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Kollar v. Sun Life Assurance Company of Canada

United States District Court, W.D. Washington, Tacoma

December 16, 2019

JAMES M. KOLLAR, Plaintiff,
v.
SUN LIFE ASSURANCE COMPANY OF CANADA, Defendant.

          ORDER ON CROSS-MOTIONS FOR SUMMARY JUDGMENT AND PLAINTIFF'S MOTION TO SUPPLEMENT THE ADMINISTRATIVE RECORD DKT. ## 12, 15

          Ronald B. Leighton, United States District Judge.

         INTRODUCTION

         THIS MATTER is before the Court on the parties' Cross-Motions for Summary Judgment and Plaintiff James M. Kollar's Motion to Supplement the Administrative Record. Dkt. ## 12, 15. This is an action under the Employee Retirement Income Security Act (ERISA). Kollar worked for policyholder First Choice Health Network as a software engineer until he was terminated on May 11, 2018. AR 000137. Prior to that, he had been diagnosed with Ankylosing Spondylitis and Hemochromatosis, among other things. AR 000106. According to his physicians, Neil F. Moody and Patricia Papadopoulos, Kollar could perform “daily activities with limitations” but his “spinal motion [was] sharply restricted” and he had issues with sitting or standing for very long without changing position. AR 000107. His doctors opined that these restrictions were “indef[inite]” and Kollar was incapable of working on April 5, 2018. Id.

         Kollar filed a claim for short term disability benefits on June 19, 2018. AR 000112. Defendant Sun Life denied his claim on August 27. AR 000167. Kollar requested that Sun Life review its decision on November 21, AR 000172, but Sun Life re-affirmed its denial on January 28, 2019. AR 000183. Sun Life's decision was based on Kollar's continued fulltime employment until his dismissal, which prevented his benefits from being triggered prior to his termination as an insured. AR AR000183-86.

         Kollar has sued challenging Sun Life's denial of benefits. In addition to moving for summary judgment, Kollar also requests that the Court supplement the record with additional documents, including his own declaration. Dkt. # 12. The Court will address each motion in turn.

         DISCUSSION

         1. Motion to Supplement the Record

         Kollar requests that the Court consider the following documents that are not part of the administrative record: (1) 71 pages of medical records that were sent to Sun Life on December 27, 2018 [Dkt. # 12-3]; (2) a Social Security Administration Notice of Award to Kollar dated December 24, 2018 [Dkt. # 12-4]; and (3) Kollar's own declaration [Dkt. # 12-5]. Sun Life does not object to the first set of documents, which it states were erroneously excluded from the record. However, Sun Life does object to the second and third documents.

         When reviewing a plan administrator's denial of benefits under ERISA, a district court may consider evidence outside the administrative record “when circumstances clearly establish that additional evidence is necessary to conduct an adequate de novo review of the benefit decision. In most cases, where additional evidence is not necessary for adequate review of the benefits decision, the district court should only look at the evidence that was before the plan administrator . . . at the time of the determination.” Mongeluzo v. Baxter Travenol Long Term Disability Ben. Plan, 46 F.3d 938, 944 (9th Cir. 1995) (quoting Quesinberry v. Life Ins. Co. of North America, 987 F.2d 1017, 1025 (4th Cir.1993) (en banc)). A district court may admit extrinsic evidence in cases involving:

claims that require consideration of complex medical questions or issues regarding the credibility of medical experts; the availability of very limited administrative review procedures with little or no evidentiary record; the necessity of evidence regarding interpretation of the terms of the plan rather than specific historical facts; instances where the payor and the administrator are the same entity and the court is concerned about impartiality; claims which would have been insurance contract claims prior to ERISA; and circumstances in which there is additional evidence that the claimant could not have presented in the administrative process.

Opeta v. Nw. Airlines Pension Plan for Contract Employees, 484 F.3d 1211, 1217 (9th Cir. 2007) (quoting Quesinberry, 987 F.2d at 1025). However, “a district court should not take additional evidence merely because someone at a later time comes up with new evidence that was not presented to the plan administrator.” Mongeluzo, 46 F.3d at 944.

         The Court grants Kollar's request to admit the 71 pages of medical records that were apparently sent to Sun Life. Dkt. # 12-3. With respect to the other documents, Kollar does not argue that they meet any of the criteria identified in Opeta. Kollar's social security administration notice of award contains no medical analysis or expertise and therefore does not shed useful light on the issues. As for the declaration, Kollar could have included this information in his personal profile; indeed, some of the information is already in the record. See AR 000010. Consequently, the Court will not admit the social security administration notice of award or Kollar's declaration.

         2. Cross-Motions

         Sun Life argues that it properly denied Kollar benefits for several reasons. First, Kollar's physicians identified April 5, 2018, as the date Kollar became disabled, but Kollar did not stop working fulltime until May 11, the day his insurance expired. Consequently, Sun Life argues that Kollar did not satisfy the policy's “Elimination Period, ” which requires that a claimant spend 7 days without working or working reduced hours after the onset of disability before receiving benefits. AR 000031. Sun Life also ...


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