Facts

Plaintiff Renee Johnson Monroe was employed as a human resources compliance specialist by Kaiser Foundation Health Plan, Inc. She enrolled in Kaiser's long-term disability benefit plan, which was funded and administered by defendant Metropolitan Life Insurance Company through a group LTD insurance policy it issued to Kaiser. The policy provides 24 months of benefits to employees who, because of a sickness or injury, are unable to perform with reasonable continuity the material duties of their own usual occupation in the usual and customary way. Thereafter, the policy provides benefits through retirement age if the employee is unable to perform the material duties of "any occupation."

During the policy's "own occupation" period, plaintiff submitted a claim to defendant. Defendant denied her claim and determined that the evidence did not demonstrate that plaintiff was disabled under the terms of the Plan. It was undisputed that plaintiff's sedentary occupation required her to sit typing at a computer for most of the workday, seven-to-eight hours per day.

Plaintiff filed an ERISA lawsuit against defendant to recover her disability benefits and to overturn defendant's denial decision.

PLAINTIFF'S CONTENTIONS: Plaintiff contended that she could no longer perform her material job duties at Kaiser because, following seven surgeries, she suffered from chronic lower back pain, multiple herniated discs, and pinched nerves that caused shooting pain down her legs and feet. She offered medical opinion evidence from her treating physicians who opined that she could sit at most two hours per workday because of these conditions and was physically unable to perform her occupational duties. Plaintiff argued that defendant erroneously denied her claim for benefits under Armani v. Northwestern Mutual, 840 F.3d 1159, 1163 (9th Cir. 2016) because, under that case, she was per se disabled from performing the material duties of her sedentary occupation. Armani held that a person that could sit four hours per day was disabled from performing a sedentary occupation.

Plaintiff contended that her examining doctors' opinions were more credible than the defendant's medical consultant because he performed just a "paper review" of her medical file. Yet plaintiff's physicians had examined her regularly for years.

Plaintiff contended further that defendant improperly discounted her subjective accounts of pain, which violated 9th Circuit law. And that since the Social Security Administration found plaintiff disabled under a more rigorous disability standard than in the policy, the court should under the policy's standard.

DEFENDANT'S CONTENTIONS: Defendant contended that it rightfully denied plaintiff's claim for LTD benefits because she was not disabled from performing her own usual occupation. Defendant relied on the opinion of a physician consultant, board certified in physiatry and internal medicine, who reviewed plaintiff's medical records and concluded that she could work full-time in her sedentary occupation. Further, the Social Security Administration's disability determination was not issued until after defendant made its final claim determination, and was decided under the "treating physician rule" which required the administrative law judge to give deference to plaintiff's treating physicians.

Damages

Plaintiff sought all benefits due and owing under the LTD policy together with prejudgment interest, costs, and her attorneys' fees.

Result

The court entered judgment in plaintiff's favor, concluding that she established eligibility for benefits under the LTD policy. The court awarded her $26,940.06 in back disability benefits for the entirety of the policy's 24-month "own occupation" period, plus prejudgment interest in an amount agreed to by the parties. The court invited plaintiff to apply for an award of her attorneys' fees and costs (which motion remains under submission). And it remanded the claim back to defendant to consider whether plaintiff remained disabled during the Plan's "any occupation" disability period. On remand, defendant approved plaintiff's claim under the Plan's "any occupation" disability standard and paid her another five years of back benefits plus interest and monthly benefits going forward. In finding that plaintiff was disabled from performing the material duties of her own sedentary occupation, the court placed significant weight on the opinions of her examining physicians. The court noted that plaintiff's treating physicians "resolved that plaintiff could not sit for more than two non-continuous hours per day and she could not stand on her own." The court found these opinions credible since they had treated plaintiff in person for several years. In contrast, the court disagreed with the conclusions reached by the physician consultant who reviewed the file at defendant's request. The court found that his conclusion about the activities plaintiff could perform was "not well-supported," noted that the consultant performed only a "paper review" of plaintiff's medical file, and overall found that his report "does not in fact refute the position of Plaintiff's treating doctors." The court stated that it appeared the consultant disregarded plaintiff's subjective reports of pain. The court noted that "it would be an abuse of discretion for the Court to fail to consider a Plaintiff's subjective account of pain", relying on Kibel v. Aetna Life Ins. Co., 725 F. App'x 475, 477 (9th Cir. 2018) (citing Demer v. IBM Corp. LTD Plan, 835 F.3d 893, 904-07 (9th Cir. 2016)). That it was suspicious for defendant not to conduct an examination of plaintiff to assess her pain reports. Finally, the court found that although the SSA decision was not available to defendant at the time it made its final determination on plaintiff's claim, the SSA's decision supported the court's finding that plaintiff was disabled under the Plan.

Other Information

By the court's judgment, plaintiff recovered $26,940.06 in past due "own occupation" LTD benefits, plus $3,761.66 in prejudgment interest thereon. Following the remand ordered by the court, she also recovered $62,920.59 in past due "any occupation" LTD benefits, plus $4,282.20 in interest on those benefits. In addition to those sums, she receives her LTD benefit of $1,193.92 each month, which she will receive through retirement so long as she remains disabled under the terms of the Plan, and she will also recover her reasonable attorneys' fees and costs if the court grants her pending motion for attorneys' fees and costs.