JANET C. HALL, District Judge.
Plaintiff Myrna Gaud-Figueroa has brought this action pursuant to section 502(a)(1)(B) of the Employee Retirement Income Security Act ("ERISA"), 29 U.S.C. § 1132, alleging that defendant Metropolitan Life Insurance Company ("MetLife") wrongfully terminated her long-term disability benefits. On July 15, 2010, MetLife filed a Motion for Summary Judgment pursuant to Rule 56 of the Federal Rules of Civil Procedure (Doc. No. 18), and Gaud-Figueroa filed a Motion for Judgment on the Administrative Record (Doc. No. 19).
Because MetLife's benefit determination was not arbitrary and capricious, except with regard to its conclusion that Gaud-Figueroa was not covered by the Plan in September and October 2008, MetLife's Motion for Summary Judgment is granted in part and denied in part. Gaud-Figueroa's Motion for Judgment on the Administrative Record is granted in part and denied in part.
Gaud-Figueroa has filed a Motion for Judgment on the Administrative Record, a type of motion that is not authorized by the Federal Rules of Civil Procedure. The court may treat a motion for judgment on the administrative record as a motion for summary judgment, provided the court has not already ruled on an earlier motion for summary judgment by that party. Muller v. First Unum Life
A motion for summary judgment "may properly be granted . . . only where there is no genuine issue of material fact to be tried, and the facts as to which there is no such issue warrant judgment for the moving party as a matter of law." In re Dana Corp., 574 F.3d 129, 151 (2d Cir.2009). Thus, the role of a district court in considering such a motion "is not to resolve disputed questions of fact but only to determine whether, as to any material issue, a genuine factual dispute exists." Id. In making this determination, the trial court must resolve all ambiguities and draw all inferences in favor of the party against whom summary judgment is sought. See Fed R. Civ. P. 56(c); Loeffler v. Staten Island Univ. Hosp., 582 F.3d 268, 274 (2d Cir.2009).
"[T]he moving party bears the burden of showing that he or she is entitled to summary judgment." United Transp. Union v. National R.R. Passenger Corp., 588 F.3d 805, 809 (2d Cir.2009). Once the moving party has satisfied that burden, in order to defeat the motion, "the party opposing summary judgment . . . must set forth `specific facts' demonstrating that there is `a genuine issue for trial.'" Wright v. Goord, 554 F.3d 255, 266 (2d Cir.2009) (quoting Fed.R.Civ.P. 56(e)). "A dispute about a `genuine issue' exists for summary judgment purposes where the evidence is such that a reasonable jury could decide in the non-movant's favor." Beyer v. County of Nassau, 524 F.3d 160, 163 (2d Cir.2008) (quoting Guilbert v. Gardner, 480 F.3d 140, 145 (2d Cir.2007)); see also Havey v. Homebound Mortgage, Inc., 547 F.3d 158, 163 (2d Cir.2008) (stating that a non-moving party must point to more than a mere "`scintilla'" of evidence in order to defeat a motion for summary judgment) (citing Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 252, 106 S.Ct. 2505, 91 L.Ed.2d 202 (1986)). In this case, neither Gaud-Figueroa nor MetLife dispute any fact material to the disposition of this matter.
The following facts are undisputed.
To be "Disabled" under the Plan "means that, due to an Injury or Sickness, you require the regular care and attendance of a Doctor and . . . you are unable to perform each of the material duties of your regular job or any gainful occupation for which you are reasonably qualified taking into account your education, training, and experience." AR 0027. The Summary Plan Description (SPD) prepared by Home Depot also defined "Disability" to mean that "due to an injury or sickness," the participant "require[s] the regular care of a qualified doctor," and the participant is "unable to perform each of the material duties of [his] regular job or any gainful occupation for which [he is] reasonably qualified, taking into account [his] education, training and experience." Def.'s 56.1, ¶ 4; AR 0070.
The SPD informed the participant that "MetLife must receive certification with accompanying medical documentation of a disability from your attending doctor before benefits are considered for payment." Def.'s 56.1, ¶ 5; AR 0070. Under the Plan, benefits may only be issued if "proof of continued Disability is submitted, at your expense, to [MetLife] upon request." AR 0029. "Proof" of a valid claim under the short and long-term disability plans "must describe the event, the nature and the extent of the cause for which a claim is made; it must be satisfactory to [MetLife]." AR 0034.
In both the SPD and the Plan itself, MetLife claimed full discretionary authority to interpret and apply the Plan. Def.'s 56.1, ¶ 7, AR 0045 ("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 or capricious."); AR 0407 ("The Plan Administrator . . . has the full power and authority in its absolute discretion to determine all questions of eligibility for and entitlement to benefits, and to interpret and construe the terms of the plans.").
The Plan featured a 24-month limit on payments for "disabilities due to mental/nervous
Gaud-Figueroa was eligible to receive 60% of her monthly salary in benefits under the long-term disability plan, or $2,054 per month. Def.'s 56.1, ¶ 79, AR 0612.
MetLife initially approved Gaud-Figueroa for Short-Term Disability (STD) benefits for spinal strain and severe back pain for the period from May 19, 2007 through June 11, 2007. Def.'s 56.1, ¶¶ 8, 30. Gaud-Figueroa returned to work part-time on June 11, 2007, and MetLife extended her STD benefits through September 23, 2007. Def.'s 56.1, ¶¶ 33, 39.
On August 24, 2007, Gaud-Figueroa submitted a new claim for STD benefits, based on foot spurs, melanoma, and pinched nerves in her left foot. Def.'s 56.1, ¶ 40. Gaud-Figueroa stopped working part-time at Home Depot on September 6, 2007. Def.'s 56.1, ¶ 42. Gaud-Figueroa's new claim was denied on September 10, 2007. Def.'s 56.1, ¶ 43. However, Gaud-Figueroa's podiatrist performed left foot surgery on Gaud-Figueroa on September 7, 2007 and right foot surgery on November 9, 2007. Def.'s 56.1, ¶ 46, 49. MetLife subsequently extended Gaud-Figueroa's STD benefits to the maximum benefit date of November 2, 2007. Def.'s 56.1, ¶ 52.
On December 5, 2007, Gaud-Figueroa applied for Long-Term Disability (LTD) benefits for extreme lower back pain. Def.'s 56.1, ¶ 53. Gaud-Figueroa submitted attending physician statements from her neurologist, Dr. Patrick Mastroianni, and her podiatrist, Dr. David Sharnoff; her psychiatrist, Dr. Sudha Sreenivasan, faxed a letter to MetLife. Def.'s 56.1, ¶¶ 58-66. Gaud-Figueroa's psychiatrist advised MetLife that Gaud-Figueroa suffered from post-traumatic stress disorder ("PTSD") and a major depressive disorder, recurrent. Def.'s 56.1, ¶ 67. However, Dr. Sreenivasan did not submit any test results, clinical office notes, or other treatment notes to MetLife. Def.'s 56.1, ¶ 74.
On January 31, 2008, a nurse consultant for MetLife recommended that Gaud-Figueroa be approved for LTD benefits for her claims of PTSD and depression, but not for her claim of back pain, because there was insufficient medical information in the file to support a diagnosis of neuropathy or radiculopathy. Def.'s 56.1, ¶¶ 75-77, AR 0813-0817.
By letter dated February 12, 2008, MetLife approved Gaud-Figueroa for LTD benefits effective as of November 3, 2007. Def.'s 56.1, ¶ 78. At that time, MetLife requested that Gaud-Figueroa provide MetLife with office visit notes and treatment notes, with physical examination findings and recent attending physician statements. Def.'s 56.1, ¶ 80, AR 0613. When MetLife did not receive that information, it reiterated its request by letter on March 7, 2008; by phone on March 17, 2008; and again by letter on March 27, 2008, warning Gaud-Figueroa that a failure to submit the required information would result in the termination of her benefits. Def.'s 56.1, ¶¶ 81-85, AR 0599-0600; 0844; 0597. On April 8, 2008, MetLife discontinued Gaud-Figueroa's LTD benefits due to her ongoing failure to submit the requested medical information. Def.'s 56.1, ¶ 86.
After her benefits were terminated, Gaud-Figueroa submitted additional material from her treating physicians. On May 19, 2008, Gaud-Figueroa's neurologist opined that Gaud-Figueroa was capable of returning to sedentary work. Def.'s 56.1, ¶ 97, AR 0587. However, on June 6, 2008, Dr. Mastroianni informed MetLife that he believed that Gaud-Figueroa was not capable
On July 28, 2008, the store manager at Gaud-Figueroa's Home Depot branch agreed to offer accommodations to convert Gaud-Figueroa's "light" duty job into a parttime position. Def.'s 56.1, ¶ 111, AR 0871. On August 8, 2008, Dr. Mastroianni informed MetLife that he did not believe Gaud-Figueroa would be able to work any hours at Home Depot, even with the proposed accommodations. Def.'s 56.1, ¶¶ 115-116, AR 0562.
On August 26, 2008, MetLife assigned an independent physician to review Gaud-Figueroa's file and consult with Gaud-Figueroa's treating physicians. Def.'s 56.1, ¶¶ 117-18. Dr. Sergio Loaiza, M.D., board certified in neurology, concluded that "there is no objective documentation to support the claimant's inability to work." Def.'s 56.1, ¶ 126, AR 0535. On, October 24, 2008, MetLife advised Gaud-Figueroa that it had determined that she was able to perform sedentary to light level work and was thus not Disabled as required by the Plan. Def.'s 56.1, ¶ 144, AR 0527-0528. MetLife noted that Gaud-Figueroa had not submitted any "abnormal physical exam findings, abnormal neurological exam findings, abnormal diagnostics, abnormal labs, or restrictions and limitations. . . ." Def.'s 56.1, ¶ 146, AR 0527.
On September 29, 2008, Gaud-Figueroa was admitted to Griffin Hospital for psychiatric reasons. AR 0518. Gaud-Figueroa was subsequently released into an intensive outpatient program on October 6, 2008. Def.'s 56.1, ¶¶ 150-151, AR 0518; 0520. At Griffin Hospital, Gaud-Figueroa was diagnosed with major depression, severe recurrent, without psychosis. Def.'s 56.1, ¶ 155, AR 0520. On November 7, 2008, MetLife received medical records from Griffin Hospital regarding this episode. Def.'s 56.1, ¶ 149, AR 0517-0526.
On April 13, 2009, Gaud-Figueroa, through counsel, appealed MetLife's termination of her LTD benefits. Def.'s 56.1, ¶ 161, AR 0509-0510. At that time, Gaud-Figueroa submitted additional medical information from her podiatrist, her psychiatrist, and a doctor from the physical medicine department at Griffin Hospital. Def.'s 56.1, ¶¶ 164-165, AR 0509-0510. MetLife referred Gaud-Figueroa's case to two independent physicians: (1) Dr. Peter Sugerman, M.D., board certified in adult psychiatry, and (2) Dr. Kevin Smith, D.O., board certified in preventive medicine and occupational medicine. Def.'s 56.1, ¶¶ 182, 191, AR 0905-0906. Both independent physicians offered opinions in their areas of expertise and concluded that the records submitted did not support a finding of disability after April 8, 2008, the date MetLife first terminated Gaud-Figueroa's LTD benefits. Def.'s 56.1, ¶¶ 187, 197-198, 200; AR 0452; 0441-0442; 0448. However, Dr. Sugerman did opine that Gaud-Figueroa "suffered severe psychiatric impairments starting in September 2008 through October 2008." AR 0452.
MetLife also commissioned an "Employability Assessment" from the Corvel Corporation that concluded that Gaud-Figueroa was vocationally qualified to perform the duties of several sedentary occupations, including telephone solicitor, information
MetLife denied Gaud-Figueroa's administrative appeal on June 19, 2009, Def.'s 56.1, ¶ 214, AR 0431-0436, and Gaud-Figueroa filed this action on September 28, 2009 (Doc. No. 1).
A challenge to the denial of benefits under section 502(a)(1)(B) is reviewed under a de novo standard, unless the plan vests the administrator with "the discretionary authority to determine eligibility." Hobson v. Metropolitan Life Insurance Co., 574 F.3d 75, 82 (2d Cir.2009); Firestone Tire and Rubber Co. v. Bruch, 489 U.S. 101, 115, 109 S.Ct. 948, 103 L.Ed.2d 80 (1989). If an employee benefits plan confers the plan administrator with discretion to determine eligibility for benefits or to interpret the plan's terms, then the administrator's decision will not be disturbed unless it is "arbitrary and capricious." Hobson, 574 F.3d at 82. In this case, the Plan and the SPD both assign discretionary authority to MetLife to interpret and apply the Plan, AR 0045, 0407, so the court applies the arbitrary and capricious standard of review. Under the arbitrary and capricious standard of review, the court:
Hobson, 574 F.3d at 83-84 (quoting Pagan v. NYNEX Pension Plan, 52 F.3d 438, 442 (2d Cir.1995) (internal quotation marks and alterations omitted). Substantial evidence "is such evidence that a reasonable mind might accept as adequate to support the conclusion reached by the decisionmaker and requires more than a scintilla but less than a preponderance." Miller v. United Welfare Fund, 72 F.3d 1066, 1072 (2d Cir.1995) (internal quotation marks and alterations omitted).
Where, as here, the plan administrator both evaluates and pays benefits claims, a structural conflict of interest exists. See Metropolitan Life Insurance Co. v. Glenn, 554 U.S. 105, 111-12, 128 S.Ct. 2343, 171 L.Ed.2d 299 (2008). Courts must "take into account" and "weigh" this conflict of interest in determining whether the administrator has abused its discretion, but the administrator's decisions are still reviewed under the deferential arbitrary and capricious standard. See Hobson, 574 F.3d at 82-83 (citing McCauley v. First Unum Life Ins. Co., 551 F.3d 126, 133 (2d Cir.2008)). The court concludes that MetLife operated under a conflict of interest. Weighing this conflict as a factor, the court still concludes that MetLife's decisions were neither arbitrary nor capricious, with the exception of their decision for the September-October 2008 time frame.
In this case, Gaud-Figueroa agrees with MetLife that the Plan grants MetLife discretionary authority to interpret the terms of the Plan and that MetLife's decision to terminate Gaud-Figueroa's LTD benefits must be reviewed under the arbitrary and capricious standard. See Pl.'s Objection to Def.'s Mot. for Summ. J., at 1. Gaud-Figueroa argues that MetLife's termination of her benefits was nevertheless arbitrary and capricious because: (1) MetLife reached its decision by adding a requirement
Gaud-Figueroa contends that MetLife impermissibly "based its decision on terms that were not in the Home Depot U.S.A., Inc. plan." Pl.'s Mot. for J. on the Admin. Record, at 12. Specifically, Gaud-Figueroa argues that MetLife added a requirement of "objective proof" to the Plan by terminating Gaud-Figueroa's LTD benefits in an initial termination letter stating that "there are no abnormal physical exam findings, abnormal diagnostics, abnormal labs, or restrictions and limitations that are supported by exam findings." See Pl.'s Objection to Def.'s Mot. for Summ. J., at 1-2.
MetLife is entitled to require Plan participants to produce objective medical evidence of total disability. See Hobson, 574 F.3d at 88. "[I]t is not unreasonable for ERISA plan administrators to accord weight to objective evidence that a claimant's medical ailments are debilitating in order to guard against fraudulent or unsupported claims of disability." Id.; see also Tortora v. SBC Communications, Inc., 739 F.Supp.2d 427, 444 (S.D.N.Y. 2010) (following Hobson, administrator "not required to accept . . . subjective complaints in the absence of objective evidence supporting disability").
Gaud-Figueroa relies on the cases Durr v. Metropolitan Life Insurance Co., 15 F.Supp.2d 205 (D.Conn.1998), and Miles v. N.Y. State Teamsters Conference Pension and Retirement Fund Employee Pension Benefit Plan, 698 F.2d 593 (2d Cir. 1983), for the proposition that administrators may not unilaterally add requirements to an insurance plan, including a requirement of objective evidence. To be sure, an administrator cannot concoct new requirements after a claim has been filed. Nevertheless, Hobson makes clear that an administrator may require objective medical support even when the requirement "is not expressly set out in the plan." Hobson, 574 F.3d at 88.
Under the Plan, participants must submit written proof of their claims. AR 0034. "Proof" of a valid claim under the short- and long-term disability plans "must describe the event, the nature and the extent of the cause for which a claim is made; it must be satisfactory to [MetLife]." Id. Similarly, the SPD states that, "MetLife must receive certification with accompanying medical documentation of a disability from your attending doctor before benefits are considered for payment." Def.'s 56.1, ¶ 5; AR 0070. Given the language in the Plan and the SPD, it was not unreasonable for MetLife to interpret the insurance contract as requiring Plan participants to provide objective documentation of their disability. "Where both the plan administrator and a spurned claimant offer rational, though conflicting, interpretations of plan provisions, the administrator's interpretation must be allowed to control." McCauley v. First Unum Life Ins. Co., 551 F.3d 126, 132 (2d Cir.2008) (citation omitted). Here, MetLife interprets the Plan to require objective evidence of total disability. It cannot be said that this interpretation of the Plan is irrational, and therefore MetLife's interpretation controls.
However, even in a claim involving an illness characterized principally by subjective symptoms, such as fibromyalgia, the Second Circuit has stated that it is not unreasonable for a plan administrator to require objective evidence of disability as long as the claimant is notified. Hobson, 574 F.3d at 88 (citing Johnson v. Metro. Life Ins. Co., 437 F.3d 809, 813-14 (8th Cir.2006)). In this case, Gaud-Figueroa has not presented any evidence that the three ailments for which she has claimed disability—(1) pain in her back; (2) pain from plantar fasciitis and heel spurs in her feet; and (3) symptoms resulting from her depression or PTSD—cannot be documented through objective medical findings. Indeed, the administrative record actually includes objective evidence that Gaud-Figueroa's back and foot conditions, while painful, were not totally disabling.
With regard to Gaud-Figueroa's back pain, her own neurologist, Dr. Mastroianni, observed that the April 2007 MRI of her spine showed that "no nerve root [was] compromised" and only "[v]ery modest changes were observed at the L5-S1 level" of the spine. AR 0726-27. Dr. Mastroianni characterized the MRI results to be "very reassuring." AR 0727. Dr. Mastroianni also ordered and reviewed a May 7, 2007 X-ray of Gaud-Figueroa's spine, which X-ray revealed "degenerative changes of the lumbosacral spine," but "no evidence to suggest instability." AR 0725. On the basis of the MRI and his direct assessment of the patient, Dr. Mastroianni opined on May 22, 2008, that Gaud-Figueroa could perform sedentary work. AR 0587.
Although it is possible that Gaud-Figueroa's spine deteriorated in the twelve months between the April 2007 MRI and her benefit termination, Gaud-Figueroa never submitted additional testing to MetLife to substantiate that claim. Dr. Krystyna Piotrowska, M.D., of the Physical Medicine Department at Griffin Hospital examined Gaud-Figueroa on September 18, 2008, and recommended that "at some point MRI of lumbosacral spine should be done to compare it with a year ago findings." AR 0513. No such tests were ever completed.
Based on the foregoing, the court cannot conclude that MetLife's determinations with regard to Gaud-Figueroa's back claims were arbitrary and capricious. MetLife permissibly credited the substantial evidence provided by two independent physicians who had reviewed Gaud-Figueroa's submissions and had spoken with her treating physicians. Both independent consultants were board-certified in relevant specialties. Cf. Demirovic v. Building Service 32 B-J Pension Fund, 467 F.3d 208, 212 (2d Cir.2006) (finding that pension fund was entitled to credit opinions of two independent physicians, even where five treating physicians reached contrary conclusions, but still holding that pension fund's decision was arbitrary and capricious because claimant lacked education, experience, and language skills necessary to perform duties of a sedentary occupation).
With regard to Gaud-Figueroa's foot problems, the second independent consultant, Dr. Smith, spoke with Gaud-Figueroa's podiatrist, Dr. Sharnoff. In Dr. Sharnoff's Report dated August 28, 2008, Dr. Sharnoff had opined that Gaud-Figueroa was disabled and unable to work, although this conclusion was based in part on his understanding that Gaud-Figueroa was experiencing "significant low back issues." AR 0511-0512. When speaking with Dr. Smith in May 2009, Dr. Sharnoff advised that Gaud-Figueroa "was doing reasonably well from a podiatric perspective," and although she still had lower back problems, he believed she was capable of "sedentary desk work with minimal walking." AR 0449. Dr. Smith's Report was sent to each of Gaud-Figueroa's testing physicians for review and comment, none of whom responded to MetLife. In his consultant report, Dr. Smith observed that "[t]here are inconsistencies in the medical information provided. There are no podiatric office notes, surgical reports, and foot x-rays since November 2007." AR 0448. Gaud-Figueroa had left and right foot surgeries
MetLife's determinations for Gaud-Figueroa's claims of PTSD and major depressive disorder present a more complicated question. Gaud-Figueroa's psychiatrist, Dr. Sudha Sreenivasan, provided statements to MetLife on four occasions: (1) a faxed letter dated December 5, 2007; (2) a completed MetLife questionnaire dated January 18, 2008; (3) an updated Attending Physician Statement dated September 15, 2008; and (4) a telephone conference with an independent physician consultant hired by MetLife on May 5, 2009. AR 0451, 0543-0546, 0615-0616, 0618-0619. Dr. Sreenivasan diagnosed Gaud-Figueroa with PTSD and a recurring major depressive disorder, and Dr. Sreenivasan opined on several occasions that Gaud-Figueroa was unable to work. AR 0616; 0619; 0545. However, Dr. Sreenivasan never submitted office notes or treatment records despite repeated requests from MetLife. Def.'s 56.1, ¶ 74. Although Dr. Sreenivasan told MetLife's physician consultant that Gaud-Figueroa had trouble focusing and had memory problems, Dr. Sreenivasan did not provide any test results that would substantiate Gaud-Figueroa's subjective complaints of cognitive problems. Def.'s 56.1, ¶¶ 185-186.
As stated earlier, the Plan required Gaud-Figueroa to provide proof of a valid claim, "satisfactory to Metropolitan." Gaud-Figueroa was advised on at least four occasions that MetLife required office notes and treatment records to evaluate her claim. Def.'s 56.1, ¶¶ 80-85, AR 0597; 0599-0600; 0613; 0844. Gaud-Figueroa never produced the requested office notes from her treating psychiatrist. In a case involving a comparable Plan provision, the Second Circuit Court of Appeals determined that "it was appellant's burden under the Plan, not MetLife's, to submit, at his own expense, `proof of disability, satisfactory to Metropolitan.'" Wojciechowski v. Metropolitan Life Insurance Co., 1 Fed. Appx. 77, 81, 2001 WL 38264 (2d Cir.2001).
Two independent physician consultants hired by MetLife reviewed Gaud-Figueroa's medical records for evidence of disabling mental conditions. Dr. Sergio Loiaza, M.D., board certified in neurology, prepared his Report on September 5, 2008, and concluded that "[t]here is no clear documentation as to how the claimant's mood disorder affects her activities of daily living, treatment plan or goals" and therefore "there is no objective documentation to support the claimant's inability to work. . . ." AR 0535. During Gaud-Figueroa's administrative appeal, MetLife hired Dr. Peter Sugerman, board certified in adult psychiatry, to review Gaud-Figueroa's medical records and produce an independent physician report regarding her psychiatric condition. Def.'s 56.1 ¶ 182, AR 0905. Dr. Sugerman produced that report on May 5, 2009. Dr. Sugerman concluded that between April 9, 2008 (the day after Gaud-Figueroa's Long-Term Disability benefits were terminated) and September 2008 (the month Gaud-Figueroa was admitted to Griffin Hospital for psychiatric reasons), "there is no psychiatric information provided that would support limitations and restrictions due to a mental health impairment." AR 0452. Dr. Sugerman added, "Dr. Sreenivasan did not provide any written notes in the file
Based on the foregoing, the court cannot conclude that MetLife's determinations with regard to Gaud-Figueroa's PTSD and depression claims were arbitrary and capricious for the period of time from April 9, 2008 to September 2008.
The complicating factor is that the Administrative Record contains ample evidence that Gaud-Figueroa was Disabled in September and October 2008, four months after her Long-Term Disability benefits were terminated. On November 7, 2008, MetLife received psychiatric records from Griffin Hospital indicating that Gaud-Figueroa had been hospitalized in September 2008. In his Report, Dr. Sugerman observes that the "claimant had become severely depressed and suicidal in September 2008," that "[s]he ended up hospitalized," and that her treating psychiatrist reported that she suffers "symptoms of PTSD, such as nightmares." AR 0451. The notes from Griffin Hospital "indicate on 10/6/08 that there are deficits in attention and concentration and there are ongoing depressive symptoms. GAF [Global Assessment of Functioning] is 45. Although this is not clear-cut in supporting a severe psychiatric impairment, the proximity to the hospitalization would justify a belief in severe impairment at that time." AR 0452. The independent physician Report from Dr. Smith observes that October 2008 psychiatry notes in Gaud-Figueroa's file indicate that she was suffering "auditory hallucinations." AR 0447. Based on the psychiatric records from September and October 2008, Dr. Sugerman opined:
AR 0452. Thus, MetLife's own independent consultant and the documentary evidence in the Administrative Record both point to the conclusion that Gaud-Figueroa was Disabled in September and October 2008. At issue then is whether Gaud-Figueroa is entitled to the payment of Long-Term Disability benefits for September and October 2008, given that her benefits were properly terminated in April 2008 for lack of sufficient proof of Disability.
The Plan provides that "[t]he Monthly Benefit will be paid to you . . . provided you remain Disabled and proof of continued Disability is submitted, at your expense, to us upon request." AR 0029. The Plan also provides that "[t]he Monthly Benefit will stop on the earliest of: a. the date that you cease to be Disabled; b. the date of your death; c. completion of the Maximum Benefit Duration shown in the SCHEDULE OF BENEFITS." Id. Here, MetLife permissibly determined that Gaud-Figueroa ceased to be Disabled on April 8, 2008, and MetLife was entitled to
MetLife argues that Ms. Gaud-Figueroa was no longer covered by the LTD policy in September 2008, the month in which she was hospitalized for major depression and auditory hallucinations. AR 0447, 0451-52. MetLife contends that Gaud-Figueroa's eligibility for benefits terminated on April 8, 2008, when MetLife determined that Gaud-Figueroa had failed to provide adequate proof of continuing Disability. See Def.'s Letter to the Ct., Doc. No. 30. MetLife correctly observes that "once benefits are terminated, an employee must be deemed "Actively at Work" under the Plan for her Long Term Disability benefits to become effective again." Id. at 2 (citing AR 0022). MetLife then erroneously asserts that an employee can only be Actively at Work when she is "performing all the material duties of [her] job with the Employer where these duties are normally carried out." Id. (citing AR 0020). However, the Plan specifically provides that:
AR 0036. The "situation[s] set forth below" include "Your Sickness or Injury." Id. Under the Plan, a "Sickness" is an "illness, disease or pregnancy." AR 0024. The parties do not dispute that Gaud-Figueroa suffered from a Sickness during the relevant time period. The parties only dispute whether Gaud-Figueroa provided adequate proof to MetLife of a Sickness that rendered her completely Disabled.
The record reveals that both MetLife and Home Depot continued to treat Gaud-Figueroa as a covered employee after the termination of her LTD benefits on April 9, 2008. On July 28, 2008, a MetLife LTD Claim Specialist contacted the store manager at Home Depot, "where Gaud-Figueroa was employed," to discuss the possibility of accommodating Gaud-Figueroa's limiting conditions. Def.'s 56.1, ¶¶ 109-11, AR 0871-72. The store manager agreed to convert Gaud-Figueroa's "light" duty position into a part-time job, with appropriate restrictions on lifting. Id. at ¶ 111. Based on this record, the court infers that Home Depot and MetLife considered Gaud-Figueroa to be "Actively at Work" in July 2008.
As stated above, an Employer may only deem an Employee to be Actively at Work for certain time periods. AR 0036. The dates after which an employee may no longer be deemed Actively at Work are: "1. the date the Employer notifies us that your benefits are not to be continued; or 2. the end of the last period for which the Employer has paid premiums to us for your benefits." Id. The Administrative Record does not contain any evidence that Home Depot notified MetLife that Gaud-Figueroa's benefits were to be discontinued or that Home Depot ceased paying premiums for Gaud-Figueroa.
Given that Gaud-Figueroa suffered from a Sickness, that Home Depot continued to treat Gaud-Figueroa as an employee through at least July 2008, and that the Administrative Record contains no mention of Home Depot terminating Gaud-Figueroa's "Actively at Work" status, the court concludes that Gaud-Figueroa was still covered by the Plan when she became Disabled in September 2008.
The Plan provides that, if a participant returns to work, but does so for less than six consecutive months, the "Recurrent Disability will be a part of the same period of Disability," and the participant does not need to complete a new Elimination Period (i.e., the six-month waiting period) before benefits become payable. AR 0031. By contrast, if the participant returns to work for more than six consecutive months, then "any Recurrent Disability will be treated as a new period of Disability" and the participant "must complete a new Elimination Period before Monthly Benefits are payable." Id.
A contract provision is ambiguous if "it is capable of more than one meaning when viewed objectively by a reasonably intelligent person who has examined the context of the entire agreement." O'Neil v. Ret. Plan for Salaried Employees of RKO Gen., Inc., 37 F.3d 55, 59 (2d Cir. 1994). In the context of the entire agreement, the Plan's silence on this issue could be interpreted in two reasonable ways. On the one hand, a return to work could be viewed as an absolute predicate condition to receiving the waiver of the Elimination Period. On the other hand, MetLife could reasonably conclude that a participant who suffers a Disability which recurs within six months of a prior period of Disability should be treated as meeting the contractual provision that waives the Elimination Period for participants who suffer a Recurrent Disability after returning to work for less than six months.
The latter conclusion is particularly appropriate where a return to work would have been impossible or unduly prejudicial to the Plan participant. In this case, Gaud-Figueroa's benefits were initially terminated for a failure to provide adequate proof of her Disability, and in the months following termination Gaud-Figueroa submitted additional documentation with the hope of having her benefits restored. If Gaud-Figueroa was indeed Disabled, but failed to provide adequate proof, then she physically would have been unable to return to work in the months between April and September 2008. Although Gaud-Figueroa did not resume her duties at Home Depot, the time frame between the April 2008 termination and the September 2008 hospitalization was less than six months, and a reasonable interpretation of the Plan might permit the immediate reinstatement of benefits without a second Elimination Period.
Where an ERISA plan is reviewed de novo by the court, "ambiguities . . . are construed in favor of the plan beneficiary." Fay v. Oxford Health Plan, 287 F.3d 96, 104 (2d Cir.2002); see also Krauss v. Oxford Health Plans, Inc., 517 F.3d 614, 622 (2d Cir.2008). However, if an ERISA plan
While MetLife cannot ignore the opinions of Gaud-Figueroa's treating physicians, it is not required to accord any special weight to their conclusions, and it is permitted to credit other reliable evidence. As the Supreme Court articulated in Black & Decker Disability Plan v. Nord, 538 U.S. 822, 123 S.Ct. 1965, 155 L.Ed.2d 1034 (2003):
Id. at 834, 123 S.Ct. 1965.
Subjective complaints of pain reported to a treating physician must be weighed by the administrator in reaching its disability determination. The Second Circuit in Hobson reiterated the court's earlier admonition that "the subjective element of pain is an important factor to be considered in determining disability." Hobson, 574 F.3d at 88 (quoting Connors v. Conn. Gen. Life Ins. Co., 272 F.3d 127, 136 (2d Cir.2001)). Here MetLife acknowledged the reports from Gaud-Figueroa's treating physicians regarding her pain, but weighed this against the absence of objective medical findings that this pain rendered her totally disabled from all gainful employment as required by the Plan. See Tortora v. SBC Communications, Inc., 739 F.Supp.2d 427, 444 (S.D.N.Y.2010) ("While an administrator may not arbitrarily disregard evidence submitted by a claimant's physician, Sedgwick was not required to accept Tortora's subjective complaints in the absence of objective evidence supporting disability.")
In this case, MetLife had three independent physicians, none of whom was a MetLife employee and all of whom were Board-certified in one or more of the specialty areas relevant to Gaud-Figueroa's conditions, review Gaud-Figueroa's file. "MetLife did not abuse its discretion by considering these trained physicians' opinions solely because they were selected and presumably compensated by MetLife." Hobson, 574 F.3d at 90. Moreover, in this case, the physicians treating Gaud-Figueroa's back and foot conditions did not indicate that Gaud-Figueroa was Disabled as that term is defined in the Plan. Gaud-Figueroa's psychiatrist concluded that Gaud-Figueroa was completely disabled from any gainful occupation, including sedentary
For the reasons stated above, MetLife's termination of Gaud-Figueroa's Long-Term Disability benefits was within their discretion as Plan administrator. However, the court remands the benefit determination for September and October 2008 to MetLife for consideration of whether Gaud-Figueroa was required to complete a second Elimination Period for her Recurrent Disability. The Defendant's Motion for Summary Judgment
The Clerk is hereby directed to close the case.
Gaud-Figueroa has failed to file a Local Rule 56(a)(2) Statement in opposition to MetLife's Motion for Summary Judgment. Accordingly, MetLife's facts are deemed admitted, to the extent they are supported by the record. See D. Conn. L. Civ. R. 56(a)(1) ("All material facts set forth in said statement will be deemed admitted unless controverted by the statement required to be served by the opposing party in accordance with Rule 56(a)2.").
