. Co., 247 F. App'x 870 (9th Cir. 2007) (citation
omitted).
The Court is not left with the definite and firm conviction that a mistake has been
committed. Quite to the contrary, the Court concludes that Hartford’s conclusion was
strongly supported by the record before it. That Hartford accepted the opinions of
reviewing physicians who concluded that Baker’s disability was attributable to a mental
illness, rather than to mycotoxicosis or chemical sensitivity, does not establish that
Hartford reached a biased result or ignored evidence. The record is clear that Hartford
considered the conclusions of Baker’s treating physicians, but ultimately chose to
question and reject the diagnosis and the methodology employed by Drs. Sponaugle and

MEMORANDUM DECISION AND ORDER - 19

Rea. That skepticism appears justified. Baker’s primary physicians expressed their
skepticism as to the mycotoxicosis diagnosis. And, the medical literature reviewed by
the Hartford physicians shows that the diagnosis is highly controversial and has not found
acceptance in the medical community.
E.

Policy interpretation

Finally, Baker maintains that “[u]nder Hartford’s interpretation of the policy,
everyone who has a mental illness, will not be physically disabled.” Pl.’s Br. at 9, Dkt.
26. Specifically, Baker argues that Hartford’s “exclusion of Dr. Baker’s disability
benefits, under the guise of being a purely mental illness, essentially renders the disability
provisions of the Plan nugatory.” Id.
When considering questions of insurance policy interpretation under ERISA,
federal courts apply federal common law. Padfield v. AIG Life Ins. Co., 290 F.3d 1121,
1125 (9th Cir. 2002). Under the federal common law of ERISA, federal courts “interpret
terms in ERISA insurance policies in an ordinary and popular sense, as would a person of
average intelligence and experience.” Id. The interpretation of an insurance policy is a
question of law, and any ambiguities in the plan are construed against the insurer. Evans
v. Safeco Life Ins. Co., 916 F.2d 1437, 1441 (9th Cir. 1990). The Court will accordingly
consider whether the Plan’s mental illness limitation indeed renders the disability
provision of the Plan nugatory.
The Plan provides, in relevant part, that “If You are Disabled because of: 1)
Mental Illness that results from any cause; 2) any condition that may result from Mental

MEMORANDUM DECISION AND ORDER - 20

Illness… then subject to all other provisions of The Policy, We will limit the Maximum
Duration of Benefits. Benefits will be payable… for a total of 24 month(s) for all such
disabilities during your lifetime.” Admin. Rec at 21, Dkt. 23-1.
Baker’s interpretation of the Plan overstates the scope of the mental illness
limitation. The mental illness limitation does not state that any person who has a mental
illness will not be physically disabled; instead, it limits the duration of benefits when the
claimant’s disability is due to mental illness. A mentally ill claimant may still receive the
full duration of benefits so long as the claimant is totally disabled as a result of a physical
condition. This interpretation is reasonable and does not conflict with the other Plan
terms.
3.

The Plan Denial of Baker’s Request for Benefits Was Reasonable
The Court finds no reason to temper its deference to Hartford’s determination

under the abuse of discretion standard. Baker has not provided material and probative
evidence showing that Hartford’s conflict of interest caused a breach of its obligation to
Baker.
Under the abuse of discretion standard, the Court is not called upon to decide
whether Baker was disabled as a result of mycotoxicosis or another physical cause.
Instead, the inquiry is far more limited. The only issue before the Court is whether, based
upon the administrative record, Hartford abused its discretion in concluding that Dr.
Baker’s disability was due to mental health issues rather than a physical condition.
Under this standard, Hartford prevails.

MEMORANDUM DECISION AND ORDER - 21

“[W]here the decision to grant or deny ERISA benefits is reviewed for abuse of
discretion, a motion for summary judgment is merely the conduit to bring the legal
question of whether discretion has been abused before the district court and the usual
tests of summary judgment, such as whether a genuine dispute of material fact exists, do
not apply.” Cady v. Hartford Life & Accidental Ins. Co., 930 F. Supp. 2d 1216, 1224
n.11 (D. Idaho 2013) (citation omitted).
A plan administrator's decision “must be upheld under the abuse of discretion
standard if it is based upon a reasonable interpretation of the plan's terms and if it was
made in good faith.” Sluimer v. Verity, Inc., 606 F.3d 584, 590 (9th Cir. 2010) (quotation
citation omitted). Therefore, the question is not “whose interpretation of the plan
documents is most persuasive, but whether the ... interpretation is unreasonable.”
Canseco v. Const. Laborers Pension Trust, 93 F.3d 600, 609 (9th Cir. 1996). The
reviewing court must look to the plain language of the plan to determine whether the
administrator's interpretation of the plan is “arbitrary and capricious.” Id.
Here, Hartford denied benefits “due to symptoms and impairment resulting from
Major Depression [and] no supported Disability from a physical perspective.” Admin.
Rec. at 109-10, Dkt. 23-3. Hartford’s decision was grounded on a reasonable factual
basis for concluding that Baker’s mycotoxicosis or chemical sensitivity, alone, was not
disabling, and that, but for his mental illness, he would be able to work. It was within
Hartford’s discretion to weigh the conflicting evidence, and Hartford did not abuse that
discretion in limiting benefits to the 24-month term provided for in the Plan.

MEMORANDUM DECISION AND ORDER - 22

IT IS ORDERED:
1.

Plaintiff’s Motion for Summary Judgment (Dkt. 25) is DENIED.

2.

Defendant’s Motion for Summary Judgment (Dkt. 24) is GRANTED

DATED: February 23, 2015

_________________________
B. Lynn Winmill
Chief Judge
United States District Court

MEMORANDUM DECISION AND ORDER - 23