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9th Cir. – Unpublished – SSDI Award and Pain Symptoms

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  • 9th Cir. – Unpublished – SSDI Award and Pain Symptoms

    Here’s a new very brief opinion out of the Ninth Circuit, Sonia Cruz-Baca v. Edison International Long Term Disability Plan. In this very brief and to the point opinion, the court first finds that the plan’s failure to adequately grapple with the SSDI award constitutes an abuse of discretion.

    1. In its termination letter to Cruz-Baca, the Plan acknowledged it was aware of her award of social security disability insurance (SSDI) benefits. Indeed, the Plan previously required Cruz-Baca to apply for such benefits so that the Plan might reduce its own payment obligation to Cruz-Baca. Failing to comply with its obligation under Ninth Circuit and Supreme Court precedent, the Plan did not meaningfully review Cruz-Baca’s SSDI award. ERISA plan administrators are not bound by prior Social Security Administration (SSA) determinations. See Montour v. Hartford Life & Accident Ins. Co., 588 F.3d 623, 635 (9th Cir. 2009); see also Salomaa v. Honda Long Term Disability Plan, 642 F.3d 666, 679 (9th Cir. 2011) (“Social Security disability awards do not bind plan administrators, but . . . are evidence of disability”). However, disregarding or failing to “grapple” with an SSDI award “raises questions about whether an adverse benefits determination was ‘the product of a principled and deliberative reasoning process.’” Montour, 588 F.3d at 635 (quoting Glen v. MetLife, 461 F.3d 660, 674 (6th Cir. 2008)); see also Glen, 461 F.3d at 671 n.3 (noting the distinction between mentioning a contrary determination and discussing it). Similarly, “not distinguishing the SSA’s contrary conclusion may indicate a failure to consider relevant evidence.” Montour, 588 F.3d at 635 (citing Metropolitan Life Ins. Co. v. Glenn, 554 U.S. 105, 123-24 (2008) (Roberts, C.J., concurring in part and concurring in the judgment). No principled reason is offered for the Plan’s failure to review Cruz-Baca’s SSDI award, which is reliable evidence of her disability. This constituted an abuse of discretion.
    Next, the court finds that failure to consider subjective complaints of pain is an abuse of discretion.

    2. It was arbitrary and capricious for Dr. Ramachandran Srinivasan to fail to discuss and consider Cruz-Baca’s subjective complaints of pain as evidence of her chronic pain syndrome. This is particularly true given that Dr. Srinivasan observed Cruz-Baca exhibiting pain symptoms during the Independent Medical Evaluation (IME), and given that he noted her long history of chronic pain. This Court has previously held that “conditioning an award on the existence of evidence that cannot exist is arbitrary and capricious.” Salomaa, 642 F.3d at 678. “Many medical conditions depend for their diagnosis on patient reports of pain or other symptoms, and some cannot be objectively established,” but “a disability insurer [cannot] condition coverage on proof by objective indicators ... where the condition is recognized yet no such proof is possible.” Id. Pain is an inherently subjective condition, and it is unclear what objective evidence the Plan was looking for in order to establish that Cruz-Baca’s pain prevented her from working. Neither the Plan nor Dr. Srinivasan offered any explanation as to why Cruz-Baca’s history of pain and pain-related treatment were insufficient to support a finding of disability. Under such circumstances, to disregard Cruz-Baca’s subjective complaints of continuing and pervasive pain was arbitrary and capricious.
    Lastly, the court concludes that the plan relied solely on the IME which favored it and completely ignored a previous IME which favored the plaintiff, finding that failure to adequately consider and credit evidence in favor of an award of benefit is an abuse of discretion. The opinion is attached below.
    Attached Files