Lydia Winz-Byone v. Metropolitan Life Insurance Co , 357 F. App'x 949 ( 2009 )

FILED
DEC 16 2009
MOLLY C. DWYER, CLERK
NOT FOR PUBLICATION U.S. COURT OF APPEALS
UNITED STATES COURT OF APPEALS
FOR THE NINTH CIRCUIT
LYDIA WINZ-BYONE, No. 08-55638
Plaintiff - Appellant, D.C. No. 5:07-cv-00238-VAP-OP
v. MEMORANDUM*
METROPOLITAN LIFE INSURANCE
COMPANY; PARK WATER
COMPANY LONG TERM
DISABILITY PLAN,
Defendants - Appellees.
Appeal from United States District Court
Central District of California
Virginia A. Phillips, District Judge, Presiding
Argued and Submitted October 8, 2009
Pasadena, California
*
This disposition is not appropriate for publication and is not precedent
except as provided by Ninth Circuit Rule 36-3.
Before: W. FLETCHER and CLIFTON, Circuit Judges, and SINGLETON,**
Senior United States District Judge.
Lydia Winz-Byone (“Winz-Byone”) appeals from a decision of the district
court dismissing her action against Metropolitan Life Insurance Company
(“MetLife”) and the Park Water Company Long Term Disability Plan (“LTD
Plan”). Specifically, Winz-Byone alleged that MetLife and the LTD Plan
wrongfully terminated her long-term disability payments under the LTD Plan in
violation of the Employee Retirement Security Act (“ERISA”). The matter was
brought before the district court for decision on the motion of MetLife and the
LTD Plan for summary judgment and the cross-motion of Winz-Byone for
summary judgment. Also before the district court was a motion by Winz-Byone to
augment the record. The district court granted MetLife and the LTD Plan’s motion
for summary judgment and denied Winz-Byone’s motions.
The district court had jurisdiction under 28 U.S.C. § 1331 and 29 U.S.C. §§
1001 and 1132(e)(1). This Court has jurisdiction under 28 U.S.C. § 1291.
“This appeal involves two different standards of review: one applying to our
review of the district court’s decision, and the other concerning the standard that
applies to court review of the ERISA plan administrator’s decision.” Sznewajs v.
**
The Honorable James K. Singleton, Senior United States District Judge for
the District of Alaska, sitting by designation.
2
U.S. Bancorp Amended and Restated Supplemental Benefits Plan, 572 F.3d 727,
732 (9th Cir. 2009).
A. Review of District Court.
“[W]e review de novo a district court’s decision to grant or deny summary
judgment. We also review de novo a district court’s ‘choice and application’ of the
appropriate standard for reviewing benefits decisions by an ERISA plan
administrator.” Id. (internal citation omitted).
B. Review of Plan Administrator’s Decision.
When a plan grants the plan administrator discretionary authority to construe
the plan’s terms, the appropriate standard of review is for abuse of discretion.
Nolan v. Heald College, 551 F.3d 1148, 1153 (9th Cir. 2009). Any conflict of
interest on the part of the plan administrator is included as a factor to be taken into
account in deciding whether the discretion has been abused. See Metropolitan Life
Ins. Co. v. Glenn, 554 U.S. ___, 128 S. Ct. 2343, 2346, 2348 (2008) (“Metlife”);
Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989); Saffon v. Wells
Fargo & Co. Long Term Disability Plan, 522 F.3d 863, 867-68 (9th Cir. 2008). A
conflict of interest commonly arises when, as in this case, a plan administrator
serves a dual role of both determining employee eligibility for benefits and paying
those benefits out of its own pocket. Metlife, 128 S. Ct. at 2346.
3
Because the plan involved in this case assigns discretionary authority to the
administrator, the informed abuse of discretion standard applies. In this case it is
undisputed that MetLife served a dual role of both determining Winz-Byone’s
eligibility for benefits and paying the benefits.
Judicial review of the decision of an ERISA plan administrator is determined
on the administrative record; thus, the district court may not hear additional
evidence not presented to the plan administrator. McKenzie v. General Telephone
Co. of Cal., 41 F.3d 1310, 1316 (9th Cir. 1994) (error for a district court to hear
additional evidence not presented to the plan administrator); Taft v. Equitable Life
Assur. Soc., 9 F.3d 1469, 1472 (9th Cir. 1993) (same).
A controlling issue in this case is whether Winz-Byone’s diagnosed
disability falls within the exclusion provision for neuromusculoskeletal and soft
tissue disorders. As presented to MetLife, the key to this case lies in Dr. Salick’s
May 24, 2006, letter submitted with Winz-Byone’s administrative appeal and
relied upon by the district court:
According to your definition of “neuromusculoskeletal and soft tissue
disorder”, [sic] which in this case, is a reflex sympathetic dystrophy of
both upper extremities; right much worse that left. This reflex
sympathetic dystrophy is sometimes called a regional pain disorder.
It is a disease of the sympathetic nervous system, which causes
extreme pain and trophic changes in those affected limbs.
4
The balance of Dr. Salick’s letter addresses the degree of Winz-Byone’s disability,
i.e., that she is totally disabled, which was not at issue.
There is nothing in the quoted portion of the letter that indicates Dr. Salick
does not agree that the term “neuromusculoskeletal and soft tissue disorder”
includes reflex sympathetic dystrophy. Indeed, as the district court noted, although
it lacks grammatical consistency, it does suggest that reflex sympathetic dystrophy
is a neuromusculoskeletal and soft tissue disorder. Even if on de novo review we
apply a somewhat higher degree of skepticism than did the district court, it cannot
be said on the administrative record that MetLife, as plan administrator, abused its
discretion in determining that the 24-month limitation period applied to Winz-
Byone. MetLife’s two reviewing physicians concluded that it did, and Dr. Salick’s
support for the opposite view was ambiguous, at best.
Because of our conclusion that MetLife permissibly concluded that reflex
sympathetic dystrophy was not covered by the policy, we need not address other
issues in the case.
AFFIRMED.
5