(PS) Zelhofer v. Metropolitan Life Ins. Co.

District Court, E.D. California·Decided February 22, 2022·No. 2:16-cv-00773·Unknown

Opinion

WALTER ZELHOFER, No. 2:16-cv-00773-TLN-AC Plaintiff, v. ORDER COMPANY and TECHNICOLOR USA, Defendants. Plaintiff Walter Zelhofer (“Plaintiff”) was an engineer for Thomson, Inc.1 who had a coronary artery stent placement and heart-related procedures in September 2009 and subsequently experienced anxiety, depression, and related psychological complaints he attributed to his cardiac problems. In February 2010, Plaintiff applied for long-term disability benefits available through his employer’s insurer, Defendant Metropolitan Life Insurance Company (“MetLife”). MetLife initially approved Plaintiff’s claim and paid benefits for almost two years until MetLife determined in March 2012 that Plaintiff was no longer disabled under the terms of the Plan. Plaintiff subsequently appealed MetLife’s determination in June 2012, and MetLife upheld its

1 Thomson, Inc. became Technicolor USA, Inc. (one of the named Defendants in this case) following a corporate reorganization. (ECF No. 49 at 6–7.) termination of benefits in October 2012. Plaintiff brought this action against MetLife and his employer Defendant Technicolor USA, Inc. (“Technicolor”) (collectively, “Defendants”) pursuant to the Employment Retirement Income Security Act (“ERISA”). This matter is before the Court on the parties’ Cross-Motions for Judgment under Federal Rule of Civil Procedure (“Rule”) 52.2 (ECF Nos. 115, 125.) Both motions are fully briefed. (ECF Nos. 128, 130, 133, 134.) Also before the Court is Plaintiff’s Motion for Admission of Extrinsic Evidence. (ECF No. 119.) This motion is also fully briefed. (ECF Nos. 129, 132.) The Court has carefully considered the parties’ arguments and hereby finds, for the reasons set forth below, that Plaintiff’s Motion for Judgment is DENIED, Defendants’ Motion for Judgment is GRANTED, and Plaintiff’s Motion for Admission of Extrinsic Evidence is DENIED. I. FINDINGS OF FACT3 A. Pertinent Plan Provisions 1. LTD Benefits: Plaintiff was a participant in the Thomson Inc. Long Term Disability (“LTD”) Plan (the “Plan”), an employee welfare benefit plan established and maintained by Technicolor. (AR 6314; ECF No. 49 at 7.) The Plan’s LTD benefits are funded by a group insurance certificate issued to Thomson Inc. by MetLife, which also is the LTD claim administrator for the Plan.5 (AR 1078–1122.)

2 Defendants correctly note that Plaintiff cites the legal standard for summary judgment pursuant to Rule 56. (ECF No. 130 at 4.) Defendants contend that to the extent Plaintiff seeks summary judgment, the request is improper and the case should be decided on a de novo review of the administrative record (“AR”). (Id. at 4.) However, in light of the fact that the Amended Pretrial Scheduling Order notes that “[e]ach party shall file a motion for summary judgment pursuant to [Rule] 52” (ECF No. 103 at 2), and the fact that Plaintiff is proceeding pro se, the Court shall construe Plaintiff’s motion as a motion for judgment pursuant to Rule 52. 3 The following findings of fact are taken mostly verbatim from Defendants’ motion for judgment. (ECF No. 115-1.) The facts are undisputed except where noted by the Court.

4 Defendants lodged the administrative record with the Court on August 8, 2018, documents bates-stamped AR 000001 through AR 001149. (ECF No. 106.)

5 Plaintiff appears to dispute this point, but really contends he was never presented with this group insurance certificate by MetLife during the time he was covered by the Plan. (ECF No. 128 at 6.) 2. Benefits are payable after the employee has been disabled for 180 days, the Plan’s “Elimination Period.” (Id. at 1095, 1107.) 3. For LTD benefits, the Plan provides: “If You become Disabled while insured, Proof of Disability must be sent to Us. When We receive such Proof, We will review the claim. If We approve the claim, We will pay the Monthly Benefit up to the Maximum Benefit Period shown in the SCHEDULE OF BENEFITS, subject to THE DATE BENEFIT PAYMENTS END section.” (Id. at 1107.) 4. The Plan defines “Disabled/Disability” as follows: Disabled or Disability means that, due 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 o unable to perform each of the material duties of Your Own Occupation; and • You are, after such period: o unable to earn more than 60% of your Predisability Earnings from any employer in Your Local Economy; and o unable to perform the duties of any gainful occupation for which You are reasonably qualified taking into account Your training, education and experience. (AR 1096.) 5. “Own Occupation” is defined as “the essential functions You regularly perform that provide Your primary source of earned income.” (Id. at 1097.) 6. “Proof” is defined as “Written evidence satisfactory to Us that a person has satisfied the conditions and requirements for any benefit described in this certificate. When a claim is made for any benefit described in this certificate, Proof must establish: [1] the nature and extent of the loss or condition; [2] Our obligation to pay the claim; and [3] the claimant’s right to receive payment.” (Id. at 1099.) 7. Thus, LTD benefits are payable for 24 months if the participant is disabled from performing the duties of his or her “own occupation.” (AR 1096.) LTD benefits are payable beyond 24 months only if the participant is disabled from performing the duties of “any gainful occupation.” (Id.) 8. The Return to Work Program: The Plan provides that disabled participants may participate in various “special services” provided by MetLife, including a Return to Work program (“RTWP”). The RTWP is designed to assist Disabled participants who are receiving disability benefits under the Plan return to work. (AR 1125.) The RTWP provides for various services such as vocational assessment, retraining programs, and job modifications/accommodations. (Id.) 9. A Participant Must Be Disabled to Receive Benefits Under the Plan: All of the Plan’s benefits, including LTD and RTWP benefits, end on “the date You are no longer Disabled.” (AR 1113.) The Plan also provides that a participant will not receive RTWP services beyond the date he or she stops receiving monthly LTD benefits under the plan. (Id. at 1108.)6 The Plan’s Summary Plan Description discusses this limitation as follows: Benefits received as a result of the [RTWP] will end either when the Insurance Company decides you are no longer eligible for the program or on any other date which monthly payments would stop under the LTD Plan, whichever is earlier. (AR 1142.)7 Thus, once MetLife determined Plaintiff was not entitled to further LTD benefits, Plaintiff’s potential entitlement to RTWP benefits and services ended. B. Plaintiff’s Claim for Disability Benefits 1. Plaintiff’s Claims for STD and LTD Benefits: Plaintiff, an electrical engineer, stopped working following cardiac procedures in September/October 2009. (AR 631, 691.) In February 2010, Plaintiff submitted an LTD claim to MetLife. (AR 619–35.) Although he 6 Plaintiff is correct that the citation Defendants provided for this proposition (AR 1108) is incorrect. (ECF No. 128 at 7.)

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(PS) Zelhofer v. Metropolitan Life Ins. Co., (E.D. Cal. 2022).

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