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Wright v. Metropolitan Life Insurance Co.

May 26, 2009

PETER WRIGHT, PLAINTIFF,
v.
METROPOLITAN LIFE INSURANCE COMPANY, D/B/A METLIFE DISABILITY, AND BEARINGPOINT, INC. LONG TERM DISABILITY PLAN, DEFENDANTS.



MEMORANDUM OPINION

The plaintiff, Peter Wright, brings this action under the Employee Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. §§ 1132(a)(1)(B), (a)(3) (2006), against defendants Metropolitan Life Insurance Company, doing business as MetLife Disability ("MetLife"), and BearingPoint Inc. ("BearingPoint") Long Term Disability Plan ("Plan"),*fn1 alleging that the defendants violated the ERISA by breaching the fiduciary duty they owed him under § 1132(a)(3) and wrongfully denying him benefit coverage under § 1132(a)(1)(B) when they terminated his long-term disability benefits following his receipt of those benefits for approximately thirty months. See generally Complaint ("Compl."). The plaintiff also alleges that MetLife did not properly provide to him upon his request documents relevant to his ERISA claim, which he contends is a violation of 29 C.F.R. § 2560.502-1(g) (2008).*fn2 Compl. ¶ 24. In response, the defendants maintain that they acted in accordance with the express terms of the Plan when they made the decision to terminate the plaintiff's benefits after his receipt of over twenty-four months of benefits, and that defendant MetLife provided the plaintiff all documents he was entitled to receive under the ERISA. See Defendants' Joint Answer ("Answer") at 4-7. Currently before the Court are the parties' cross-motions for summary judgment. Defendants' Motion for Summary Judgment ("Defs.' Mot."); Plaintiff's Cross Motion for Summary Judgment ("Pl.'s Mot.").*fn3 Upon consideration of the parties' written submissions and the administrative record in this case, and for the reasons set forth below, the Court must grant summary judgment to the defendants.

I. BACKGROUND

A. The Terms of the Plan

At all times relevant to this litigation, BearingPoint sponsored an insurance package for its employees as a benefit of their employment*fn4 -- the defendant Plan -- the only component of the package pertinent to this action being the provision for long-term disability coverage. Compl. ¶ 7; Answer ¶ 7. See generally Defs.' Mem. at 17, Ex. A at ML00069 (Your [BearingPoint] Employee Benefit Plan . . . [,] Long Term Disability Benefits ("Long-Term Disability Benefits Plan")). The Plan provides that BearingPoint, as the employer, is the Plan administrator. Defs.' Mem. at 17, Ex. A at ML00099 (Long-Term Disability Benefits Plan). The Plan also provides that MetLife serves a dual role, both as the insurer of the policy and as the processor of claims for benefits under the policy. Id. at ML00099-100. Specifically, the Plan details a process by which a participant seeking long-term disability benefits must submit evidence of a qualified disability to MetLife in order to establish entitlement to monthly benefits. Id. at ML00079-80, ML00099-100.

Under the Plan, monthly long-term disability benefits were only awardable if a participant had a qualifying disability, which requires that the participant be

[1.] unable to perform the material and substantial duties of [a participant's] Own Occupation, [be] under the regular care of a Doctor and [be unable to] work[] at any job for wage or profit, unless in an approved Rehabilitation Program; [and]

2. after the first 36 month period, [the participant is] unable to perform any job for which [the participant is] qualified or for which [the participant] may become reasonably qualified taking into account [the participant's] training, education or experience[.]

Id. at ML00081. The Plan states that monthly benefits can be terminated for various reasons, including "the end of the period specified in the Limitation for Disabilities Due to Particular Conditions," id. at ML00080, and it expressly includes a twenty-four month limitation period for the receipt of benefits for certain disabilities, with exceptions. Regarding the plaintiff's challenge to the termination of his benefits, the only relevant provision of the Plan states that the receipt of benefits arising from a "[n]euromusculoskeletal and soft tissue disorder including, but not limited to, any disease or disorder of the spine or extremities and their surrounding soft tissue[,] including sprains and strains of joints and adjacent muscles, [are limited to twenty-four months] unless the Disability has objective evidence of . . . seropositive arthritis." Id. at ML00088. Rheumatoid arthritis is an example of a neuromusculoskeletal and soft tissue disorder, which can be classified as either seronegative or seropositive.*fn5 Defs.' Mem. at 6; Pl.'s Mem. at 12. Therefore, under the provisions of the Plan applicable to this case, a person with rheumatoid arthritis can receive coverage for only twenty-four months for claims arising from a neuromusculoskeletal and soft tissue disorder, unless the participant can prove that the condition is seropositive, which is an exception to the coverage limitation. Defs.' Mem., Ex. A at ML00087-88 (Long-Term Disability Benefits Plan). The Plan defines "Seropositive Arthritis" as "[a]n inflammatory disease of the joints supported by clinical findings of arthritis plus positive serological tests for connective tissue disease." Id. at ML00088.

With respect to MetLife's dual role under the Plan as both the insurer and claims processor processor, id. at ML00099-100, the Plan delegates this authority to MetLife in two separate provisions, id. at ML00071, ML00101. The first provision, titled "Certificate of Insurance," states: "MetLife in its discretion has authority to interpret the terms, conditions, and provisions of the entire contract. This includes the Group Policy, Certificate and any Amendments." Id. at ML00071. The second provision, contained within a subsection under the heading "Claims Information," states:

Discretionary Authority of Plan Administrator and Other Plan Fiduciaries

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 and capricious.

Id. at ML00100-01.

B. The Plaintiff's Disability

The plaintiff, an employee of BearingPoint, is a participant in the Plan. Compl. ¶ 6; Answer ¶ 6; Defs.' Mem. at 2. Early in 2002, he was diagnosed with rheumatoid arthritis and was approved for long-term disability benefits on or about August 23, 2002. Compl. ¶¶ 11, 13; Answer ¶¶ 11, 13; see also Defs.' Mem., Ex. A at ML02871-72 (June 24, 2002 Letter from Chris Drzata to Peter Wright). Due to the plaintiff's condition, he was (and is likely still) unable to maintain a work schedule equivalent to the schedule he maintained prior to his diagnosis. Pl.'s Mem. at 4. His physicians determined that sometimes the plaintiff could not operate a computer due to his inability to use his hands, id., needed arm guards, suffered from "stiffness of [his] hips and feet," had been prescribed multiple medications, and "ha[d] limitations with all functional upper extremity activities including perineal care, dressing, combing hair, washing axilla, working, eating with utensils, among others," id. at 5. However, during his treatment, the plaintiff's doctors confirmed that he had the seronegative form of rheumatoid arthritis, not the seropositive form of the disease. Defs.' Mem., Ex. A at ML00545 (Dec. 30, 2004 Letter from Claudia J. Svara, M.D., to Whom It May Concern); ML00546-47 (Dec. 20, 2004 Letter from Rex McCallum, M.D., to Sirs); ML00551 (Dec. 7, 2004 Letter from A. Silvia Ross, M.D., to Sirs).

Twenty-seven months after the plaintiff's receipt of long-term benefits, MetLife sent him a letter to the plaintiff requesting additional medical information demonstrating that he was entitled to continued long-term benefits; in other words, that his condition met one of the exceptions to the twenty-four month limitation coverage period. Defs.' Mem., Ex. A at ML00112-13 (Nov. 24, 2004 Letter from Jaci Mangene to Peter Wright). Specifically, MetLife sought "additional medical information . . . . in regard to [the plaintiff's] current rheumatoid factor" and indicated that because his condition fell within the "[n]euromusculoskeletal and soft tissue disorder" provision of the Plan, he would have to provide "objective evidence" that his condition met one of the exceptions to the coverage limitation -- in this case the only applicable exception being that his condition was diagnosed as "seropositive arthritis" -- or his benefits would be terminated. Id. at ML00012.

MetLife prematurely "denied" and "closed" the plaintiff's claim for continued long-term disability benefits based on its mistaken belief that the plaintiff had not submitted the additional medical documentation requested by MetLife's deadline of December 8, 2004. See id. at ML00110-11 (Dec. 8, 2004 Letter from Jaci L. Mangene to Peter Wright); ML02566-67 (Dec. 20, 2004 Letter from Jaci L. Mangene to Peter Wright). However, when MetLife discovered that the plaintiff had, in fact, submitted information about his medical condition by the designated deadline, see id. at ML02582-89 (Dec. 8, 2004 Memorandum from Peter Wright to MetLife Insurance); ML02610 (Dec. 8, 2004 Memorandum from Peter Wright to EJ); ML02619-26 (Dec. 8, 2004 Memorandum from Peter Wright to EJ (Team Lead)); ML02592-93 (Dec. 10, 2004 Memorandum from Peter Wright to Mary); ML02590-91 (Dec. 13, 2004 Memorandum from Peter Wright to Jaci Mangene); ML02540-50 (Dec. 30, 2004 Letter from Justin C. Frankel to Jaci L. Mangene), it reversed its decision closing the plaintiff's claim and proceeded to determine his eligibility, id. at ML02573 (Dec. 13, 2004 Letter from Jaci L. Mangene to Peter Wright) (informing the plaintiff that MetLife had received his medical information submissions and would review his claim); see also id. at ML00109 (Dec. 16, 2004 Letter from Jaci L. Mangene to Peter Wright) (informing the plaintiff that MetLife desired "[s]erological test results for connective tissue disease as of initial diagnosing of rheumatoid arthritis" for it to further consider his claim); ML02566-67 (Dec. 20, 2004 Letter from Jaci L. Mangene to Peter Wright) (informing the plaintiff that MetLife would be "continuing [the plaintiff's] monthly benefit until a determination is made" on his claim for long-term benefits). Ultimately, MetLife determined that the plaintiff was not entitled to receive further long-term benefits due to his condition not being classifiable under one of the exceptions to the coverage limitation, and terminated his benefits as of January 10, 2005. Id. at ML02498-500 (Jan. 19, 2005 Letter from Jaci L. Mangene to Peter Wright).

Prior to MetLife's denial of his claim, the plaintiff, who had in the interim acquired the services of an attorney, requested several documents from MetLife related to his claim. Id. at ML00568 (Dec. 21, 2004 Letter from Justin C. Frankel to Jaci L. Mangene). In response to the request, MetLife provided a copy of the Plan to the plaintiff.*fn6 Defs.' Mem., Ex. A at ML00556 (Dec. 28, 2004 Letter from Jaci L. Mangene to Justin C. Frankel). However, not satisfied with MetLife's document production, the plaintiff submitted subsequent document requests to MetLife, seeking, for example, its "claim handling practices, policies and procedures," its "agreements with third parties performing any outside reviews," any "service agreements" between BearingPoint and Metlife, all e-mails and related information in MetLife's computer system or in hard copy form pertaining to the plaintiff's claim, and all surveillance materials compiled by MetLife. Id. at ML00821-23 (Mar. 14, 2005 Letter from Justin C. Frankel to Jaci L. Mangene); ML00815-19 (Jan. 21, 2005 Letter from Justin C. Frankel to Jaci L. Mangene). MetLife responded with the production of additional documentation, including the plaintiff's updated claim file and "all medical documentation and correspondence on file" related to the plaintiff's claim, id. at ML02496 (Feb. 11, 2005 Letter from Jaci L. Mangene to Justin C. Frankel); ML02484 (Mar. 10, 2005 Letter from Jaci L. Mangene to Justin C. Frankel); ML00825 (Mar. 28, 2005 Letter from Jaci L. Mangene to Justin C. Frankel). Ultimately, however, MetLife told the plaintiff that it had provided all the information relevant to his claim under its ERISA-imposed obligations, id. at ML00860-61 (Sept. 12, 2005 Letter from Jaci L. Mangene to Justin C. Frankel).

On May 26, 2005, the plaintiff appealed MetLife's denial of his benefits to the company's Appeals Unit. Id. at ML02310-39 (May 26, 2005 Letter from Justin C. Frankel to Appeals Unit, MetLife Disability). After an independent claim review was conducted, MetLife affirmed its denial of the plaintiff's claim for the receipt of continued long-term benefits. Id. at ML00826 (June 2, 2005 Letter from Appeal Unit, ...


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