Reetz v. Hartford Life and Accident Insurance Company
Filing
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ORDER denying Plaintiff's 14 Motion to supplement the record signed by Judge James L. Robart. (PM)
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UNITED STATES DISTRICT COURT
WESTERN DISTRICT OF WASHINGTON
AT SEATTLE
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KRISTEN REETZ,
CASE NO. C17-0084JLR
ORDER DENYING MOTION TO
SUPPLEMENT THE
ADMINISTRATIVE RECORD
Plaintiff,
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v.
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HARTFORD LIFE AND
ACCIDENT INSURANCE
COMPANY,
Defendant.
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I.
INTRODUCTION
Before the court is Plaintiff Kristen Reetz’s motion to supplement the
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administrative record in this action with the Social Security Administration’s (“SSA”)
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determination that she is disabled and the vocational evidence presented at the SSA
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hearing. (Mot. (Dkt. # 14).) Having considered the parties’ submissions, the relevant
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portions of the record, and the applicable law, the court DENIES Ms. Reetz’s motion to
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supplement.
ORDER - 1
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II.
BACKGROUND
This case arises from Defendant Hartford Life and Accident Insurance Company’s
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(“Hartford”) termination of Ms. Reetz’s long-term disability (“LTD”) benefits. (Compl.
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(Dkt. # 1) ¶¶ 5.2-5.5.) Ms. Reetz was at all times a participant, as defined by the
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Employee Retirement Income Security Act (“ERISA”), 29 U.S.C. § 1002(7), in a Group
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Long Term Disability Plan (the “Plan”) provided by Hartford (Compl. ¶¶ 4.6-4.14). The
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Plan is an “employee benefit plan” as defined by ERISA. See 29 U.S.C. § 1002(3).
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Hartford issues benefits for those who meet the terms and conditions of the Plan.
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(Compl. ¶ 4.7.)
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As a result of an illness that began on or about March 7, 2014, Ms. Reetz was
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allegedly unable to perform one or more of the essential duties of her job. (Id. ¶ 4.19.)
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Hartford determined that Ms. Reetz was disabled within the meaning of the Plan and
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began paying her LTD benefits on June 6, 2014. (Id. ¶ 4.21.)
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On October 24, 2014, Hartford advised Ms. Reetz that she must apply to the SSA
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for Social Security Disability Insurance (“SSDI”) benefits. (Id. ¶ 4.23.) SSDI benefits
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would offset any LTD payments that Hartford made to Ms. Reetz. (Administrative
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Record (Dkt. # 15) (“AR”) at 6-7, 18, 22, 449, 459.) Hartford provided Ms. Reetz with
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attorneys who assisted her in submitting a SSDI application. (Compl. ¶ 4.24.) Although
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Ms. Reetz’s application was initially denied, Ms. Reetz filed a request for reconsideration
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and initiated the SSA administrative appeal process. (See id. ¶¶ 4.25-4.29.)
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On April 28, 2016, as Ms. Reetz’s SSA appeal was pending, Hartford terminated
Ms. Reetz’s LTD benefits, explaining via letter that she no longer qualified as disabled
ORDER - 2
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under the Plan. (Id. ¶ 4.31.) Ms. Reetz, without representation, appealed the benefit
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termination in May. (Id. ¶ 4.34.) Hartford informed Ms. Reetz that “it is her
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responsibility to provide info[rmation] on appeal and [that] she may submit whatever she
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chooses.” (Id. ¶ 4.35.)
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Two months later, on July 30, 2016, the SSA determined that Ms. Reetz was
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disabled based on the testimony of a vocational expert, Dr. Paul Prachyl. (Id. ¶ 4.36;
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Reetz Decl. (Dkt. # 16) ¶¶ 9-10, Ex. 7 at 27.) Due to the award of SSDI benefits, Ms.
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Reetz repaid Hartford $28,817.99 on August 4, 2016. (AR at 538.)
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On August 19, 2016, Hartford denied Ms. Reetz’s appeal of the termination of
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benefits. (Id. at 324-29.) Hartford stated that it considered the “SSA’s disability
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determination as one piece of relevant evidence” but determined that the ultimate
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decision of non-disability was “based on vocational evidence which the SSA is not
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required to use in the same way.” (Id. at 328-29.) Having exhausted her administrative
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remedies, Ms. Reetz initiated this suit in federal court. (See generally Compl.)
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Hartford’s claim file—the current administrative record—contains neither the SSA’s
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disability determination nor Dr. Prachyl’s testimony. (Crawford Decl. (Dkt. # 15) ¶ 4;
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see generally AR.)
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III.
ANALYSIS
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Ms. Reetz moves the court to supplement the existing administrative record with
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the SSA’s disability determination and Dr. Prachyl’s testimony at the hearing. (Mot. at
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1.) Hartford opposes the motion and argues that Ms. Reetz has not shown any
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exceptional circumstances that would warrant supplementing the administrative record.
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(Resp. (Dkt. # 24) at 1.)
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The parties agree that the court’s review of Hartford’s benefit determination is de
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novo. (See Mot. at 5-6; Resp. at 1-2; Crawford Decl. ¶ 5.) Under de novo review, “[t]he
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court simply proceeds to evaluate whether the plan administrator correctly or incorrectly
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denied benefits.” Abatie v. Alta Health & Life Ins. Co., 458 F.3d 955, 963 (9th Cir.
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2006). The administrator’s decision is accorded no deference. Kearney v. Standard Ins.
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Co., 175 F.3d 1084, 1090 n.2 (9th Cir. 1999). The court evaluates whether the claimant
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was “entitled to benefits based on the evidence in the administrative record and other
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evidence as might be admissible under the restrictive rule of [Mongeluzo v. Baxter
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Travenol Long Term Disability Benefits Plan, 46 F.3d 938, 943 (9th Cir. 1995)].” Opeta
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v. Nw. Airlines Pension Plan for Contract Emps., 484 F.3d 1211, 1217 (9th Cir. 2007)
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(internal quotation marks omitted).
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In Mongeluzo, the Ninth Circuit explained that “[i]n most cases . . . the district
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court should only look at the evidence that was before the plan administrator . . . at the
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time of the determination.” 46 F.3d at 944. This restriction to the administrative record
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is based on the principle that district courts “should not function ‘as substitute plan
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administrators,’ and that expanding the record on appeal ‘would frustrate the goal of
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prompt resolution of claims by the fiduciary under the ERISA scheme.’” Dorsey v.
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Metro. Life Ins. Co., No. 2:15-cv-02126-KJM-CKD, 2017 WL 3720346, at *10 (E.D.
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Cal. Aug. 29, 2017) (quoting Taft v. Equitable Life Assurance Soc’y, 9 F.3d 1469, 1472
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(9th Cir. 1993)). Evidence outside of the administrative record is considered “only when
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circumstances clearly establish that additional evidence is necessary to conduct an
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adequate de novo review of the benefit decision.” Mongeluzo, 46 F.3d at 944 (quoting
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Quesinberry v. Life Ins. Co. of N. Am., 987 F.2d 1017, 1025 (4th Cir. 1993) (en banc))
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(internal quotation marks omitted).
The Ninth Circuit has articulated what “certain limited circumstances” may render
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the consideration of additional evidence necessary. Opeta, 484 F.3d at 1217 (citing
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Mongeluzo, 46 F.3d at 943-44). These exceptional circumstances include:
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claims that require consideration of complex medical questions or issues
regarding the credibility of medical experts; the availability of very limited
administrative review procedures with little or no evidentiary record; the
necessity of evidence regarding interpretation of the terms of the plan rather
than specific historical facts; instances where the payor and the administrator
are the same entity and the court is concerned about impartiality; claims
which would have been insurance contract claims prior to ERISA; and
circumstances in which there is additional evidence that the claimant could
not have presented in the administrative process.
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Id. (quoting Quesinberry, 987 F.2d at 1027).
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Although Ms. Reetz does not explicitly argue that her situation falls within any of
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the above exceptional circumstances (see Mot.), she implies that the SSA determination
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and hearing evidence qualify as “additional evidence that the claimant could not have
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presented in the administrative process.” See Opeta, 484 F.3d at 1217; (see also Mot. at
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7 (citing cases where SSA determinations could not have been presented during the
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administrative process)). The court disagrees and finds that Ms. Reetz could have
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presented her SSA decision and the hearing evidence during her appeal of the Hartford
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denial; thus, Ms. Reetz fails to establish any exceptional circumstance in which
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consideration of evidence outside the administrative record is necessary.
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//
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The Ninth Circuit considered similar circumstances in Kearney v. Standard
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Insurance Company, 175 F.3d at 1091. In that case, the district court had declined to
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consider extrinsic evidence because the claimant “could as easily have submitted this
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material to [the administrator].” Id. The Ninth Circuit agreed. Id. Because “[n]o reason
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has been suggested why [the claimant] could not have submitted the [extrinsic evidence]
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to [the administrator],” the consideration of the extrinsic evidence “under Mongeluzo [is]
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disfavored.” Id. Thus, the Ninth Circuit held that the district court correctly limited its
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review to the administrative record. Id. (characterizing the district court’s reasons as
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“good ones under Mongeluzo” and “sensible in the circumstances of this case”).
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Similarly here, Ms. Reetz could have submitted the SSA materials—which she
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now wishes to include—to Hartford during the administrative process. The SSA
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determination occurred in July 2016, while the Hartford appeal was still pending.
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(Compl. ¶ 4.36.) Hartford did not issue a final decision until August 2016. (Id. ¶ 4.40.)
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Thus, like the claimant in Kearney, Ms. Reetz “could as easily have submitted” both the
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SSA’s written decision and Dr. Prachyl’s testimony to Hartford during the appeal
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process. See 175 F.3d at 1091. Accordingly, Ms. Reetz has not demonstrated any
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“limited circumstances” that render consideration of extrinsic evidence necessary. See
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id.; Opetz, 484 F.3d at 1217.
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Indeed, the timing of Ms. Reetz’s benefits determination distinguishes the
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circumstances here from the various cases on which she relies. Ms. Reetz identifies three
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cases where “courts specifically considered evidence regarding [SSA] awards when that
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evidence was not in the insurer’s claim file.” (Reply at 1-2.) Each of those cases,
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however, considered SSA determinations that occurred after the administrator’s final
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decision. See O’Neal v. Life Ins. Co. of N. Am., 10 F. Supp. 3d 1132, 1136-37 (D. Mont.
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2014) (referring to “post-denial award of Social Security disability benefits”)1; Oldoerp v.
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Wells Fargo & Co. Long Term Disability Plan, 12 F. Supp. 3d 1237, 1248, 1250 (N.D.
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Cal. 2014) (considering July 14, 2008, SSA determination after the administrator’s final
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decision on June 5, 2008); Schramm v. CNA Fin. Corp. Insured Grp. Ben. Program, 718
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F. Supp. 2d 1151, 1161, 1165 (N.D. Cal. 2010) (considering October 15, 2009, SSA
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determination after the administrator’s final decision on March 12, 2009). The court
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agrees that in such a situation—where the SSA determination did not occur until after the
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administrator’s final decision—the claimant could not have presented the additional
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evidence in the administrative process. But, as discussed above, that is not the
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chronology here. Thus, these cases do not support Ms. Reetz’s motion.
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Ms. Reetz argues that she cannot be blamed for failing to provide Hartford with
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the SSA evidence because Hartford should have asked for the information. (See Mot. at
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10; Reply at 3-4.) In support, she cites to various cases that place the responsibility of
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obtaining additional information on the administrator. (See, e.g., Mot. at 10 (citing
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Robertson v. Standard Ins. Co., 139 F. Supp. 3d 1190, 1206 (D. Or. 2015).) But Ms.
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Reetz misunderstands this case law. Those cases were all determined under an abuse of
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Ms. Reetz characterizes O’Neal v. Life Insurance Company of North America, 10 F.
Supp. 3d at 1136-37, as a case where the court specifically considered an SSA determination.
(Reply at 1-2.) This characterization is inaccurate. O’Neal mentioned SSA determinations only
in passing and in fact, explicitly states that “neither party contends that . . . any additional
evidence outside the administrative record should be considered.” 10 F. Supp. 3d at 1136-37.
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discretion standard, where an administrator’s failure to adequately consider an SSA
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decision may constitute an abuse of discretion. See Robertson, 138 F. Supp. 3d at 1206;
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Sterio v. HM Life, 369 F. App’x 801, 803 (9th Cir. 2010); Gorbacheva v. Abbott Labs.
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Extended Disability Plan, No. 5:14-cv-02524-EJD, 2016 WL 3566979, at *7 (N.D. Cal.
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June 30, 2016). In an abuse of discretion context, an administrator cannot shirk its
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obligation by arguing that the claimant did not submit the SSA information. See id. But
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on de novo review, it is “irrelevant whether and to what extent [the administrator]
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considered the SSA’s decision in making its ultimate decision.” Pearson v. Aetna Life
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Ins. Co., No. C15-0245JLR, 2016 WL 2745299, at *6 n.11 (W.D. Wash. May 10, 2016).
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Thus, an administrator’s obligation to ask for extrinsic evidence under an abuse of
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discretion standard does not necessarily exist under a de novo standard of review, and the
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court declines to apply such a requirement on de novo review to excuse Ms. Reetz’s
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failure to provide the evidence she now seeks to include.2
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Even if Ms. Reetz had established the existence of an “exceptional circumstance”
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as is required under Opetz, 484 F.3d at 1219, the court is unpersuaded that the SSA
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decision is relevant to the de novo review of Hartford’s disability determination under the
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Plan. Ms. Reetz insists that the SSA determination is “highly relevant” because it
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employed a “more strict standard . . . than the Hartford definition.” (Reply at 4-5
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Ms. Reetz also points out that she was unrepresented during the administrative appeal
process. (Mot. at 10; Reply at 4.) But she provides no case law stating that proceeding pro se
impacts whether a claimant “could” have presented the extrinsic evidence. (See generally id.);
see Opetz, 484 F.3d at 1219. Indeed, the court is not aware of any precedent suggesting that pro
se status is relevant to a motion to supplement. Thus, the court finds that Ms. Reetz’s pro se
status does not mean that she “could not have presented” the SSA evidence to Hartford.
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(emphasis removed).) The court addressed a similar argument in Pearson v. Aetna Life
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Insurance Company, where the claimant also emphasized that “the SSA determination
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was based on a more stringent standard than the [Plan] imposes.” 2016 WL 2745299, at
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*6. But because the court would “base[] its analysis on a different record than the ALJ
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reviewed,” the Pearson court found the SSA decision “only somewhat relevant,”
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“[w]hether or not [the claimant’s] comparison of the applicable standards is fully
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accurate.” Id. at *7. The court reaches the same conclusion here. Regardless of whether
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the SSA standard was more stringent, the court will be analyzing a different record than
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the one the SSA reviewed. Thus, the court concludes that the SSA determination and the
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underlying testimony would be, at best, “somewhat relevant” to determining whether
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Hartford correctly or incorrectly denied benefits under the Plan. See id.
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Because Ms. Reetz has failed to establish the existence of any “exceptional
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circumstances” to warrant the consideration of extrinsic evidence, the court limits its
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review to the administrative record that was before Hartford at the time of its decision.
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IV.
CONCLUSION
For the foregoing reasons, the court DENIES Ms. Reetz’s motion to supplement
the record (Dkt. # 14).
Dated this 8th day of November, 2017.
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A
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JAMES L. ROBART
United States District Judge
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ORDER - 9
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