Valdez v. At & T Umbrella Benefit Plan No. 1

371 F. Supp. 3d 754
CourtDistrict Court, S.D. California
DecidedMarch 4, 2019
DocketCase No.: 16-cv-2613-BTM-BGS
StatusPublished
Cited by1 cases

This text of 371 F. Supp. 3d 754 (Valdez v. At & T Umbrella Benefit Plan No. 1) is published on Counsel Stack Legal Research, covering District Court, S.D. California primary law. Counsel Stack provides free access to over 12 million legal documents including statutes, case law, regulations, and constitutions.

Bluebook
Valdez v. At & T Umbrella Benefit Plan No. 1, 371 F. Supp. 3d 754 (S.D. Cal. 2019).

Opinion

Honorable Barry Ted Moskowitz, United States District Judge

I. INTRODUCTION

Plaintiff Lizbeth Valdez brings this action for short and long term disability benefits under 29 U.S.C. § 1132(a)(1)(B), which provides for civil enforcement of employee benefit plans pursuant to the Employee Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. §§ 1001 et seq. Plaintiff asserts her short term disability benefits were wrongfully denied and that but for the wrongful denial, she would be entitled to long term benefits. Pending before the Court are cross-motions for summary judgment submitted by Plaintiff and Defendant AT & T Umbrella Benefit Plan No. 1 ("the Plan"). The question before the Court on summary judgment is whether the Plan administrator's decision to deny Plaintiff's short term disability benefit claim was an abuse of discretion. For reasons set forth below, the Court concludes that it was.

II. BACKGROUND

A. FACTS

1. The Disability Plan

As an employee of Pacific Bell Telephone Company ("PacBell"), Plaintiff was a participant in AT & T Umbrella Benefit Plan No. 1 ("the Plan"), which is governed by the Employee Retirement Income Security *758Act of 1974 ("ERISA"). A third-party claims administrator, Sedgwick Claims Management Services ("Sedgwick" or "the claim administrator"), determines all claims and appeals for benefits under the Plan. (AR 88). Regular claims are determined by Sedgewick employees at AT & T Integrated Disability Service Center; Sedgewick's Quality Review Unit decides appeals and denials of benefit claims under the Plan. (AR 93, 94).

The Plan provides short term disability ("STD") benefits upon a showing of disability. Under the Plan, a participant is disabled when she has "a sickness, injury or other medical, psychiatric or psychological condition that prevents [her] from engaging in [her] normal occupation or employment ... in accordance with [her employer's] normal practices." (AR 64, 69). If a participant is "able to perform a modified duty" and her employer "is able to accommodate [her] restrictions," then the participant is not considered disabled. (AR 64, 69).

In order to be considered for STD benefits under the Plan, the participant must "be under the care of a physician and follow a treatment plan that is reasonably designed (where practicable) to result in [the participant's] recovery and return to work." (AR 69). The participant must periodically file medical evidence of her disability, and her medical providers must furnish medical reports and necessary information to the claims administrator in a timely manner. (AR 69). STD benefits are terminated if the participant "fail[s] to furnish objective Medical Evidence" of her alleged disability or "fail[s] to follow a medically appropriate treatment plan that is reasonably designed (where practicable)" to facilitate her recovery and eventual return to work. (AR 75). The claim administrator may require claimants to undergo additional medical examinations before making an STD benefits determination. (AR 70). Claimants are not required to pay for these requested medical examinations. (AR 70).

2. Plaintiff's Job Duties and Diagnoses

In April 2015, Plaintiff Lizbeth Valdez began working as a sales consultant at PacBell. (AR 124). Plaintiff's work duties included answering customer phone calls while wearing a headset and entering customer data into the computer. (Id.) The work was largely sedentary, involving reading, typing, and using a mouse while viewing a computer screen. (Id.). However, Plaintiff had been in ill health for some time.

In November 2012, when Plaintiff was 25 years old, she was diagnosed with multiple sclerosis ("MS"). Her MRI showed "innumerable dawsons fingers as well as high cervical lesion," and subsequent MRI's revealed increasing numbers of active brain lesions. (AR 119, 431-32). Between November 2012 and October 2015, Plaintiff suffered five MS related relapses. (AR 119, 436). In addition to her MS diagnosis, Plaintiff began suffering from headaches in May 2014 and was hospitalized with viral meningitis in July 2014. (AR 340). The following year, she was diagnosed with depression secondary to her MS. (AR 340). As early as July 2015, Plaintiff began suffering from chronic migraine headaches that led her to seek medical attention. (AR 117, 340). These chronic migraines are the basis for Plaintiff's STD benefits claims and appeals.

Migraines are defined as "painful, throbbing headaches" that "may cause nausea and vomiting and make you sensitive to light, sound or smell." (AR 468). Left untreated, migraines can last from four hours to a few days. (AR 468). Prescription medication helps resolve migraines, and Plaintiff's self-care instructions included *759"rest[ing] in a quiet, dark room until [her] headache is gone" and avoiding watching TV or reading. (AR 469). The self-care instructions told Plaintiff to seek immediate medical care if she experienced "new or worse nausea and vomiting," "a new or higher fever," or a progressively worse headache. (AR 470).

3. History of Plaintiff's Benefits Claims From October 2015 to April 2016

In early October 2015, Plaintiff was hospitalized for two days after reporting head pain and vertigo. (AR 117). She was admitted for a migraine, anxiety, and possible exacerbation of multiple sclerosis. (AR 117). Her MRI was unchanged from August 2015, but showed more lesions than her November 2012 MRI. (AR 436). Plaintiff submitted her first STD claim during that hospital stay. (AR 98, 104). Her medical provider, Kaiser Permanente, submitted a work status report and a discharge summary for October 6, 2015, which stated she "was started on i/v solumedrol, was seen by [inpatient] neurology consult, had MRI head which is negative for acute issues, and ... [was] stable to be discharged home." (AR 140). The claim administrator noted it was "unclear why [Plaintiff] could not return to work shortly after the discharge while only on [prescription management]" and without a "complex [treatment] plan." (AR 108-09). Plaintiff's claim was approved, but the claim administrator told Plaintiff she would need to submit additional medical information should she remain out of work. (AR 109).

Plaintiff continued to suffer weeks-long migraine headaches after her discharge, prompting nine medical visits between October 14 and November 17. (AR 113-122, 430, 501-09, 680). Her other symptoms included severe fatigue, insomnia, and weakness. (AR 447).

Plaintiff opened her second STD benefits claim on October 20, 2015. Kaiser Permanente submitted a work status report by Plaintiff's treating neurologist, Dr. Cynthia Elizabeth Spier, placing her off work from October 25, 2015 through November 2, 2015. (AR 200-201, 646-654).

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Bluebook (online)
371 F. Supp. 3d 754, Counsel Stack Legal Research, https://law.counselstack.com/opinion/valdez-v-at-t-umbrella-benefit-plan-no-1-casd-2019.