GREGORY M. SLEET, Chief District Judge.
On April 19, 2012, the plaintiff, Teresa A. Seeman ("Seeman"), brought this action against the defendant, Metropolitan Life Insurance Company ("MetLife"), the fiduciary and administrator of the Bank of America Long-Term Disability Plan (the "Plan"), seeking the payment of allegedly past-due benefits and a determination of her rights to ongoing benefits.
The Plan is an employee welfare benefit plan governed by ERISA that provides long-term disability benefits ("LTD benefits") to qualified participants. (D .I. 1; D .I. 17 at 3.) MetLife served as both the fiduciary and claim administrator of the Plan. (D.I. 17 at 3; D.I. 18 at 11.) The Plan defines "disability" as follows:
(D.I. 18 at 27.) The Plan, however, also imposes certain restrictions on eligibility for LTD benefits through the following "Limitation for Disability Due to Particular Conditions" provision:
(Id. at 34.) Finally, the Plan provides that benefit payments end on the earliest of (1) the end of the "Maximum Benefit Duration," (2) the end of the period set forth in the "Limitation for Disabilities Due to Particular Conditions" section or the "Limitation for Alcohol, Drug or Substance Abuse or Dependency" section, (3) the date on which the participant is no longer "disabled," as defined above, (4) the date on which the participant fails to provide information listed in the "Plan Highlights" section, (5) the date of the participant's death, or (6) the date on which the participant fails to attend a medical examination requested by MetLife. (Id. at 26.)
In 2007, Seeman was a First Vice President/Unit Manager II at Bank of America and a participant in the Plan. (Id. at 1; D.I. 21 at 3.) She was diagnosed with infectious mononucleosis in December 2007 with symptoms of fever, extreme fatigue, trouble breathing, flu-like symptoms, inability to concentrate, and inability to sleep. (D.I. 21 at 3.) Seeman submitted a claim for and received short-term disability benefits from December 5, 2007 until June 3, 2008. (Id.; D.I. 19 at 1671.) Seeman then applied for LTD benefits, and MetLife approved her application, making her eligible for LTD benefits effective June 4, 2008.
Seeman received LTD benefits from June 4, 2008 through July 16, 2010, when MetLife informed Seeman by letter that her benefits had been terminated. (D.I. 17 at 5; D.I. 19 at 998; D.I. 21 at 5.) MetLife's termination decision was based upon its review of Seeman's medical records and a Neuropsychological Testing Report prepared by Dr. Glen Greenberg (the "Greenberg report"), following a June 11, 2010 independent medical examination.
Additionally, MetLife noted that the Greenberg report diagnosed Seeman with "Undifferentiated Somatoform Disorder, Major Depressive Disorder, Single Episode, RIO Anxiety Disorder and Obsessive-Compulsive Personality traits." (Id. at 1000.) The termination letter proceeded to explain that "[s]omatoform disorders arise from psychological conflicts or issues that manifest and present with physical symptoms," and that "[t]hey can also arise with depression, which may be present, in [Seeman's] case." (Id. at 1001.) On this basis, the Greenberg report concluded that Seeman's "impairment exists due to psychiatric reasons and not neurological ones." (Id. at 1002.) MetLife's July 16, 2010 letter stated that the Greenberg report was "consistent" with the collective findings of Seeman's treating physicians, which revealed "an emphasis on psychological factors giving rise to or exacerbating the physical and cognitive complaints." (Id.)
Supposedly on the basis of the Greenberg report and the medical records, MetLife thus characterized Seeman's disability as resulting from a "Mental or Nervous Condition" under the "Limitation for Disability Due to Particular Conditions" provision rather than from any physical ailment.
Seeman then appealed MetLife's termination decision. (D.I. 19 at 946.) On appeal, MetLife reviewed her file and the decision from the Administrative Law Judge (the "ALJ") of the Social Security Administration (the "SSA"), in which the SSA rejected Seeman's claim for Social Security Disability Income ("SSDI") benefits.
(D.I. 18 at 303.)
Rule 56 provides that "[t]he court shall grant summary judgment ifthe movant shows that there is no genuine dispute as to any material fact and the movant is entitled to judgment as a matter of law." Fed. R. Civ. P. 56(a). "Facts that could alter the outcome are material, and disputes are genuine if evidence exists from which a rational person could conclude that the position of the person with the burden of proof on the disputed issue is correct." Horowitz v. Fed. Kemper Life Assurance Co., 57 F.3d 300, 302 n.1 (3d Cir. 1995) (internal citations omitted). In determining whether a genuine issue of material fact exists, the court views the evidence in the light most favorable to the nonmoving party and draws all reasonable inferences in that party's favor. See Scott v. Harris, 550 U.S. 372, 378 (2007); Conopco, Inc., 572 F.3d at 165; Wishkin v. Potter, 476 F.3d 180, 184 (3d Cir. 2007). This standard remains the same where there are cross motions for summary judgment. Lawrence v. City of Phila., 527 F.3d 299, 309 (3d Cir. 2008); see also Rains v. Cascade Indus., Inc., 402 F.2d 241, 245 (3d Cir. 1968) ("Cross-motions are no more than a claim by each side that it alone is entitled to summary judgment, and the making of such inherently contradictory claims does not constitute an agreement that if one is rejected the other is necessarily justified ....").
A plan participant or beneficiary is permitted by statute to bring a civil action "to recover benefits due to him under the terms of his plan, to enforce his rights under the terms of the plan, or to clarify his rights to future benefits under the terms of the plan." 29 U.S.C. § 1332(a)(1)(B). The Supreme Court has held that "a denial ofbenefits challenged under§ 1132(a)(l)(B) is to be reviewed under a de novo standard unless the benefit plan gives the administrator or fiduciary discretionary authority to determine eligibility for benefits or to construe the terms of the plan." Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989). Where such discretionary authority is provided, the court reviews a benefits determination under an arbitrary and capricious standard. See Doroshow v. Hartford Life & Accident Ins. Co., 574 F.3d 230, 233 (3d Cir. 2009); Post v. Hartford Ins. Co., 501 F.3d 154, 160-62 (3d Cir. 2007); Mitchell v. Eastman Kodak Co., 113 F.3d 433, 437 (3d Cir. 1997). The court asks whether there exists "sufficient evidence for a reasonable person to agree with the decision," Courson v. Bert Bell NFL Player Ret. Plan, 214 F.3d 136, 142 (3d Cir. 2000), seeking to determine if the plan administrator abused its discretion in reaching its conclusion, see Fisher v. Aetna Life Ins. Co., 890 F.Supp.2d 473, 480-81 (D. Del. 2012); Malin v. Metropolitan Life Ins. Co., 845 F.Supp.2d 606, 611-12 (D. Del. 2012).
When the plan administrator is burdened by a conflict of interest, the court will include that conflict as one of the many considerations informing its review. Metropolitan Life Ins. Co. v. Glenn, 554 U.S. 105, 116-117 (2008). The Supreme Court has made clear that such a conflict exists where "the entity that administers the plan, such as an employer or an insurance company, both determines whether an employee is eligible for benefits and pays benefits out of its own pocket." Id. at 108.
There appears to be no dispute that the Plan provided MetLife with discretionary authority to interpret the Plan's provisions and make eligibility determinations. (D.I. 17 at 3 n.1; D.I. 18 at 47; D.I. 21 at 9.) As such, the court will apply the "arbitrary and capricious" standard of review discussed above.
Seeman makes four primary arguments in support of her position that MetLife abused its discretion in terminating her LTD benefits: (1) MetLife reversed its own 2008 conclusion that Seeman suffered from physical disorders without sufficient basis; (2) MetLife's decision was compromised by its conflict of interest; (3) MetLife largely disregarded the medical evidence that Seeman suffered from physical disorders; and (4) MetLife failed to give Seeman advance notice of termination and thus deprived her of an opportunity to seek additional medical pinions or rebut MetLife's relied-upon diagnoses. (D.I. 21 at 1-3.) The court addresses each of these contentions below.
As noted above, a plain conflict of interest arises when an insurer such as MetLife assumes the dual role of reviewing and paying claims under a benefits plan. Such situations, however, are quite common, as "the `lion's share of ERISA plan claims denials are made by administrators that both evaluate and pay claims." Glenn, 554 U.S. 105, 120 (Roberts, C.J., concurring in the judgment) (internal quotation marks omitted). It is well settled that the court need not give such a conflict dispositive weight or even alter its standard of review. See Doroshow, 574 F.3d at 233-34. Rather, the conflict functions as merely one factor considered in the court's abuse of discretion analysis. Id. at 234. The Supreme Court has observed that:
Glenn, 554 U.S. at 117 (internal citations omitted).
Here, while both parties acknowledge the conflict, neither presents the court with particulaiized argument as to the weight it should accord this factor. (D.I. 17 at 14 n.9; D.I. 21 at 12.) As such, the court views the remaining considerations through the lens of this conflict, but does not grant it any special significance in the abuse of discretion analysis.
The Third Circuit has stated that "[a]n administrator's reversal of its decision to award a claimant benefits without receiving any new medical information to support this change in position is an irregularity that counsels towards finding an abuse of discretion." Miller v. Am. Airlines, Inc., 632 F.3d 837, 848 (3d Cir. 2011). Seeman argues that MetLife improperly terminated her LTD benefits despite the absence of any meaningful change in her medical condition. (D.I. 21 at 1-2.) MetLife responds simply that Seeman's assertions lack support in the administrative record and that her "medical records speak for themselves." (D.I. 25 at 2.)
The court cannot agree with Seeman on this point, as there was at least some new medical information before MetLife at the time of termination. Of course, the court also understands the root of Seeman's concern-the primary "new" information before MetLife when it issued its July 16, 2010 letter was the Greenberg report. Dr. Greenberg, however, is a psychologist, not a medical doctor. While his report may have suggested that Seeman suffered from certain mental disorders, it could not directly present new information regarding her physical conditions.
The court, however, does not believe its inquiry can end there. Dr. Greenberg's diagnosis of undifferentiated somatoform disorder provided an alternative explanation for Seeman's physical symptoms, since "[s]omatoform disorders arise from psychological conflicts or issues that manifest and present with physical symptoms." (D.I. 19 at 1001.) His report thus may have warranted a reassessment of the preexisting medical evidence. Viewing old records through this new somatoform disorder lens, MetLife, in a sense, was presented with new medical information. Additionally, the court recognizes that, in April 2010, Dr. Fred Reinhardt, Seeman's infectious disease physician, confirmed Seeman's diagnoses of fibromyalgia, chronic fatigue syndrome, and TMJ but expressed some doubt as to whether she was eligible for disability. (D.I. 19 at 1073) This additional piece of new medical evidence was also before MetLife at the time of its initial termination decision. (D.I. 19 at 1000.)
Accordingly, this particular consideration is inapplicable here and does not counsel an abuse of discretion finding. However, as discussed below, the mere presence of new medical information does not mean that MetLife weighed it properly alongside the existing physician opinions and other medical evidence.
At the heart of Seeman's challenge is a complaint that MetLife failed to properly consider her various physical diagnoses in determining her continued eligibility for LTD benefits. While the Plan's coverage for disabilities arising from "Mental or Nervous Disorders" is limited to twenty-four months, no such restriction applies to disabilities arising from physical conditions. For the reasons that follow, the court agrees with Seeman on this point and finds it controlling as to its abuse of discretion inquiry.
The court agrees with Seeman that the initial termination letter "was based almost entirely on Dr. Greenberg's opinion of a psychological disability while ignoring the numerous treating physicians that had indicated the presence of physical disabilities." (D.I. 21 at 16-17.) While MetLife referenced statements from the treating physicians concerning Seeman's mental health issues, it did not address the fact that each of these physicians-Dr. Berlin, Dr. Reinhardt, Dr. Epps, Dr. Snowden, Dr. Carunchio-reported that Seeman suffered from recognized physical conditions.
As an initial matter, the court notes that "[a]n administrator's failure to address all relevant diagnoses in terminating a claimant's benefits is ... a cause for concern that suggests the decision may have been arbitrary and capricious." Miller, 632 F.3d at 853; see also Kosiba v. Merck & Co., 384 F.3d 58, 68-69 (3d Cir. 2004). MetLife apparently takes the position that its termination letter, in fact, did address Seeman's physical diagnoses through its references to her various treating physicians and its concluding statement that "medical information in your file no longer substantiates an inability to perform the duties of your own or any occupation from a physical standpoint." (D.I. 25 at 8.) Such cursory treatment, however, does little to allay the court's concern regarding the reasonableness of MetLife's decision-paying lip service to a diagnosis is no less arbitrary than ignoring it entirely. See Miller, 632 F.3d at 854.
At best, the termination letter reflects an unfounded decision to discount the physical diagnoses of Seeman's doctors in contravention of the rule that "[p]lan administrators ... may not arbitrarily refuse to credit a claimant's reliable evidence, including the opinions of a treating physician." Black & Decker Disability Plan v. Nord, 538 U.S. 822, 834 (2003). Here, the medical evidence drawn from the reports of the treating physicians suggested that Seeman was disabled as a result of certain physical conditions, including fibromyalgia and chronic fatigue syndrome, and it was MetLife's burden to demonstrate a factual basis for any conclusion to the contrary.
For example, while MetLife justified discounting Dr. Berlin's reports by citing a lack of clinical evidence to support his assessments, it based its conclusions as to the absence of clinical evidence on the "test results" previously discussed in its termination letter. (D.I. 19 at 1000.) Those relied-upon test results were: (1) an MRI of the brain from which Dr. Carunchio was unable to determine whether Seeman suffered from a disturbance affecting the central nervous system and (2) an ENMG study of Seeman's right arm and leg, which found no evidence of an underlying polyneuropathy, entrapment neuropathy, radiculopathy, myopathy, or neuromuscular junction disorder. (Id. at 998-1000.) Yet, as Seeman notes, chronic fatigue syndrome and fibromyalgia cannot be established via objective tests. (D.I. 21 at 17.) It thus appears that MetLife's decision to dismiss Dr. Berlin's diagnoses and disability findings lacked a proper foundation.
The court recognizes that it is not an abuse of discretion for an insurer to weigh certain medical evidence more heavily than conflicting evidence. See Nord, 538 U.S. at 834; Fisher, 890 F. Supp. 2d at 484. Likewise, there is no requirement that an administrator grant special deference to the opinions of a claimant's treating physicians. See Nord, 538 at U.S. 834. MetLife's July 16, 2010 termination decision, however, failed to accord any meaningful weight to the physical diagnoses and disability determinations offered by Seeman's doctors.
As noted above, MetLife's decision on appeal rested upon its conclusion that Seeman's "diagnoses of [mental conditions] fell under the ... limited disability benefits plan limitations" and that her "diagnoses of [physical conditions] . . . did not support functional limitations beyond July 16, 2010." (D.I. 18 at 303.) In addition to Seeman's preexisting file, MetLife reviewed various medical records submitted by Seeman, including the December 2010 forensic psychiatric report prepared by Dr. Kaye. (Id. at 296-97.) MetLife also hired three IPCs to review Seeman's records, meet with her physicians, and prepare written reports, which were then incorporated into its broader review.
Neither the reports submitted by the occupational medicine IPC, Dr. Green, nor MetLife's summary of its findings in the June 17, 2011 decision letter adequately address the potential disability resulting from Seeman's physical conditions. Both the reports and the letter contain conclusory statements suggesting that her physical ailments were insufficient to support a disability finding. They fail, however, to explain the basis for these determinations or the reasons for seemingly discounting the opinions of Dr. Berlin, Dr. Carunchio, Dr. Reinhardt, Dr. Kaye, and Dr. Diaz-Stanchi, each of whom opined as to the physical nature of Seeman's disorders.
The initial Green report provided the following answer in response to the question of whether the medical information supported physical functional limitations:
(D.I. 18 at 495.) The court notes at least two problems with this assessment. First, as discussed above, "[t]he Third Circuit has explicitly concluded that requiring objective medical evidence is arbitrary and capricious when a claim for long-term disability benefits is a result of chronic fatigue syndrome or fibromyalgia diagnoses." Fisher, 890 F. Supp. 2d at 483 (citing Steele, 225 F. App'x at 74-75). Dr. Green apparently would require such objective indicia to find Ms. Seeman disabled.
Additionally, while the Green report includes at least a brief discussion of its reasons for disregarding Dr. Berlin's opinions and diagnoses, (D.I. 18 at 490), it provides no meaningful explanation for discounting the physical diagnoses offered by several of Seeman's other treating physicians.
Seeman also complains that she was prejudiced by MetLife's failure to warn that it was considering termination of her benefits in advance of its July 16, 2010 decision letter. (D.I. 21 at 19.) She suggests that prior notice would have allowed her the opportunity to gather additional medical opinions and evidence, review the Greenberg report relied upon by MetLife, and generally attempt to refute MetLife's eligibility conclusions. (Id. at 19-20.)
The court, however, does not view the absence of advance warning as evidence that the benefits decision itself was arbitrary and capricious. Even if one assumes that constructive notice was not already provided by the Plan's 24-month limitation provision, Seeman cites no authority for the proposition that the failure to provide notice indicates an abuse of discretion. Additionally, Seeman's specific contention that the lack of warning preyented her from adequately refuting MetLife's eligibility determination is belied by the fact that she presented additional evidence and arguments on appeal.
Viewing the facts in the light most favorable to MetLife, the court finds that, while MetLife did not abuse its discretion in determining that Seeman had significant mental health issues or even that her mental disorders were her most severe medical problems, it was arbitrary and capricious in deciding that her remaining physical diagnoses did not independently render her disabled. On a broad level, the court simply cannot locate "sufficient evidence for a reasonable person to agree with [MetLife's] decision," in either the Greenberg report (which focused on Seeman's mental condition), the three IPC reports (two of which focused on Seeman's mental condition), or MetLife's cherry-picked fragments of Seeman's medical records. Bert Bell NFL Player Ret. Plan, 214 F.3d at 142. More specific problems include: (1) Dr. Green's demand for objective evidence of physical impairments and MetLife's discounting of Dr. Berlin's opinion due to his failure to perform-objective tests; (2) the failure to consider all Seeman's relevant physical diagnoses; and (3) to the extent physical diagnoses were considered, MetLife's failure to offer an adequate basis for discounting certain physician opinions.
Upon finding that a plan administrator's benefits decision was arbitrary and capricious, the court has discretion to fashion an appropriate remedy. See Carney v. Int'l Bhd. of Elec. Workers Local Union 98 Pension Fund, 66 F. App'x 381, 386 (3d Cir. 2003); Fisher, 890 F. Supp. 2d at 485-86. In Miller v. Am. Airlines, Inc., 632 F.3d 837 (3d Cir. 2011), the Third Circuit noted that:
Id. at 856-57 (internal citation omitted).
While the court recognizes that Miller ordinarily would counsel reinstatement of benefits in a case such as this, where the plan administrator abused its discretion to terminate ongoing payments, it notes that MetLife's July 16, 2010 termination decision occurred at the end of the initial 24-month LTD coverage period under the Plan. As discussed above, the Plan sets forth one disability standard applicable to the first 24-month claim period and another more stringent standard that attaches thereafter.
Indeed, even absent this shift in the Plan's disability standard, the court has some doubt that it could simply reinstate Seeman's LTD benefits. For the reasons provided in detail above, the court recognizes that MetLife's termination decision was arbitrary and capricious, and this conclusion entitles Seeman to summary judgment in light of MetLife's responsibility to render benefit decisions with reasonable discretion. It does not necessarily follow, however, that Seeman's physical diagnoses, taken alone, resulted in a "disability," even under the pre-June 4, 2010 standard.
In sum, though MetLife's termination decision was improper, it was not necessarily incorrect-to determine its accuracy, more information is required about how Seeman's physical diagnoses affected her earning capacity. The court thus will remand for MetLife to evaluate whether Seeman remained disabled under the post-June 3, 2010 disability standard consistent with the guidance provided throughout this Memorandum and its duty to exercise reasonable discretion in reviewing benefit claims.
For the foregoing reasons, the court will deny MetLife's Motion for Summary Judgment (D.I. 16), grant Seeman's Motion for Summary Judgment (D.I. 20), and order that this case be remanded to MetLife for further proceedings consistent with this Memorandum.
At Wilmington this
(D.I. 19 at 1002.)
(Id. at 593.)
MetLife might point out that it does not contest the scientific basis for the physical diagnoses but simply believes those diagnoses are not so severe as to be disabling. The court does not believe this distinction changes its analysis-the Lasser court stated that it is the insurer's burden to support its challenge to the basis of the physicians' reports (not just their medical diagnoses), and, where such reports indicate a claimant is disabled, the insurer must provide some evidence for its contrary conclusion. See Lasser, 344 F.3d at 391. Here, the Plan defmes "disability" by reference to a claimant's ability to work and earn in occupations for which she is reasonably qualified, and Seeman's doctors have opined that her physical ailments prevent her from working. (D.I. 19 at 1200.) Dr. Diaz-Stanchi, for example, observed that Seeman had "debilitating fatigue of multifactorial etiology" and was "incapacitated such that disability and functional evaluation [could not] be performed." (D.I. 18 at 362.)
The court recognizes that MetLife's appeal decision may also have drawn some support from the ALI's opinion rejecting Seeman's claim for SSDI benefits. MetLife received the ALI's decision on June 27, 2010, (D.I. 19 at 2072), and, while the appeal denial letter did not actually mention the SSA opinion, (D.I. 18 at 295-304), both parties seemingly acknowledge that the administrative ruling was considered by MetLife, (D.I. 24 at 15-19; D.I. 29 at 8-10). The court, however, does not believe the ALI's opinion is sufficient to rescue MetLife's appeal determination. As an initial matter, while the consistency of a plan administrator's decision with an SSDI finding can function as one factor in the abuse of discretion analysis, it certainly is not dispositive. See Russell v. Paul Revere Life Ins. Co., 148 F.Supp.2d 392, 409 (D. Del. 2001); see also Edgerton v. CNA Ins. Co., 215 F.Supp.2d 541, 549 (E.D. Pa. 2002). Not only are different standards applicable in each context, see Nord, 538 U.S. at 832-33, but the plan administrator may be aware of facts unavailable to the ALJ, see Goletz v. Prudential Ins. Co. of Am., 383 F. App'x 193, 198 (3d Cir. 2010). Here, for example, Dr. Kaye's report was prepared several months after the ALJ issued his opinion. (D.I. 18 at 586; D.I. 19 at 2072.) For these reasons, even assuming for the purposes of this summary judgment motion that MetLife did rely, in part, on the ALJ determination, the court cannot conclude that this lone administrative ruling outweighs the numerous indications of MetLife's arbitrary and capricious decision making.
(D.I. 18 at 27.)
