Dioquino v. United of Omaha Life Insurance Company

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10 UNITED STATES DISTRICT COURT

11 SOUTHERN DISTRICT OF CALIFORNIA

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JONI DIOQUINO, Case No. 20-cv-00167-BAS-RBB

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Plaintiff, ORDER GRANTING IN PART

14 AND DENYING IN PART

DEFENDANT’S MOTION FOR

15 v. PARTIAL SUMMARY

JUDGMENT (ECF No. 22)

16 UNITED OF OMAHA LIFE

INSURANCE COMPANY,

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Defendant.

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19 Plaintiff Joni Dioquino brings this action under the Employee Retirement Income

20 Security Act of 1974 (“ERISA”). She seeks disability benefits under two employee benefit

21 plans funded by Defendant United of Omaha Life Insurance Company. Now before the

22 Court is Defendant’s motion for partial summary judgment. (ECF No. 22.) Defendant

23 argues part of Plaintiff’s action is moot. And it believes the remainder is not properly

24 before the Court because she did not exhaust her plan-based remedies. Plaintiff opposes.

25 (ECF No. 25.) The Court finds this motion suitable for determination on the papers

26 submitted and without oral argument. See Fed. R. Civ. P. 78(b); Civ. L.R. 7.1(d)(1). For

27 the following reasons, the Court GRANTS IN PART and DENIES IN PART Defendant’s

28 motion.

1 BACKGROUND

2 I. Disability Insurance Plans

3 In 2013, Plaintiff started working for Children’s Physicians Medical Group, Inc.

4 (Joint Statement of Undisputed Facts (“JSUF”) 6:2–5, ECF No. 27.) Plaintiff participated

5 in two employee welfare benefit plans that her employer sponsored: a short-term disability

6 benefits plan (“STD Plan”) and a long-term disability benefits plan (“LTD Plan”). (Id.

7 1:7–12, 1:23–2:1.) Children’s Medical served as the administrator for the plans, and

8 Defendant issued the group insurance policies that funded the plans. (Id. 1:14–17; 2:3–5;

9 6:7–13; see also STD Policy, Campbell Decl. Ex. 1, ECF No. 22-4; LTD Policy, Campbell

10 Decl. Ex. 3, ECF No. 22-6.) Plaintiff’s lawsuit seeks benefits under both plans. (Complaint

11 ¶¶ 57–65, ECF No. 1.)

12 A. Short-Term Disability Plan

13 The STD Plan provides disability benefits for a maximum of eleven weeks. (STD

14 Plan 2.) Although the plan provides benefits for both partial and total disability, this

15 dispute centers on the benefits for total disability. (Compl. ¶¶ 7, 10.)

16 Total Disability. A plan participant like Plaintiff is “Totally Disabled” when she is

17 “unable to perform, with reasonable continuity, the Substantial and Material Acts necessary

18 to pursue [her] Usual Occupation” because of “an Injury or Sickness.” (STD Plan 17.)

19 “Substantial and Material Acts” are “the important tasks, functions and operations

20 generally required from employers” in the employee’s Usual Occupation “that cannot be

21 reasonably omitted or modified.” (Id.) And the employee’s “Usual Occupation” is “any

22 employment, business, trade or profession and the Substantial and Material Acts of the

23 occupation [she was] regularly performing for the Policyholder when the Disability

24 began.” (Id. at 17–18.)

25 Elimination Period. An employee who becomes disabled is not immediately entitled

26 to benefits. Rather, the employee must first satisfy the “Elimination Period,” which is a

27 minimum “period of continuous Total or Partial Disability.” (STD Plan 16.) The STD

28 Plan’s Elimination Period is fourteen calendar days. (Id. at 2.) Therefore, an employee

1 can first start receiving benefits only after fourteen days of continuous disability. (Id. at

2 8.)

3 Benefits. Assuming an employee is disabled and satisfies the Elimination Period,

4 the STD Plan provides a “Weekly Benefit” that is the lesser of: (a) 70% of the employee’s

5 weekly earnings, less “Other Income Benefits,” or (b) “the maximum Weekly Benefit,

6 which is $2,000, less Other Income Benefits.” (STD Plan 2.) The “Other Income Benefits”

7 that offset the Weekly Benefit include state government disability benefits. (Id. at 3.)

8 Claims Procedure. The STD Plan requires an employee to submit written proof of

9 loss in order for a claim for benefits to be considered. (STD Plan 11.) An employee

10 satisfies this requirement by submitting either a completed claim form or a written

11 statement that includes the cause of the disability, treating physician contact information,

12 and any restrictions and limitations preventing the employee from performing job duties.

13 (Id.) Consistent with ERISA regulations, the STD Plan requires Defendant to evaluate the

14 claim within a set period. (Id.) If Defendant denies the claim, it must provide notice of

15 the denial, including “specific reason(s) for the denial” and a “reference to specific Policy

16 provisions on which the denial is based.” (Id. at 13.) The employee has a right to appeal

17 the claim decision within 180 days, and Defendant must again respond to the appeal within

18 a set period. (Id. at 14.)

19 B. Long-Term Disability Plan

20 Whereas the STD Plan provides benefits for up to eleven weeks, the LTD Plan

21 provides benefits for a participant like Plaintiff until potentially up to her Social Security

22 retirement age. (See LTD Plan 3.) The LTD Plan similarly provides benefits for partial

23 and total disability, but the focus here remains on its total disability benefits. (Compl. ¶¶

24 8–10.)

25 Total Disability. The LTD Plan’s “Total Disability” definition is two-phased. For

26 the first two years, a Total Disability is materially the same as under the STD Plan. An

27 employee is totally disabled when an illness prevents her from doing the Substantial and

28 Material Acts necessary to pursue her Usual Occupation. (LTD Plan 21.) After two years

1 of benefits, the definition becomes more stringent. An employee is totally disabled only if

2 she cannot perform any reasonable occupation in light of her “age, education, training,

3 experience, station in life, and physical and mental capacity.” (Id.)

4 Elimination Period. The LTD Plan likewise includes a waiting period before an

5 employee is entitled to benefits. (LTD Plan 19.) The “Elimination Period” is the later of:

6 (a) “90 calendar days,” or (b) the date . . . short-term disability payments under the

7 Policyholder’s insured or self-insured group plan end.” (Id. at 2.)

8 Benefits. Assuming an employee is totally disabled and satisfies the ninety-day

9 Elimination Period, the LTD Plan provides for a monthly benefit that is the lesser of:

10 (a) 60% of the employee’s gross monthly pay, less Other Income Benefits; or (b) $6,000,

11 less any Other Income Benefits. (LTD Plan 2.)

12 Claims Procedure. The LTD Plan has the same claims procedure as the STD Plan.

13 (Compare LTD Plan 11–14, with STD Plan 14–17.) The employee must submit a written

14 claim, Defendant must respond, and the employee has the right to appeal an adverse

15 decision within 180 days. (LTD Plan 11–14.)

16 II. Plaintiff’s Request for Benefits

17 Claim. Plaintiff worked as a Financial Analyst/Accountant for Children’s Medical.

18 (STD Claim Form, United 428–30.1) On November 8, 2018, she completed Defendant’s

19 Short-Term Disability Claim Form. (United 665–68.) Plaintiff listed her disability as

20 beginning on August 20, 2018, and wrote that she was “unable to sit for [a] period of time”

21 and needed to elevate her legs. (Id. 665.) Plaintiff stated she was first treated for her illness

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1 The Court cites to the bate stamps on Plaintiff’s claim file. The corresponding exhibits are

24 included below. The two gaps in the bate stamps are the STD and LTD policies, which the Court cites to

by their page numbers.

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United-000044 to United-000188 Campbell Decl. ¶ 4, Ex. 2-1, ECF No. 34-1

26 United-000189 to United-000438 Campbell Decl. ¶ 4, Ex. 2-2, ECF No. 34-2

United-000439 to United-000613 Campbell Decl. ¶ 4, Ex. 2-3, ECF No. 34-3

27 United-000614 to United-000788 Campbell Decl. ¶ 4, Ex. 2-4, ECF No. 34-4

United-000833 to United-001025 Campbell Decl. ¶ 4, Ex. 4, ECF No. 34-5

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1 on August 29, 2028, and identified Dr. Richard Campbell as her treating physician. (Id.)

2 Children’s Medical completed the employer’s portion of the form, where it noted Plaintiff’s

3 job was sedentary and checked a box indicating that Defendant “cover[s] the Employee for

4 group long-term disability.” (Id. 666.)

5 Dr. Campbell completed the attending physician’s portion of the disability form.

6 (United 667–68.) According to Dr. Campbell, Plaintiff needs to elevate her legs frequently,

7 and she is “unable to sit/stand/walk” for more than ten minutes per hour, as she needs to

8 frequently get up from sitting for stretch breaks. (Id. 668.) Dr. Campbell also checked a

9 box indicating Plaintiff is unable to work with modifications to her job. (Id.)

10 Claim Decision. Defendant’s claims manager referred Plaintiff’s claim for medical

11 review by its Clinical Nurse Consultant. (United 670–72.) The nurse summarized

12 Plaintiff’s medical file, including Dr. Campbell’s treatment notes from August 29, 2018,

13 and November 8, 2018. (Id. 671–72.) In those notes, Dr. Campbell diagnosed Plaintiff

14 with “Achilles tendinitis of left lower extremity (M76.62),” “Arthritis of knee (M17-10),”

15 and “Left knee sprain (S83.92XA).” (Id. 449.) His diagnosis relied on an August 29, 2018,

16 x-ray of Plaintiff’s knee. (Id. 448.) The x-ray did not reveal that Plaintiff’s knee was

17 dislocated or fractured, but it did show there was mild arthrosis, joint effusion, and

18 moderate-to-severe narrowing of the patellofemoral compartment. (Id.) Therefore, the x-

19 ray led to an impression of bilateral knee arthrosis. (Id.) After reviewing Plaintiff’s file,

20 Defendant’s nurse consultant wrote on January 8, 2019:

21 While it would be reasonable to support restrictions and limitations of

elevating the left leg frequently, being unable to sit/stand/walk greater than 10

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minutes per hour, and the need to get up from sitting frequently for stretch

23 breaks, for 2-3 days, without a higher level of evaluation or treatment[,] one

would not expect ongoing restrictions and limitations beyond that time.

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25 (Id. 672.)

26 Defendant later referred Plaintiff’s claim for review by an outside occupational

27 physician, Gregory Smith. (United 702–07.) In a report dated February 6, 2019, Dr. Smith

28 agreed that Plaintiff met the criteria for “Achilles tendinitis and left knee arthritis with

1 effusion.” (Id. 703.) However, he opined that “[f]or the period under review 8/15/18 and

2 forward,” Plaintiff’s diagnosis “is only consistent with moderate functional limitations of

3 the left lower extremity”; that is, only “use of [a] cane” and “some limitations on

4 weightbearing and repeated use of the left leg.” (Id. 703.) Consequently, Dr. Smith

5 concluded Plaintiff can stand “occasionally, 30 minutes at a time, 3 hours [a] day” and can

6 sit “constantly.” (Id. 703–04.)

7 On March 7, 2019, Defendant denied Plaintiff’s claim for STD benefits. (United

8 647–52.) After incorporating Plaintiff’s medical records and Dr. Smith’s report, Defendant

9 reasoned Plaintiff’s restrictions and limitations “do not preclude [her] from working”

10 because she has “a sedentary occupation.” (Id. 649.) Hence, Defendant determined no

11 benefits are payable and advised Plaintiff of her right to appeal. (Id. 649–50.)

12 Appeal. On June 22, 2019, Plaintiff appealed the denial of her disability benefits.

13 (JSUF 8:4–7.) She forwarded updated medical records, x-ray results, MRI results, a list of

14 exercises for physical therapy, reference materials, and Dr. Campbell’s visit summary

15 dated January 3, 2019. (Id.) Defendant again referred Plaintiff’s complete file for review

16 by a different orthopedic consultant. (Id. 127.) That physician, Dr. Hulett, opined that the

17 “clinical findings are limited despite multiple complaints.” (Id. 249.) Dr. Hulett concluded

18 those findings do not “clearly indicate functional impairment,” with “no restrictions

19 supported from 8/22/18–7/9/19.” (Id. 249.)

20 On August 22, 2019, Plaintiff responded to Dr. Hulett’s review and submitted

21 additional documentation. (United 246–47.) Dr. Hulett reviewed the supplemental records

22 the following week but concluded they did not alter her opinions. (Id. 199–200.)

23 On September 1, 2019, after considerable back-and-forth, and over a year after

24 Plaintiff stopped working, Defendant denied Plaintiff’s appeal. (United 125–32.) The

25 appeal letter notes that Defendant considered Plaintiff’s additional documentation,

26 including supplemental state disability certifications from Dr. Campbell and test results.

27 (Id. 126–27.) The letter then incorporates Dr. Hulett’s opinions. (Id. 128.) The insurance

28 company concludes:

1 Based upon our review, the medical information contained in your file supports

various diagnoses; however, these diagnoses do no[t] support [restrictions and

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limitations] that would preclude the performance of the substantial and material acts

3 of your usual occupation, which is performed at a sedentary level. Therefore, the

denial of the claim is upheld.

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5 (Id. 129.) After exhausting her plan remedies for STD benefits, Plaintiff did not file a

6 separate claim for LTD benefits with Defendant. (See JSUF 4:24–5:28.)

7 III. Plaintiff’s Action

8 On January 24, 2020, Plaintiff filed this action seeking both STD and LTD benefits.

9 (ECF No. 1.) After Defendant answered, the parties participated in an early neutral

10 evaluation conference on April 23, 2020. (ECF No. 14.) When the case did not settle,

11 Defendant issued Plaintiff a check for $1,244.76 plus interest, which it calculated to be the

12 maximum amount she is owed under the STD Plan. (JSUF 1:19–21; Hess Decl. ¶ 3, Ex.

13 B, ECF No. 22-10.) Defendant claims it did so because “it makes no sense to continue to

14 litigate a claim that is worth less than $1,300.” (Hess Decl. ¶ 3, Ex. B.) The amount of

15 STD benefits is lower than one might expect because, as mentioned above, the STD Plan

16 provides that state government disability benefits offset the plan’s benefits, and Plaintiff

17 received those benefits from California. (See id.; see also STD Plan 2–3.) Defendant now

18 moves for partial summary judgment, arguing Plaintiff’s STD claim is moot. (Mot., ECF

19 No. 22.) The company also argues her LTD claim is not properly before the Court because

20 Plaintiff lacks standing and failed to exhaust her remedies under the LTD Plan. (Id.)

21 LEGAL STANDARD

22 “A party may move for summary judgment, identifying each claim or defense—or

23 the part of each claim or defense—on which summary judgment is sought.” Fed. R. Civ.

24 P. 56(a). Summary judgment is appropriate under Rule 56(c) where the moving party

25 demonstrates the absence of a genuine issue of material fact and entitlement to judgment

26 as a matter of law. See id. 56(c); Celotex Corp. v. Catrett, 477 U.S. 317, 322 (1986). A

27 fact is material when, under the governing substantive law, it could affect the outcome of

28 the case. Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 248 (1986). A dispute about a

1 material fact is genuine if “the evidence is such that a reasonable jury could return a verdict

2 for the nonmoving party.” Id. at 248.

3 When resolving a summary judgment motion, the court must view all inferences

4 drawn from the underlying facts in the light most favorable to the nonmoving party.

5 Matsushita Electric Indus. Co., Ltd. v. Zenith Radio Corp., 475 U.S. 574, 587 (1986).

6 “Credibility determinations, the weighing of evidence, and the drawing of legitimate

7 inferences from the facts are [factfinder] functions, not those of a judge, [when] he [or she]

8 is ruling on a motion for summary judgment.” Anderson, 477 U.S. at 255.

9 ANALYSIS

10 I. Mootness of Short-Term Disability Claim

11 There is no dispute that ERISA governs the employee benefit plans at issue. ERISA

12 § 502 allows a plan participant like Plaintiff to bring an action to recover benefits due to

13 her under a plan, to enforce her rights under a plan, or to clarify her rights to future benefits

14 under a plan. 29 U.S.C. § 1132(a)(1)(B). Defendant argues Plaintiff’s claim for benefits

15 under the STD Plan is moot because the insurer has since paid her the maximum amount

16 of benefits. (Mot. 10:27–11:12.)

17 “A claim is moot if it has lost its character as a present, live controversy.” Rosemere

18 Neighborhood Ass’n v. U.S. Env’t Prot. Agency, 581 F.3d 1169, 1172–73 (9th Cir. 2009).

19 Hence, a claim “becomes moot when a plaintiff actually receives all of the relief he or she

20 could receive on the claim through further litigation.” Chen v. Allstate Ins. Co., 819 F.3d

21 1136, 1144 (9th Cir. 2016) (emphasis omitted).

22 Plaintiff’s claim for STD benefits is moot. The payment she received from

23 Defendant is all the relief she “could receive on the claim through further litigation.” See

24 Chen, 819 F.3d at 1144.

25 Plaintiff still opposes Defendant’s motion because she argues ERISA entitles her to

26 recover her reasonable attorney’s fees and costs. (Opp’n 6:8–7:9, ECF No. 25.) See Hardt

27 v. Reliance Std. Life Ins. Co., 560 U.S. 242, 244–45 (2010) (providing that where ERISA’s

28 fee-shifting provision applies, the court may award fees and costs to either party so long as

1 the claimant shows “some degree of success on the merits”). Even so, Plaintiff’s

2 underlying claim is moot. The Court can resolve any request for attorney’s fees and costs

3 at the end of this case. See Tom v. Hartford Life & Accident Ins. Co., No. C 16-01067

4 WHA, 2017 WL 6209306, at *1 (N.D. Cal. Dec. 8, 2017) (resolving a plaintiff’s motion

5 for attorney’s fees and costs under ERISA where the court had dismissed the action as moot

6 after the defendant provided the requested benefits). Therefore, the Court grants

7 Defendant’s request for summary judgment on Plaintiff’s request for STD benefits.

8 II. Propriety of Long-Term Disability Claim

9 Although Plaintiff has received her STD benefits, she is also seeking LTD benefits

10 under the LTD Plan. Defendant argues summary adjudication of this claim is appropriate

11 on justiciability and exhaustion grounds.

12 A. Standing

13 Defendant briefly argues Plaintiff lacks standing to seek LTD benefits because she

14 did not file a claim for LTD benefits with Defendant. (Mot. 11:14–12:12.) “There is no

15 ERISA exception to Article III.” Thole v. U. S. Bank N.A, 140 S. Ct. 1615, 1622 (2020).

16 That said, an “ordinary Article III standing analysis” shows Plaintiff can bring her ERISA

17 § 502 claim. See id. Plaintiff has a concrete stake in this dispute because she claims

18 entitlement to monetary benefits from Defendant under the LTD Plan, which she has not

19 received. Cf. id. (holding plaintiffs lacked standing where winning or losing the lawsuit

20 would not change their pension benefits under the plan). And as fully explored below, she

21 asserts Defendant’s treatment of her claim for STD benefits doomed any request for LTD

22 benefits from Defendant. In addition, the Court can award relief that remedies Plaintiff’s

23 asserted injury. See Lujan v. Defs. of Wildlife, 504 U.S. 555, 560–61 (1992) (explaining

24 the standing requirements).

25 Moreover, the ERISA case Defendant cites for this argument is distinguishable.

26 There, the court determined the plaintiffs lacked standing because they sought healthcare

27 plan benefits based on medical services that had not yet been rendered. Delgado v. ILWU-

28 PMA Welfare Plan, No. 2:18-CV-5539 CBM, 2018 WL 8014336, at *3 (C.D. Cal. Nov.

1 20, 2018). Here, in contrast, Plaintiff claims she already meets the plan’s definition of

2 disability and is entitled to LTD benefits. The Court is therefore unpersuaded by

3 Defendant’s standing argument.

4 B. Exhaustion of Plan Remedies

5 The heart of Defendant’s motion relies on the judicially created exhaustion

6 requirement for this type of claim. Defendant argues the Court should not entertain

7 Plaintiff’s cause of action because her failure to file a separate claim for LTD benefits

8 means she did not exhaust her remedies under the LTD Plan. (Mot. 12:13–25:19.) Plaintiff

9 responds that she was excused from doing so because exhaustion would have been futile.

10 (Opp’n 7:10–19:8.) Defendant both anticipates this argument and counters that Plaintiff

11 fails to meet her burden of demonstrating futility. (Mot. 17:12–25:19; Reply 3:22–10:21,

12 ECF No. 26.) The Court will review the exhaustion requirement and then resolve the

13 parties’ well-briefed futility contentions.

14 1. Exhaustion Rule

15 “Quite early in ERISA’s history,” the Ninth Circuit “announced as the general rule

16 governing ERISA claims that a claimant must avail himself or herself of a plan’s own

17 internal review procedures before bringing suit in federal court.” Diaz v. United Agr. Emp.

18 Welfare Ben. Plan & Tr., 50 F.3d 1478, 1483 (9th Cir. 1995) (citing Amato v. Bernard, 618

19 F.2d 559, 566–68 (9th Cir.1980)). This requirement is not “explicitly set out in the statute,”

20 but “the exhaustion doctrine is consistent with ERISA’s background, structure and

21 legislative history.” Id. The doctrine also “serves several important policy considerations,

22 including the reduction of frivolous litigation, the promotion of consistent treatment of

23 claims, the provision of a nonadversarial method of claims settlement, the minimization of

24 costs of claim settlement and a proper reliance on administrative expertise.” Id. Therefore,

25 “courts have the authority to enforce the exhaustion requirement in suits under ERISA, and

26 . . . as a matter of sound policy they should usually do so.” Amato, 618 F.2d at 568.

27 Because this requirement is prudential—and not jurisdictional—there are exceptions

28 to the rule. Vaught v. Scottsdale Healthcare Corp. Health Plan, 546 F.3d 620, 626–27 (9th

1 Cir. 2008). The exception relevant here is “when resort to the administrative route is

2 futile.” Id. (quoting Amato, 618 F.2d at 568).

3 2. Futility Exception

4 “The futility exception is ‘designed to avoid the need to pursue an administrative

5 review that is demonstrably doomed to fail.’” A.F. v. Providence Health Plan, 157 F. Supp.

6 3d 899, 909 (D. Or. 2016) (quoting Diaz, 50 F.3d at 1485 (9th Cir.1995)). Consequently,

7 “bare assertions of futility are insufficient to bring a claim within the futility exception.”

8 See Diaz, 50 F.3d at 1485. And a plan’s “refusal to pay” does not, by itself, show futility.

9 See id.

10 For instance, in Diaz, the plan denied the participant’s claim for medical expenses

11 for his daughter who succumbed to leukemia based on the plan’s pre-existing condition

12 limitation. 50 F.3d at 1482. The plan provided for a right to appeal, but the participant did

13 not do so before he and his spouse sued. Id. The district court granted the defendants’

14 motions for summary judgment on exhaustion grounds. Id. The Ninth Circuit affirmed.

15 Id. at 1486. It reasoned the district court did not abuse its discretion because the plaintiffs

16 put forth only a bare assertion that exhaustion would be futile: the argument “that it would

17 have been ‘futile’ for them to demand administrative review because both defendants have

18 demonstrated by their continued refusal to pay that they have no intention of doing so.” Id.

19 at 1485–86. Further, the record contained “nothing but speculation to suggest that the

20 administrators would have reached a preconceived result” when examining the merits. Id.

21 at 1486.

22 In comparison, in Burnett v. Raytheon Co. Short Term Disability Basic Benefits

23 Plan, 784 F. Supp. 2d 1170 (C.D. Cal. 2011), the district court excused exhaustion of an

24 LTD claim under the futility exception. There, the same insurance company—MetLife—

25 served as the claims administrator for the employer’s self-funded STD and LTD benefit

26 plans. Id. at 1174–75. MetLife initially granted the plaintiff’s claim for STD benefits

27 based on major depressive disorder, but later terminated his benefits. Id. at 1176–77. The

28 plaintiff appealed the determination, and MetLife referred his claim for review by a board-

1 certified psychiatrist. Id. at 1177. Ultimately, like here, MetLife reaffirmed its denial of

2 the claim while reasoning the clinical data did not support that the plaintiff was totally

3 disabled and unable to perform his normal occupation. Id. at 1179. Further, again like

4 here, the plaintiff never submitted an LTD claim before filing suit. Id. at 1181.

5 After a bench trial, the district court found the plaintiff’s exhaustion of plan remedies

6 would have been futile for several reasons:

7 First, the definitions for “fully disabled” for purposes of STD benefits and

LTD benefits are substantially the same. Second, the STD and LTD plans are

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integrated, such that they rely on and refer to each other. MetLife’s

9 termination of Burnett’s STD Plan benefits essentially doomed any claim he

might have to LTD Plan benefits. Finally, because MetLife is the designated

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Claim Administrator under both the STD and LTD plans, the plans are

11 administered by the same entity. In light of the foregoing—considered

together with MetLife’s unwavering denial of Burnett’s . . . STD benefits—

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MetLife likely would have denied any LTD benefits claim Burnett submitted

13 for the same reasons it terminated his STD benefits claim.

14 Burnett, 784 F. Supp. 2d at 1185. The court also considered the policies underlying the

15 exhaustion doctrine and reasoned they do not preclude application of the futility exception.

16 Id.

17 As indicated, there is no genuine dispute that Plaintiff failed to comply with the LTD

18 Plan’s internal procedures. (See JSUF 4:24–5:28.) There is, however, a genuine issue of

19 material fact as to whether exhaustion would have been futile. Viewing the evidence in

20 the light most favorable to Plaintiff—as the Court must on summary judgment—a

21 reasonable factfinder could conclude her LTD claim was doomed to fail.

22 In seeking to preempt Plaintiff’s futility argument, Defendant submits a declaration

23 from one of its employees who is a Group Claims Team Leader. (Campbell Decl., ECF

24 No. 22-3.) The employee states he is aware of “other claims where [Defendant] initially

25 found that the claimant was not entitled to STD benefits,” but later favorably resolved a

26 claim for LTD benefits when “additional and later information was submitted in support

27 of the claimant’s LTD claim.” (Id. ¶ 8.) Defendant contends this declaration is the only

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1 evidence before the Court concerning futility. (Reply 5:16–20, n.4.) And because it is

2 unchallenged, Defendant argues it defeats Plaintiff’s futility claim. (Id.)

3 The Court is unconvinced. Plaintiff points to several items a factfinder could

4 consider for the futility inquiry. The Court starts with what is obvious: Defendant is the

5 one resolving claims under both plans. A factfinder could rely on the fact that the same

6 entity is the arbiter of claims under both plans in determining whether exhaustion would

7 have been futile. See, e.g., Burnett, 784 F. Supp. 2d at 1185 (relying on the fact that the

8 employer’s two plans were administered by the same entity).

9 Moreover, the terms of the benefit plans inform the futility determination. The STD

10 Plan’s definition of Total Disability is materially the same as under the LTD Plan for the

11 first two years of LTD benefits. See supra Part I.A–B. Yet the LTD Plan requires a longer

12 Elimination Period—a period of continuous disability—than the STD Plan. Whereas a

13 participant must be fully disabled for fourteen days under the STD Plan to obtain benefits,

14 the LTD Plan requires at least ninety days of total disability. See supra Part I.A–B. As

15 Plaintiff argues, a factfinder could infer from these terms that if the claims administrator

16 determined she did not satisfy the STD Plan’s total disability definition for the Elimination

17 Period, then the LTD Plan’s claims administrator would almost certainly conclude she did

18 not satisfy the same definition for an even longer period of continuous disability for LTD

19 benefits. (See Opp’n 16:4–13.) Other courts have reached the same conclusion.2

20 Finally, the way Defendant resolved Plaintiff’s STD claim is relevant for the futility

21 inquiry. For example, if Defendant had denied her STD claim because she failed to fill out

22 a form or submit any information from her doctor, it would be unreasonable for a factfinder

23 to infer that filing an LTD claim would have been futile. Here, however, Defendant denied

24

25 2 See Burnett, 784 F. Supp. 2d at 1185 (noting “the definitions for ‘fully disabled’ for purposes of

STD benefits and LTD benefits are substantially the same”); see also Darensbourg-Tillman v. Robins,

26 Kaplan, Miller & Ciresi LLP Short Term Disability Plan, No. CV 04-2903 AHM (VBKx), 2004 WL

5603225, at *3 (C.D. Cal. Sept. 3, 2004) (“Given these definitions, it is highly probable that the undisputed

27 denial of Plaintiff’s claim for benefits under the STD plan means that any claim under the LTD plan,

which contains a more restrictive definition of disabled, would also be denied.”); Young v. UnumProvident

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1 Plaintiff’s claim on the merits for reasons that apply equally to a claim under the LTD Plan,

2 which—again—has the same relevant definition of disability and the same arbiter of

3 claims.

4 Further, Defendant reaffirmed its denial on appeal after considering additional

5 information from Plaintiff that stretched well past the Elimination Periods for both STD

6 and LTD benefits. (See United 126–27.) Defendant determined Plaintiff’s medical

7 information supported “various diagnoses,” but concluded those diagnoses do not support

8 restrictions and limitations that would preclude her from performing her sedentary

9 occupation. (United 129.) Defendant did so while knowing it “cover[s] [Plaintiff] for

10 group long-term disability.” (Id. 666.) Therefore, as Plaintiff argues, a factfinder could

11 conclude that requiring Plaintiff to file a separate LTD claim “would have merely been an

12 exercise of [Defendant] reevaluating the same medical evidence that it had just finished

13 evaluating to deny Plaintiff’s STD claim.” (Opp’n 18:20–22.)

14 Nor do the policies underlying the exhaustion doctrine demand a different result.

15 Plaintiff’s case is not frivolous. And viewing the record in her favor, it is not clear why

16 requiring the same insurer to reevaluate the same medical evidence for the same definition

17 of disability to reach the same result would minimize the costs of claim settlement or

18 promote proper reliance on administrative expertise before judicial review. See Diaz, 50

19 F.3d at 1483. The Court already has the insurer’s reasoned explanation for why it believes

20 Plaintiff does not qualify for benefits under a definition of disability that is materially the

21 same as under the LTD Plan.

22 In sum, given the specific circumstances of this case, a reasonable factfinder could

23 find Plaintiff’s LTD claim was “doomed to fail.” See Diaz, 50 F.3d at 1485. Consequently,

24 the Court denies Defendant’s request for summary judgment on exhaustion grounds.

25 CONCLUSION

26 For the foregoing reasons, the Court GRANTS IN PART and DENIES IN PART

27 Defendant’s motion for partial summary judgment. (ECF No. 22.) The Court grants

28 Defendant’s request to summarily adjudicate Plaintiff’s request for STD benefits as moot.

1 ||The Court denies, however, Defendant’s request to summarily adjudicate □□□□□□□□□□□

2 request for LTD benefits on standing and exhaustion grounds. The parties shall proceed to

3 || their mandatory settlement conference before the Magistrate Judge on June 8, 2021. (ECF

4 ||No. 33.) Ifthe case does not settle, the parties shall promptly contact the Court to schedule

5 bench trial to resolve Defendant’s exhaustion defense and the remainder of □□□□□□□□□□□

6 action. Finally, the Court DENIES AS MOOT Defendant’s ex parte application to submit

7 || supplemental authority consisting of two out-of-circuit district court decisions. (ECF No.

8 ||38.) Both decisions rely on their respective circuits’ futility rules and do not persuade the

9 || Court to reach a different result.

10 IT IS SO ORDERED.

11 /)

12 || DATED: April 9, 2021 (Yin A (Lyohaa é

13 United States District Judge

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