Rick LaLonde v. Metropolitan Life Insurance Company

UNITED STATES DISTRICT COURT

CENTRAL DISTRICT OF CALIFORNIA

RICK LALONDE, No. 2:24-cv-01781-DSF-MBK

Plaintiff, Findings of Fact and Conclusions

of Law After Court Trial on the

v. Administrative Record

METROPOLITAN LIFE

INSURANCE COMPANY,

Defendant.

I. Introduction

Plaintiff Rick LaLonde brings this action pursuant to the

Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C.

§ 1001 et seq., to challenge Defendant Metropolitan Life Insurance

Company’s (MetLife) denial of his continued long-term disability (LTD)

benefits. A court trial on the administrative record was held on

February 25, 2025. After consideration of the parties’ trial briefs, oral

arguments, and the evidence in the Administrative Record,1 the Court

makes the following findings of fact and conclusions of law.

1 The Court refers to pages from the Administrative Record as “AR ___.”

II. Findings of Fact2

A. The Plan

LaLonde is a former employee of Providence Health & Services

(Providence), which established an ERISA-governed plan that provides

LTD benefits to eligible employees (the Plan). Dkt. 30-1 ¶ 2; Dkt. 31-1

¶ 2. The group disability insurance policy that funds the Plan’s LTD

benefits is issued by MetLife. Id. MetLife also acts as the fiduciary

responsible for adjudicating claims for LTD benefits under the Plan.

Id.; PLAN 0058-0061.3 At all relevant times, LaLonde was a

participant in the Plan as a benefit of his employment with Providence.

Dkt. 30-1 ¶ 2; Dkt. 31-1 ¶ 2.

The Plan provides monthly LTD benefits, after a 180-day

elimination period, to participants that are disabled under the terms of

the Plan. PLAN 0021. The Plan defines “disabled” or “disability” as

follows:

[D]ue to Sickness or as a direct result of accidental injury:

 You are receiving Appropriate Care and Treatment and

complying with the requirements of such treatment; and

 You are unable to earn:

o during the Elimination Period and the next 24 months of

Sickness or accidental injury, more than 80% of Your

Predisability Earnings at Your Own Occupation from any

employer in Your Local Economy; and

2 Any finding of fact deemed to be a conclusion of law is incorporated into the

conclusions of law. Any conclusion of law deemed to be a finding of fact is

incorporated into the findings of fact. Where the Court declined to adopt a

fact submitted by a party, the Court found the fact was either unsupported,

unnecessary, or irrelevant to its determination.

3 The Court refers to pages from the Plan’s policy documents (Dkt. 26) as

“PLAN ___.”

o after such period, more than 60% of your Predisability

Earnings from any employer in Your Local Economy at any

gainful occupation for which You are reasonably qualified

taking into account Your training, education and

experience.

Id. at 0023.

The Plan also limits LTD benefits to 24 months for disabilities

due to alcohol, drug, or substance abuse or addiction and for disabilities

due to mental or nervous disorders or diseases. Id. at 0046.

B. LaLonde’s Employment

LaLonde was employed in the medical field from 1991 until he

stopped working on February 23, 2017 due to his health conditions. AR

3987. The last position LaLonde held was at Providence as Manager of

the Sterile Processing Department. AR 4355-4356. In that role,

LaLonde was responsible for managing the Sterile Processing

Department; interpreting policies, procedures, standards and

regulations as was appropriate to personnel/nursing and medical staff;

and overseeing the activities of the department’s supply personnel

regarding the stocking and furnishing of sterile and non-sterile

supplies and equipment. AR 3728-3729.

C. LaLonde’s Medical Condition

On February 22, 2017, LaLonde was involved in a hit and run

automobile accident on his way to work. Id. at 3772. After the

accident, LaLonde was treated by John Villanueva, M.D., a specialist in

pain management, and Criselda Abad-Santos, M.D., a psychiatrist. Id.

at 3702. LaLonde was also treated by Sun Lee, MD., a neurosurgeon.

Id. at 3028.

LaLonde was first treated by Dr. Villanueva on March 17, 2017.

Id. at 3286. After that examination, Dr. Villanueva’s assessment was

that LaLonde’s clinical symptoms and physical exam findings were

suggestive of lumbar and cervical radiculopathy. Id. at 3295. Because

of these findings, he referred LaLonde for cervical and lumbosacral

MRI without contrast. Id. After his MRI, LaLonde had another

appointment with Dr. Villanueva. In his SOAP note from that April 26,

2017 appointment, Dr. Villanueva stated that LaLonde was

“present[ing] with symptoms and clinical findings concerning for a

lumbar radiculopathy,” which he concluded “correlates with [LaLonde’s

MRI] imaging.” Id. at 3303. At that time, Dr. Villanueva prescribed

eight sessions of physical therapy. Id.

After he completed physical therapy, see id. at 3335, LaLonde

had another appointment with Dr. Villanueva. Id. at 3319. At that

June 12, 2017 appointment, Dr. Villanueva prescribed LaLonde a Quad

Cane for better stability during ambulation—LaLonde had previously

been using a single point cane—and stated that, based on his findings,

LaLonde may benefit from lumbar epidural steroid injections to help

reduce pain and inflammation and restore range of motion with the

hope of avoiding surgery. Id. at 3323.

However, LaLonde was ultimately unable to avoid spinal surgery.

Based on a diagnosis of severe spinal stenosis and spondylolisthesis

with severe compression on the nerve roots, on August 7, 2017, Dr. Lee

performed a total laminectomy L4/L5 and bilateral decompression and

fusion from L4 to L5 on LaLonde. Id. at 2838-2839.

After the accident, LaLonde also received ongoing mental health

treatment from Dr. Abad-Santos, who had been his psychiatrist since

December 2016, for diagnoses of major depressive disorder, post-

traumatic stress disorder, and panic disorder. Id. at 1870-1918.

D. MetLife’s Initial Approval of LaLonde’s Claim

In July 2017, LaLonde submitted a claim to MetLife for LTD

benefits, listing February 22, 2017 as the date he had last worked. Id.

3702-3703. In that application, LaLonde represented that he was

prevented from performing the duties of his job because he was unable

to walk freely or lift with work restrictions. Id. at 3702. During its

review of LaLonde’s claim, MetLife requested and received LaLonde’s

medical records, as well as Attending Physician Statement (APS) forms

by Drs. Villanueva, Abad-Santos, and Lee.

In the APS form submitted by Dr. Villanueva, LaLonde’s pain

management specialist, Dr. Villanueva diagnosed LaLonde with

lumbar radiculopathy and cervical radiculopathy/spine degeneration.

Id. at 3698. That APS form also stated that LaLonde’s self-reported

symptoms included muscle spasms, leg pain, and weakness, and that

Dr. Villanueva’s clinical findings included weakness and decreased

range of motion, limited due to pain. Id. Dr. Villanueva recommended

physical therapy and possibly an evaluation with a spinal surgeon. Id.

at 3699. Dr. Villanueva stated that he had advised LaLonde to stop

working on March 17, 2017 (the date of their first appointment), and

that he anticipated LaLonde would be able to return to modified duty

work on December 7, 2017, with the following restrictions: work no

more than 6 hours a day with 5-minute breaks every hour and no

lifting, pulling, or pushing over 10 lbs. Id. at 3700.

LaLonde’s psychiatrist, Dr. Abad-Santos, also submitted APS

forms to MetLife. Id. at 3634-3639. On those APS forms, Dr. Abad-

Santos listed major depressive disorder, recurrent; panic disorder; and

post-traumatic stress disorder (PTSD) as LaLonde’s diagnoses. Id. at

3635, 3637. Dr. Abad-Santos stated that LaLonde was unable to work

as of February 23, 2017, and that she anticipated that LaLonde would

be able to return to work on May 17, 2017 if he had no “destabilization

or setbacks.” Id. at 3637. In describing her rationale for recommending

that LaLonde stay home from work, Dr. Abad-Santos stated that he

was “complaining of depressed mood, anxiety, insomnia, panic attacks,

avoidance of reminders about the abuse [he had previously suffered],

hypervigilance, exaggerated startle response, problems with memory

and concentration.” Id.

MetLife also received an APS form from Dr. Lee, LaLonde’s

orthopedic surgeon. Id. at 3028-3031. Dr. Lee diagnosed LaLonde with

spondylolisthesis L4-L5 level and spinal stenosis. Id. at 3029. Dr. Lee

stated that LaLonde had undergone spinal surgery on August 7, 2017—

a total laminectomy at L4-L5 with bilateral decompression and L4-L5

fusion—and that he anticipated LaLonde would be unable to work until

November 17, 2017. Id. at 3030-3031.

Based on its review of LaLonde’s medical records and other

evidence submitted, MetLife approved LaLonde’s LTD claim. Id. at

3015-3017. MetLife notified LaLonde by letter dated August 31, 2017

that his claim was approved starting on February 23, 2017, and his

benefits were payable as of August 22, 2017 following the Plan’s

mandatory 180-day elimination period. Id.

E. MetLife’s Ongoing Review of LaLonde’s Claim

After MetLife approved LaLonde’s claim, it periodically requested

and received updated medical records and APS forms to assess

LaLonde’s ongoing entitlement to benefits. See id. at 2927, 2871-2926,

2807, 2825-2828, 2831-2922, 2721-2774.

In March 2018, MetLife ordered physical on-site and social media

surveillance. Id. at 3954-3956. During that surveillance, the MetLife

Special Investigations Unit (SIU) observed LaLonde driving himself to

a few brief errands without assistance. The SIU noted that LaLonde

“utilized a walking cane for support as he moved about on [those]

date[s] and also appeared to enter and exit his vehicle slowly.” Id. at

2648. On one of those occasions, LaLonde was observed pushing a

shopping cart at Walmart and placing grocery bags into his vehicle. Id.

On March 21, 2018, after three days of surveillance, the SIU

closed LaLonde’s investigation. Id. at 2648-2649. From a physical

standpoint, the SIU concluded that “activity observed during efforts

appears consistent with [LaLonde’s] stated physical condition.” Id. at

2649. From a mental standpoint, the SIU noted that LaLonde’s

restrictions and limitations “indicate that he requires a support person

when shopping, etc.,” but he had been observed shopping at Walmart

without a support person. Id. The SIU discussed conducting an in-

person interview, but his claim manager “did not feel it was necessary

at [that] point.” Id.

1. Psychiatric Conditions Claim Review

In March 2018, MetLife also referred LaLonde’s claim for clinical

psychiatric assessment. Id. at 3979. On March 8, MetLife psychiatric

clinical specialist William Morgan, Licensed Marriage and Family

Therapist (LMFT), conducted a clinical interview with LaLonde. Id. at

3974. During that phone interview, LaLonde stated that he was unable

to return to work because his job would not work with his restrictions,

he was still falling and struggling with balance, and he was suffering

from “paranoia about driving,” “constant anxiety,” reduced attention

span, and an inability to concentrate. Id. at 3976-3978. LaLonde also

stated that he was struggling to stay on top of paying his bills, could go

a week without showering, was anxious about socializing, and did not

want to leave the house. Id. After the interview, Morgan called Dr.

Abad-Santos and left her a voicemail informing her that LaLonde had

made statements during the interview expressing suicidal ideation;

that he had a plan, but no intent; and that he had promised to contact

the police or his psychiatrist if he felt as though he might act on his

suicidal ideation. Id. at 3974.

Morgan referred LaLonde’s file for physician consultant review,

which was conducted by psychiatrist Elbert Greer Richardson, M.D. on

May 7, 2018. Id. at 2569. Following a paper review of LaLonde’s file,

Dr. Richardson concluded that the medical information did not support

functional limitations, defined as “any reduction in ability to work full

time,” beyond March 1, 2018. Id. at 2571. Having determined that no

psychiatric restrictions or limitations were warranted, Dr. Richardson

explained the basis for his conclusion as follows:

A review of the medical record yields evidence that the

claimant presents with a history of PTSD, Panic Disorder,

Depression and Alcohol Use Disorder. The claimant

continues to present with subjective complaints of an

inability to work due to insomnia, social withdrawal,

feelings of worthlessness and helplessness, poor

concentration, psychomotor retardation, panic attacks,

avoidance of reminders of physical abuse by ex-partner,

hypervigilance, exaggerated startle, nightmares and

flashbacks. However, the clinical evidence does not support

global psychiatric impairment that would preclude

occupational functioning. There is no evidence that

symptoms were documented and tracked with screening

measures such as BAI, BDI-11, GAD7, PHQ, or cognitive

screenings to document and track cognitive symptoms such

as MoCA, MMSE, full formal MSE. The claimant’s mental

status was clinically recorded to be within functional limits

since October 2017 by Dr. Santos, MD (Psychiatry). It

appears, though, that Dr. Santos’ recommendation for

continued “disability” is being made primarily upon the

basis of subjective complaints without clinical

documentation. Furthermore, there are no indicators of

psychiatric severity that would warrant occupational

restrictions, such as active suicidality or homicidality,

suicide attempts, psychosis, or psychiatric hospitalizations.

Specifically regarding Alcohol Use Disorder, most recent

documentation indicates that claimant is in early remission

and as such no restrictions and limitations are warranted

for this diagnosis in the specified time period. Specifically

regarding surveillance, there is no surveillance that yields

pertinent psychiatric evidence. If there is additional

surveillance that features evidence of psychiatric

impairment, I would be happy to review it and alter my

opinion, if warranted.

Id.

As “pertinent documentation,” Dr. Richardson listed three of Dr.

Abad-Santos’ provider notes from appointments in late 2017 (October

26, November 22, and December 21), which each “note[d] a functional

mental status and continued sobriety.” Id. Dr. Richardson left two

messages with Dr. Abad-Santos’ office but received no response. Id. at

2569. MetLife also faxed Dr. Richardson’s evaluation to Dr. Abad-

Santos but again received no response. Id. at 2568.

MetLife concluded that, from March 18, 2018 forward, LaLonde’s

claim was no longer supported for a psychiatric condition, and benefits

continued exclusively for LaLonde’s physical conditions. Id. at 4103-

4106.

2. Physical Conditions Claim Review

MetLife continued its review of LaLonde’s claim as to his physical

conditions, sending letters to LaLonde, Dr. Villanueva, and Dr. Lee

requesting updated information. Id. at 2374-2393, 2491-2509. Dr. Lee

provided an office note from a February 9, 2018 follow-up appointment.

Id. at 2372. In the note, Dr. Lee stated that he had informed LaLonde

he could not complete the temporary disability form because the

operation had been about six months earlier. Id.

On September 5, 2018, LaLonde informed MetLife he was no

longer treating with Dr. Villanueva and Dr. Lee due to a change in his

health insurance plan. Id. at 4178. LaLonde stated that he was now

treating with Phyllis Cohen, M.D., a specialist in family medicine and

HIV, and that Dr. Cohen had referred him for neurology, pain

management, physical therapy, and radiology. Id. In an APS form

dated September 13, 2018, Dr. Cohen reported that she had been

treating LaLonde since May 2, 2018. Id. at 2303. On that APS form,

Dr. Cohen listed a diagnosis of chronic low back pain, symptoms of low

back pain and gait disturbance, and the following clinical findings:

walks with a cane, lumbar pain to palpitation, and unsteady gait. Id.

Dr. Cohen advised LaLonde not to return to work and imposed on him

the following restrictions and limitations: sit no more than 4 hours

continuously; stand no more than 2 hours intermittently; walk no more

than 1 hour continuously; perform continuous eye/hand movements no

more than 1 hour continuously; and no climbing, twisting, bending,

stooping, reaching above shoulder level, reaching to the front or to the

side at desk level, fine finger movements, lifting or carrying, or pushing

or pulling. Id. at 2304.

In a clinical assessment conducted on October 5, 2018, the nurse

reviewer concluded that the restrictions and limitations outlined in Dr.

Cohen’s September 13, 2018 APS form were medically supported and

that LaLonde could not return to work. Id. at 4230-4238. The reviewer

also opined that LaLonde “may need an additional 4-5 months for

recovery” before he could be expected to return to work. Id. at 4232.

MetLife continued to approve LTD benefits for LaLonde based on his

physical conditions. Id. at 4244.

F. MetLife’s Termination of Benefits

On January 7, 2019, MetLife notified LaLonde by letter that it

was reviewing his continued eligibility for LTD benefits under the

Plan’s definition of disability. Id. at 2236-2264. The letter explained

that MetLife had previously determined LaLonde was disabled under

the Plan’s definition of disability, and that he would continue to receive

benefits through August 21, 2019 only if he remained disabled from

performing his own occupation. Id. at 2236. The letter also explained

that, to continue to receive benefits after August 21, 2019, MetLife

needed to determine that LaLonde was disabled from any gainful

occupation under the Plan’s definition of disability. Id.

On April 1, 2019, MetLife received a Power of Attorney (POA)

that was executed in December 2018, and by which LaLonde appointed

Judith Weyant as his POA. Id. at 2195-2203. MetLife claims specialist

April Cloutier had spoken with Weyant by phone on March 29, 2019,

and on that call Weyant had stated that LaLonde is unable to maintain

any one physical position (i.e., sitting, standing, laying down) and was

being treated by Daria Younessi, M.D. (family medicine) and Abraham

Argun, Psy.D. (forensic clinical psychology). Id. at 4282-4283. Weyant

also represented that LaLonde lives alone, can run simple errands,

orders groceries online, and uses a walker and cane to mobilize. Id.

Upon receiving Dr. Argun’s records on April 9, 2019, see id. at

2157-2167, MetLife learned LaLonde had been arrested and charged

with attempted murder on November 11, 2018. He was convicted and

sentenced to five years in prison, id. at 112-113.

On April 10, 2019, MetLife referred LaLonde’s file for physician

review by consultant Mahdy Flores, D.O., who is board-certified in

family medicine and occupational medicine. Id. at 2146. Following a

paper-only review of LaLonde’s file, Dr. Flores concluded that the

medical information did not support functional limitations, defined as

“any reduction in ability to work full time,” beyond April 10, 2019. Id.

at 2148. Having determined no physical restrictions or limitations

were warranted,4 Dr. Flores explained the basis for his conclusion, in

part, as follows:

We can see that there is a decrease in [LaLonde’s] lumbar

pain after the [total laminectomy] operation. At the same

time, there is no mention of muscle weakness or movement

limitation in the last medical examinations. Other

diseases/complaints of the claimant are under control or

temporary conditions and there are no functional

limitations. The claimant’s surveillance findings from

March of 2018 identified him utilizing a cane, but able to

walk, drive, shop, push a shopping cart and put items in a

car trunk. Using a cane is significant, but I am unable to

concur this with the medical information, as there is no

established motor/sensory deficit, gait/balance loss to

require assistive devices. . . . The claimant per the recent

records, which are subsequent to surveillance findings, has

no focal neurological deficit.

Id. at 2149.

MetLife sent a copy of Dr. Flores’ report to Dr. Younessi and Dr.

Cohen. Id. at 2131-2150. Dr. Cohen did not respond. Id. at 1802. On

May 16, 2019, Dr. Younessi responded, informing MetLife that “the

clinical picture does not support [Dr. Flores’] findings” and requesting a

brief extension to keep LaLonde’s claim open because “[i]t would be

medically prudent to repeat an MRI of the lumbar spine as it has been

two years since the last one.” Id. at 1932. MetLife did not provide the

requested extension. Id. at 1802.

After Dr. Flores completed his review, MetLife received medical

records from Dr. Abad-Santos reflecting appointments from December

21, 2016 through October 31, 2018, as well as medical records from the

4 Dr. Flores deferred review of LaLonde’s psychiatric disorders “to a more

appropriate specialty reviewer.” AR 2149.

Los Angeles County Jail reflecting consultations from November 11,

2018 through May 18, 2019. Id. at 1832-1867, 1868-1918. On June 5,

2019, MetLife’s psychiatric clinical specialist reviewed those records

and concluded that they did not reflect any severe or debilitating

psychiatric symptoms at the present time and that the barrier to

LaLonde’s return to work was not psychiatric, but rather was due to his

incarceration. Id. at 4405. On June 18, 2019, a clinical nurse

consultant reviewed the additional records and concluded that they did

not support an ongoing physical disability because there were “no exam

findings, diagnostics, or dictated notes” regarding LaLonde’s physical

condition and they reflected that an April 22, 2019 x-ray of LaLonde’s

right hip was “essentially normal.” Id. at 4419-4420.

In a letter dated June 24, 2019, MetLife notified LaLonde it

would not approve benefits on his claim beyond June 25, 2019. Id. at

231-235. The letter stated that MetLife had “determined that [he] no

longer satisf[ies] the definition of disability as [he is] not disabled from

performing [his] own occupation or any occupation according to the

Plan.” Id. at 233.

G. LaLonde’s Appeal

On October 4, 2022, LaLonde contacted MetLife, informing it that

he had recently been released from jail and asking what he needed to

do so that his claim could be reinstated. Id. at 4447. LaLonde later

submitted to MetLife medical records and APS forms by his current

providers at Tarzana Treatment Centers, Michael Soles, M.D., internal

medicine, and Nicholas Hermann, PA-C, as well as a Behavioral Health

Assessment completed by Dr. Abad-Santos. Id. at 1698-1725. LaLonde

advised MetLife he had been approved for Social Security Disability

Insurance (SSDI) benefits by the Social Security Administration (SSA).

Id. at 238-241. On May 19, 2023, LaLonde submitted to MetLife a

formal written appeal. Id. at 215-216.5

5 MetLife agreed to review LaLonde’s appeal even though it was submitted

beyond the deadline for appeal.

MetLife sent LaLonde’s file back to Dr. Flores to determine

whether the newly submitted records would change his opinion. Id. at

193-202. In a report dated May 22, 2023, Dr. Flores concluded that

“the evidence does not suggest that [LaLonde] suffers from a medical

condition or combination of conditions of such severity to warrant the

placement of restrictions or limitations on his activities” from June 19,

2019 to the present. Id. at 199. Dr. Flores again noted that LaLonde’s

psychiatric conditions were “beyond the scope of [his] review.” Id. Dr.

Flores explained the basis for his conclusion, in part, as follows:

The claimant enters medical examinations wearing a back

brace, with the use of a walker or cane. However, the

claimant has good muscle tone and good muscle strength,

with a steady gait. It has also been evidenced that the

claimant has the ability to walk without the use of assistive

devices. The claimant has no physical limitations with

good range of motion, is able to perform his daily activities,

has no red flags and no indication for new imaging to

evaluate his bone structure. . . . Therefore, despite the

claimant’s ongoing reported symptoms, in the absence of

clinically evident deficits, restrictions are not warranted for

the timeframe under review.

Id. at 200.

MetLife sent Dr. Flores’ report to Dr. Soles and PA Hermann for

their review, but received no response. Id. at 173-186.

MetLife referred LaLonde’s file to another independent

physician, Hossein Molazadeh, M.D., board-certified in internal

medicine, as part of the appeal review. Id. at 31-45. In a report dated

June 16, 2023, Dr. Molazadeh concluded that “the evidence does not

suggest that [LaLonde] suffers from a medical condition or combination

of conditions of such severity to warrant the placement of restrictions

or limitations on his activities” from June 25, 2019 to the present. Id.

at 43. In explaining the basis for his conclusion, Dr. Molazadeh

acknowledged that LaLonde “continues to experience ongoing lumbar

and left leg pain,” but noted that a healthcare professional had reported

observing LaLonde walk with a steady gait and without an assistive

device and that “no abnormal findings have been observed on physical

examination.” Id. at 43-44. Dr. Molazadeh summarized his conclusions

as follows:

Overall, although the claimant has medical symptoms

related to spondylolisthesis, lumbar fusion in the lumbar

region, hypertension (HTN), hyperlipidemia (HLD), chronic

low back pain (LBP), skin dermatitis, renal mass, hearing

loss, and left ankle pain, these symptoms have been

controlled by medications, and there were no diagnostic

tests or clinical findings to support the severity of his

condition requiring restrictions and limitations as of June

25, 2019. Additionally, the surveillance report revealed

significant functioning by the claimant after the date of his

condition, without revealing any impairment. As such,

restrictions are not warranted.

Id. at 44.

MetLife’s psychiatric clinical specialist reviewed the updated

medical records LaLonde submitted and suggested that the appeal be

referred to an outside psychiatric professional for review. Id. at 4526-

4540. Consistent with that recommendation, LaLonde’s file was

referred for review by independent licensed psychologist Gabriel Jasso,

Psy.D. Id. at 46-66. In a report dated June 27, 2023, Dr. Jasso

concluded that, considering “both the self-reported symptoms and

clinical observations, the evidence does not suggest that [LaLonde] is

impaired by a mental health condition or combination of conditions of

such severity to warrant the placement of restrictions or limitations on

his activities” from June 25, 2019 to the present. Id. at 51. In

explaining the basis for his conclusion, Dr. Jasso acknowledged

LaLonde’s “long-standing history of Depression, Panic disorder, PTSD,

and Alcohol abuse,” but noted that an October 18, 2022 mental status

exam “was unremarkable,” and that impairments noted in a November

1, 2022 MetLife document had “no support from records, and [LaLonde]

was independently performing [activities of daily living] prior to that.”

Id. at 52. Dr. Jasso also noted that “the records [did] not include

neurocognitive testing and there [were] no abnormalities in

recent/remote memory, attention, concentration, or cognition in the

available records to support” the self-reported cognitive symptoms. Id.

On June 28, 2023, MetLife sent copies of the reports from Dr.

Molazadeh and Dr. Jasso to LaLonde for his review and to provide to

his treating physicians. Id. at 16. On July 5 and 6, LaLonde requested

that MetLife provide an extension to give his providers time to respond

to the reports of the independent physicians. Id. MetLife denied both

requests. Id. By letter dated July 10, 2023, MetLife notified LaLonde

that it completed its review of his appeal and its final determination

was that the decision to terminate his benefits beyond June 24, 2019

was appropriate. Id. at 14-18.

III. Standard of Review

The court reviews a challenge to an ERISA plan’s denial of

benefits 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). The parties agree the proper standard

of review is de novo.

When review is de novo, “the court does not give deference to the

claim administrator’s decision, but rather determines in the first

instance if the claimant has adequately established that he or she is

disabled under the terms of the plan.” Muniz v. Amec Constr. Mgmt.

Inc., 623 F.3d 1290, 1295-96 (9th Cir. 2010); see Abatie v. Alta Health

& Life Ins. Co., 458 F.3d 955, 963 (9th Cir. 2006) (en banc) (when a

court reviews the denial of benefits de novo, the court “simply proceeds

to evaluate whether the plan administrator correctly or incorrectly

denied benefits”). The Court is not required to accept the conclusion of

any particular treatment provider or medical file reviewer. For

instance, the Court does not accord special deference to the opinions of

treating physicians based on their status as treating physicians. Black

& Decker Disability Plan v. Nord, 538 U.S. 822, 834 (2003). Instead,

opinions must “be accorded whatever weight they merit.” Jebian v.

Hewlett-Packard Co. Emp. Benefits Org. Income Prot. Plan, 349 F.3d

1098, 1109 n.8 (9th Cir. 2003) (citing Black & Decker, 538 U.S. at 834).

The Court may, however, give greater weight to a treating physician’s

opinion where it is evident a particular physician has had a “‘greater

opportunity to know and observe the patient’ than a physician retained

by the plan administrator” who conducts a file review. Id. (quoting

Black & Decker, 538 U.S. at 832).

In performing a de novo review, the Court’s “task is to determine

whether the plan administrator’s decision is supported by the record,

not to engage in a new determination of whether the claimant is

disabled.” Collier v. Lincoln Life Assurance Co. of Bos., 53 F.4th 1180,

1182 (9th Cir. 2022). The Court then “must examine only the

rationales the plan administrator relied on in denying benefits and

cannot adopt new rationales that the claimant had no opportunity to

respond to during the administrative process.” Id.

A claimant challenging a plan administrator’s decision bears the

burden of proving entitlement to benefits by a preponderance of the

evidence. See Shaw v. Life Ins. Co. of N. Am., 144 F. Supp. 3d 1114,

1123 (C.D. Cal. 2015) (citing Muniz, 623 F.3d at 1294).

IV. Conclusions of Law

LaLonde is diagnosed with spondylolisthesis and lumbar region

status post lumbar fusion. AR 31. The record reflects numerous

reports of chronic and severe back and leg pain, radiating pain through

the left leg, and numbness related to those diagnoses. See, e.g., AR

298, 307, 2209, 1720-1724, 2253-2254. These self-reported symptoms

are supported by LaLonde’s history of spinal surgery, modifications to

various prescription pain medication regimes, and repeated efforts at

physical therapy. See, e.g., id. at 1699-1703, 2222-2223, 2206-2207,

2254. The record also reflects that LaLonde suffers ongoing deficits in

balance and mobility, as demonstrated by antalgic gait, falls, and use of

assistive devices. See, e.g., id. at 307, 1699-1703, 1720-1724, 1976.

During his incarceration, the record reflects LaLonde’s ongoing

pain management efforts, such as using an egg crate cushion on his

bunk, initiating numerous discussions with prison healthcare providers

about pain medications and muscle relaxants, and filing inmate

grievances complaining of inadequate medical treatment for his back

and leg pain. Id. at 277, 1024, 1080-1094, 1589. The record also

reflects continued mobility deficits during LaLonde’s incarceration,

including multiple falls and using a walker and wheelchair. Id. at 277,

298, 307, 1976. And after LaLonde was released from custody, he

returned to the primary care group he had been treating with prior to

his arrest, Tarzana Treatment Centers, seeking treatment for his

chronic pain symptoms and receiving referrals for pain management,

physical therapy, and orthopedic surgery. Id. at 1699-1703, 1720-1724.

Over the years, LaLonde’s treating physicians have consistently

reported that he faces disabling functional limitations from his spinal

conditions and related chronic pain. Id. at 2253-2254, 2257-2260, 2303-

2304, 2722-2725, 2879-2882, 2885-2887, 2922, 3028-3031, 3698-3700.

Against the background of his lengthy treatment history, the Court

finds it appropriate to give greater weight to the opinions of LaLonde’s

treating physicians, each of whom had a “greater opportunity to know

and observe” LaLonde than the MetLife-retained physicians who based

their opinions solely on a paper review of LaLonde’s file. See Jebian,

349 F.3d at 1109 n.8; see also Salomaa v. Honda Long Term Disability

Plan, 642 F.3d 666, 676 (9th Cir. 2011) (finding opinions from medical

provider’s in-person examination of claimant more persuasive than

contrary opinions from plan administrator’s paper-only file review).

The conclusions of MetLife’s physician consultants merit less

weight not only because they “lack the level of credibility normally

attributed to physicians who have personally observed a patient,” Nagy

v. Grp. Long Term Disability Plan for Emps. of Oracle Am., Inc., 183

F.Supp.3d 1015, 1031 (N.D. Cal. 2016), but also because they failed to

meaningfully grapple with either the contrary reports in LaLonde’s

medical records or the contrary conclusions of LaLonde’s treating

physicians, who had personally examined him. For example, Dr. Flores

concluded that the medical information did not support any physical

functional limitations without even acknowledging the restrictions and

limitations that had been advised by LaLonde’s treating physicians, let

alone indicating the basis for his disagreement. See AR 2149. And Dr.

Molazadeh’s report highlighted one healthcare professional’s conclusion

that LaLonde “didn’t appear to need a walker” and broadly asserted

that, despite his ongoing lumbar and left leg pain, “no abnormal

findings” were observed on LaLonde’s physical exams, id. at 43, but

failed to address the fact that multiple physicians affirmed LaLonde’s

need for an assistive device and documented abnormal clinical findings,

including unsteady gain, lumbar pain on palpitation, pain with back

movement, and weakness. Compare AR 43 (Molazadeh Report), with

AR 2253-2254 (February 4, 2019 progress note by Dr. Younessi

documenting weakness from the waist down, chronic back and leg pain,

gait disturbance, and numbness and referring to physical therapy and

pain management specialist), AR 2303 (September 13, 2018 APS form

by Dr. Cohen reporting clinical findings of unsteady gait and lumbar

pain on palpitation), and AR 2223-2224 (May 2, 2018 progress note by

Dr. Cohen documenting back pain on movement and referring to

physical therapy for stretching and strengthening exercises and other

treatment modalities and pain management specialist). Ultimately,

Dr. Flores and Dr. Molazadeh reached many of their conclusions by

selectively focusing on certain reports in LaLonde’s file (mostly from his

inmate medical records) that they deemed inconsistent with the reports

of his treating physicians. But “such inconsistencies do not

automatically negate any medical condition” at issue here, and if either

physician “wished to more persuasively articulate why such

inconsistencies demonstrated [that LaLonde] did not have functional

impairment, [he] should have explained why the more positive health

findings were more trustworthy than the more negative ones.” Myers

v. Aetna Life Ins. Co., No. 19-cv-9555 DSF-KSX, 2020 WL 7423109, at

*12 (C.D. Cal. Dec. 17, 2020).

The Court disagrees with MetLife’s conclusion that LaLonde’s

physical conditions are no longer disabling for a variety of additional

reasons. First, MetLife overemphasizes what it deems to be

insufficient objective evidence that LaLonde’s physical conditions are

severe enough to be disabling and improperly discounts the significance

of LaLonde’s self-reported pain. It is widely accepted that “disabling

pain cannot always be measured objectively.” Saffon v. Wells Fargo &

Co. Long Term Disability Plan, 522 F.3d 863, 873 n.3 (9th Cir. 2008).

And although it is true that self-reported symptoms are not necessarily

determinative, particularly when contradicted by objective evidence,

the record does not adequately establish the unreliability of LaLonde or

his treating physicians.

The Court finds Montour v. Hartford Life & Accident Insurance

Company, 588 F.3d 623 (9th Cir. 2009), instructive here. In Montour,

claimant Montour brought an ERISA action against plan administrator

Hartford after his long-term disability benefits were terminated. Id. at

626. In deciding to terminate Montour’s benefits, Hartford relied

heavily on the opinions of two retained physicians, Dr. Brown and Dr.

Sukhov, who had each raised questions about Montour’s self-reported

pain following paper-only file reviews. Id. at 634. As the Ninth Circuit

explained, “[i]t would probably have been unreasonable for Hartford to

require Montour to produce objective proof of his pain level, per Dr.

Sukhov, or to reject his subjective claims of ‘excess pain’ based solely on

Dr. Brown’s observation” that Montour’s back condition “should not

cause [him] as much pain as he was reportedly suffering.” Id. at 635.

However, the circuit recognized that Dr. Brown and Dr. Sukhov had

also observed evidence from pharmacy records indicating limited and

relatively mild use of pain medication and evidence from medical

records suggesting no recent engagement in pain treatment programs,

and so it reasoned that those two additional “observations probably

constitute[d] sufficient ‘objective’ evidence to support their conclusion

that Montour’s pain does not rise to the level of disabling pain.” Id. By

contrast, here MetLife and its retained physicians have not identified,

and the Court has not found, sufficient objective evidence to support

the conclusion that Montour’s symptoms (including his pain) are not as

severe as he claims.

Second, MetLife’s arguments centering on its March 2018

surveillance findings are unpersuasive. MetLife fails to explain why

the surveillance findings should be considered evidence of “significant

functioning” that “calls LaLonde’s credibility, and therefore his self-

reported complaints of pain and resulting disability, into question”

today when MetLife previously concluded that those same surveillance

findings were “consistent with [LaLonde’s] stated physical condition”

and reflected ongoing functional limitations that precluded LaLonde

from returning to work. Compare Dkt. 22 at 14, 21, with AR 2649

(MetLife March 21, 2018 surveillance summary concluding LaLonde’s

observed activity was consistent with his physical restrictions and

limitations) and AR 4230-4238 (MetLife October 5, 2018 clinical

assessment determining LaLonde’s physical function remained “less

than sedentary” and that he was unable to return to work from a

physical perspective). Moreover, neither MetLife nor its physician

reviewers explain how the limited activity observed during the

surveillance corresponds to occupational function, and the Court sees

nothing in the surveillance findings that would automatically negate

LaLonde’s medical conditions or occupational limitations.

Third, MetLife’s argument that the “essentially normal” x-ray of

LaLonde’s right hip from April 2019 is evidence supporting the

opinions of its independent physician reviewers and reflecting “the lack

of support for the contrary opinions of LaLonde’s various providers” is

perplexing. See Dkt. 22 at 10, 20; see also AR 232, 4419-4420. The

record is clear that LaLonde’s physical disability is related to conditions

of the spine (not hips) and, although he suffers from radiating pain, he

consistently reports those symptoms as impacting his left leg, not right.

Fourth, although a claims administrator need not honor every

extension request it receives, MetLife’s repeated refusal to honor

modest extension requests that would have afforded LaLonde’s treating

physicians an opportunity to respond to the contrary conclusions of

MetLife’s independent physician reviewers raises questions about the

thoroughness and accuracy of MetLife’s benefits determination in this

case. At the initial termination stage, Dr. Younessi emailed MetLife

after she completed her review of Dr. Flores’ report to communicate her

medical opinion that “the clinical picture does not support [the]

independent reviewer’s findings” and to request a small extension to

repeat an MRI of LaLonde’s lumbar spine to allow for “a more informed

decision.” Id. at 1932. Because MetLife never granted Dr. Younessi’s

request, and terminated LaLonde’s benefits shortly thereafter, any

complaints by MetLife that it did not receive updated medical

documentation from Dr. Younessi prior to its termination decision carry

little weight. Id. at 233. At the appeal stage, MetLife did not provide

the reports of its independent physician reviewers to any of LaLonde’s

treating physicians. Id. at 30. Instead, on June 28, 2023, MetLife sent

the reports to LaLonde and asserted that his healthcare providers had

until July 8 to respond—only 11 days. Id. On July 5 and 6, LaLonde

called MetLife and requested an extension to afford his providers the

opportunity to respond. Id. at 16. But MetLife denied the request on

July 7 and notified LaLonde by letter dated July 10—only three days

later—that it had completed its review of his appeal and was upholding

the termination of his LTD claim. Id. at 14-16.

Finally, the Plan requires claimants to apply for SSDI benefits

from the SSA and, if denied, to exhaust all possible appeals. Id. at

2651. LaLonde applied for and was awarded SSDI benefits, from which

MetLife benefitted significantly as it received a financial offset that

reduced its liability under the terms of the Plan. Id. at 2328. Yet, in

both its initial termination decision, id. at 233, and its decision denying

LaLonde’s appeal, id. at 16, MetLife “acknowledged the SSA’s decision

but did not articulate why the SSA might have reached a different

conclusion.” Montour v. Hartford Life & Acc. Ins. Co., 588 F.3d 623,

635 (9th Cir. 2009).

As the Ninth Circuit has explained, although “ERISA plan

administrators are not bound by the SSA’s determination, complete

disregard for a contrary conclusion without so much as an explanation

raises questions about whether an adverse benefits determination was

‘the product of a principled and deliberative reasoning process.’” Id.

(quoting Glenn v. MetLife, 461 F.3d 660, 674 (6th Cir. 2006), aff’d sub

nom. Metro. Life Ins. Co. v. Glenn, 554 U.S. 105 (2008)).

MetLife argues the SSDI award “should be afforded little to no

weight” because SSDI determinations are based on a different set of

guidelines, including that the SSA is required to accord special

deference to the opinions of treating physicians whereas ERISA plan

administrators are subject to no similar requirement. Dkt 29 at 16.

But “this distinction alone does not provide a basis for disregarding the

SSA’s determination altogether, because in some cases, such as this

one, the SSA deploys a more stringent standard for determining

disability than does the governing ERISA plan.” Montour, 588 F.3d at

636. Specifically, after twenty-four months, the Plan defines

“disability” as when a claimant is unable, due to sickness or as a direct

result of accidental injury, to earn “more than 60% of [his] Predisability

Earnings from any employer in [his] Local Economy at any gainful

occupation for which [his] [is] reasonably qualified taking into account

[his] training, education and experience.” PLAN 0023. By contrast,

under the SSA’s more exacting standard, “disability” is defined as when

a claimant is unable “‘to engage in any substantial gainful activity by

reason of any medically determinable physical . . . impairment’ that is

of ‘such severity that [he] . . . cannot, considering his age, education,

and work experience, engage in any other kind of substantial gainful

work which exists in the national economy, regardless of whether such

work exists in the immediate area in which he lives.’” Montour, 588

F.3d at 636 (quoting 42 U.S.C. § 423(d)(1)(A), (2)(A)). “In other words,

unlike the Plan, the SSA’s standard does not take into account a

claimant’s past earnings or location.” Id.

MetLife argues LaLonde’s SSDI award is of “no evidentiary

value” because he did not submit his SSDI claim file to MetLife, dkt. 29

at 16, but the Ninth Circuit has explained that this is also not a basis

for an ERISA plan administrator to completely disregard a contrary

disability determination by SSA:

Although the Plan places the burden on [the claimant] to

submit “written proof” of his disability, that is, the

pertinent documents and information necessary to

facilitate a disability determination, regulations

promulgated by the Secretary of Labor authorize, if not

require, plan administrators working with an apparently

deficient administrative record to inform claimants of the

deficiency and to provide them with an opportunity to

resolve the problem by furnishing the missing information.

We have also construed this regulation to require a plan

administrator denying benefits in the first instance to

notify the claimant not just of the opportunity for internal

agency review of that decision but also of what additional

information would be necessary to perfect the claim.

Montour, 588 F.3d at 636 (internal citations and quotations omitted).

Although MetLife’s initial decision acknowledged LaLonde’s

SSDI award and noted that it had not received his SSDI claim file, the

letter went on to inform LaLonde that “the award of SSDI benefits does

not guarantee the approval or continuation of LTD benefits under a

private plan” and that the SSA’s “decision is based on different

standards than the Plan.” AR 233. At the appeals stage, MetLife

simply parroted that same language. Id. at 16. This falls far short of

satisfying MetLife’s obligation to “set forth, in a manner calculated to

be understood by the claimant . . . [a] description of any additional

material or information necessary for the claimant to perfect the claim

and an explanation of why such material or information is necessary”

in the ERISA-mandated notification of adverse benefit determination.

29 C.F.R. § 2560.503-1(g)(1)(iii); see also Collier, 53 F.4th at 1185.

The decision to completely disregard the SSA’s contrary disability

determination is particularly problematic here, where the basis for

MetLife’s termination of benefits was its determination that LaLonde

did not have any functional limitations from a physical or psychological

perspective. AR 233; see also AR 14. Even without the SSDI claim file,

it is patently obvious that MetLife’s determination that LaLonde has no

functional limitations whatsoever cannot be reconciled with the SSA’s

determination that LaLonde satisfies the stringent federal standard for

SSDI claims. See Montour, 588 F.3d at 636 (quoting DeLisle v. Sun

Life Assurance Co. of Canada, 558 F.3d 440, 446 (6th Cir.2009) (“Even

though [the administrator] did not have the opinion accompanying the

notice of award, it still was well aware of the uniform federal standard

that applies to Social Security claims.”)).

The Court finds that, on balance, the evidence weighs in

LaLonde’s favor, and he meets his burden of establishing his continued

entitlement to LTD benefits. A preponderance of the evidence shows

LaLonde’s medical symptoms related to spondylolisthesis, lumbar

region status post lumbar fusion, and chronic pain render him disabled

under the terms of the Plan. Having concluded that LaLonde meets his

burden of establishing continued entitlement to LTD benefits on the

basis of his physical conditions, the Court need not consider the parties’

arguments related to LaLonde’s psychiatric conditions.

V. Conclusion

For the foregoing reasons, the Court finds in favor of LaLonde.

LaLonde is ordered to submit a proposed judgment no later than May

19, 2025. MetLife may submit objections to the proposed judgment no

later than June 2, 2025. Counsel are ordered to meet and confer and

attempt to resolve the issue of attorneys’ fees and costs no later than

June 30, 2025. If no resolution is reached, LaLonde’s motion for

attorneys’ fees must be filed no later than July 28, 2025. The motion

must comply with the requirements described in the 2021 Order re

Requirements for Motion for Attorneys’ Fees, which is publicly

available on the district’s website at https://tinyurl.com/2fzf9su2.

IT IS SO ORDERED.

Date: May 7, 2025

The Honorable Dale S. Fischer

United States District Judge

oA