Ramos v. Bank of Am.

Decision Date15 March 2011
Docket NumberNo. C 08–1375 PJH.,C 08–1375 PJH.
Citation779 F.Supp.2d 1058
PartiesLena M. RAMOS, Plaintiff,v.BANK OF AMERICA, Defendant.
CourtU.S. District Court — Northern District of California

OPINION TEXT STARTS HERE

Joseph Andrew Creitz, The Law Office of Joseph Creitz, P.C. Joseph Allen Garofolo, Law Office of Joseph A. Garofolo, P.C. San Francisco, CA, for Plaintiff.Patricia K. Gillette, Kristen Marie Jacoby, Orrick Herrington & Sutcliffe LLP, Rebecca A. Hull, Michelle Yumi McIsaac, Sedgwick Detert Moran & Arnold LLP, San Francisco, CA, for Defendant.

ORDER RE MOTIONS FOR SUMMARY JUDGMENT

PHYLLIS J. HAMILTON, District Judge.

The parties' motions for summary judgment came on for hearing before this court on November 10, 2010. Plaintiff appeared by her counsel Joseph Creitz, and defendants appeared by their counsel Kristen Jacoby and Rebecca Hull. Having read the parties' papers and carefully considered their arguments and the relevant legal authority, and good cause appearing, the court hereby GRANTS defendants' motion, and DENIES plaintiff's motion.

BACKGROUND

This is a case brought under the Employee Retirement Income Security Act of 1974, 29 U.S.C. § 1001, et seq. (ERISA). Plaintiff Lena Monzon Ramos is a former employee of Bank of America (BofA). In November 2004, after 22 years with the bank, she left her employment, claiming to be fully disabled and unable to perform any of the functions of her job (Senior Operations Representative).

As set forth in the BofA Associate Handbook, BofA offers “illness, injury and disability benefits” that include occasional illness days, short-term disability (“STD”), long-term disability (“LTD”), worker's compensation for work-related injuries, and long-term care insurance. Administrative Record (“AR”) 0153.

In 2003, defendant Metropolitan Life Insurance Company (“MetLife”) issued BofA a group policy of insurance to fund long-term disability (“LTD”) benefits payable under the Bank of America Long Term Disability Benefits Plan (2003 LTD Plan” or “the Plan”). Defendant Bank of America Corporation Corporate Benefits Committee (“BofA Program” or “Program”—sued as “Bank of America”) is the administrator of the 2003 LTD Plan. MetLife is an insurer, and is the entity to whom BofA Program delegated its duties as claims administrator.

The Plan grants MetLife discretionary authority to make benefit decisions, as follows:

In carrying out their respective responsibilities under the Plan, the Plan administrator and other Plan fiduciaries shall have discretionary authority to interpret the terms of the Plan and to determine eligibility for and entitlement to Plan benefits in accordance with the terms of the Plan. Any interpretation or determination made pursuant to such discretionary authority shall be given full force and effect, unless it can be shown that the interpretation or determination was arbitrary and capricious.

AR 0065.

To make a claim for benefits under the LTD Plan, “the claimant must complete the appropriate claim form and submit the required proof.” AR 0064. “Proof must describe ... the nature and the extent of the cause for which a claim is made; it must be satisfactory to [MetLife].” AR 0056.

Plan participants are eligible to receive LTD benefits, following a 180–day Elimination Period, if they become “disabled” while covered under the Plan. See AR 0045, 0051.

The Plan defines “disabled” as follows:

“Disability” or “Disabled” means that, due to an Injury or Sickness, you require the Appropriate Care and Treatment of a Doctor, unless, in the opinion of a doctor, future or continued treatment would be of no benefit and:

1. you are unable to perform each of the material duties of your occupation; and

2. after the first 24 months of benefit payments, you must also be unable to perform each of the material duties of any gainful work or service for which you are reasonably qualified taking into consideration your training, education, experience, and past earnings; or

3. you, while unable to perform all of the material duties of your own occupation on a full-time basis, are:

a. performing at least one of the material duties of your own occupation or any other gainful work or service on a part-time or full-time basis; and

b. earning currently at least 40% less per month than your Indexed Basic Monthly Earnings due to that same Injury or Sickness.

AR 0050–0051.

The Plan sets forth procedures for making benefit claims with MetLife, including procedures for the submission and determination of claims, review of claims that have been denied in whole or in part, and information regarding a participant's rights under ERISA. AR 0056–0057, 0064–0067.

BofA employees receive sickness and Family and Medical Leave Act (“FMLA”) 1 coverage through the STD Plan, which pays income replacement benefits for up to six months (depending on length of employment) to any employee who submits a request completed by the employee and his/her doctor, along with “medical documentation” of “illness, injury or pregnancy disability” sufficient to demonstrate that he/she was “unable to work” for more than 14 consecutive calendar days. AR 0154–0155.

In November 2004, plaintiff applied for benefits under the STD Plan administered by BofA. (MetLife took over administration of the STD Plan in March 2005.) Plaintiff's claim was approved for the period beginning November 19, 2004, and was ultimately extended through June 2, 2005—the longest period allowable under the provisions of the STD Plan.

In February 2005, MetLife informed plaintiff of her eligibility to apply for LTD benefits. In a letter dated February 21, 2005, MetLife advised plaintiff that in order for her claim to be evaluated, she would have to provide an Attending Physician Statement of Functional Capacity (“APS”); an Employee Statement; contact information for all physicians who had treated her for the allegedly disabling condition; an authorization to release medical information; and information regarding training, education, experience, job description, plus proof of age and a copy of her driver's license. AR 0365. MetLife instructed plaintiff that in addition to the APS, her physician “should also include all office notes and test results from [the] date of disability that support the stated diagnosis and restrictions and limitations.” Id.

MetLife added that the above forms “must be completed and returned by March 21, 2005, to give your claim consideration and to minimize delay in benefit payments that may be due,” and that [u]nless we receive these forms by March 21, 2005, we will assume you are no longer interested in pursuing your claim for disability and will close your file.” AR 0365–0366.

Plaintiff submitted her application for LTD benefits in March 2005. She listed her job duties as performing data entry, typing, and receiving incoming wires. AR 0352. She described her medical condition as shortness of breath, with constant coughing, with symptoms that “feel like an asthma attack.” AR 0349. She reported that her current medications included albuterol, ferosemide, Singulair®, Advair®, Ecotrin®, Phenergan®, Nexium®, and Relpax®. AR 0353.

Plaintiff stated that the date of first treatment for her condition was 2003; that her last day of work as an Operations Representative was November 15, 2004; and that the date her disability began was November 19, 2004. AR 0348. She listed three physicians who had treated her within the past two years—Dr. Melanie Lee, a specialist in internal medicine; Dr. John Hadley, a specialist in pulmonology; Dr. Agustin Argenal, a specialist in cardiology. AR 0348–0349.

Based on the Plan's 180–day elimination period, plaintiff was not eligible for LTD benefits unless she showed that she was disabled, and that she had been continuously disabled throughout the period from November 15, 2004 to and including May 15, 2005. See AR 0045, 0051.

With her application, plaintiff submitted an APS from her pulmonologist, Dr. Hadley, dated March 8, 2005. See AR 0360–0362. The APS provided the “latest reading” of plaintiff's blood pressure, taken December 22, 2004. AR 0361. The APS stated that plaintiff had been diagnosed with cardiac asthma and congestive heart failure, and reported that plaintiff could not work due to “extreme asthma and coughing attacks” that left her “unable to talk.” Id.

The APS also stated, however, that plaintiff could sit continuously for 8 hours, stand intermittently for 1 hour, and walk intermittently for 1 hour. While she had no ability to climb, she could lift up to 20 pounds occasionally, and could twist/bend/stoop, reach above shoulder level, and operate a motor vehicle. She could also perform repetitive tasks with both hands. Id.

The APS indicated that the treatment plan for plaintiff's condition included referral to a cardiologist, “nebulizer therapy,” and a prescription for cough syrup; and stated that improvement was “possible, if cough & asthma become controlled; cough medicine given.” Id. The APS included the notation, “See records attached.” AR 0360. However, no records were attached or received by MetLife. AR 0312.

According to MetLife's claim file notes, a MetLife case manager contacted Dr. Hadley's office on March 15, 2005, regarding the missing records, and was told they were in the possession of plaintiff. Id. A MetLife case manager then spoke with plaintiff, who claimed she had sent the records to MetLife once, but that they had been returned to her. She stated that she had sent them again on March 11 or 12, 2005. AR 0313. However, according to MetLife, it never received the records.

Because of the lack of medical records supporting plaintiff's claim, MetLife denied the claim in a letter dated March 23, 2005. The letter stated that MetLife had reviewed the information submitted by plaintiff—the Initial Claims Packet, and the APS signed by Dr. Hadley on March 8, 2005—but that certain information had not been received. AR 0341–0342. Specifically, MetLife reminded plaintiff that she had previously been instructed to...

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  • James v. AT & T W. Disability Benefits Program
    • United States
    • U.S. District Court — Northern District of California
    • 2 Junio 2014
    ... ... Def. Opp'n 2223 (citing Ramos v. Bank of Am., 779 F.Supp.2d 1058, 1075 (N.D.Cal.2011), vacated by Ramos v. Bank of Am., No. 08cv1375 PJH, 2012 WL 379445 (N.D.Cal. Feb. 6, ... ...
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    ... ... 29 U.S.C. 1132(c). As such, it does not extend to documents identified in 29 C.F.R. 2560.5031. See Ramos v. Bank of America, 779 F.Supp.2d 1058, 1083 (N.D.Cal.2011) (While 2560.5031 does impose requirements on plans with regard to claim procedures, ... ...

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