BLAND v. Metropolitan Life Insurance Company

Filing 31

ORDER GRANTING 16 Defendant's Motion for Judgment as a Matter of Law; DENYING 17 Plaintiff's Motion for Judgment as a Matter of Law. Ordered by Judge Marc Thomas Treadwell on 1/3/2013. (tlh)

IN THE UNITED STATES DISTRICT COURT
FOR THE MIDDLE DISTRICT OF GEORGIA
MACON DIVISION
LYNN B. BLAND,
Plaintiff,
v.

METROPOLITAN LIFE INSURANCE
COMPANY,
Defendant.

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CIVIL ACTION NO. 5:11-CV-277(MTT)

ORDER
Before the Court are the Parties’ Cross Motions for Judgment as a Matter of Law.
(Docs. 16 and 17). For the following reasons, the Defendant’s Motion is GRANTED,
and the Plaintiff’s Motion is DENIED. The Court makes the following Findings of Facts
and Conclusions of Law.
I.

FINDINGS OF FACT

Plaintiff Lynn Bland is a fifty-eight year old female who was employed by Novartis
Pharmaceuticals Corporation until she became disabled. (Doc. 17-2 at 1). While
employed by Novartis, the Plaintiff was a participant in Novartis’ Welfare Benefits Plan
(the “Plan”). (Doc. 17-2 at 2; Doc. 16-1 at 1). The Plan is a self-funded employee
welfare benefit plan and is governed by the Employer Retirement Income Security Act
of 1974, 29 U.S.C. § 1001 et seq. (ERISA). The Plan is administered by Defendant

Metropolitan Life Insurance Company. (Doc. 17-2 at 2; Doc. 16-1 at 1-2).1
In 2004, the Plaintiff injured her back in an automobile accident. (Doc. 16-8 at
85).2 She had back surgery because of this injury in 2005. Specifically, she underwent
an L5 laminectomy with discectomy and fusion at L5-S1. (Doc. 16-8 at 50). The
procedure required the permanent placement of connecting rods. (Doc. 16-8 at 50).
The Plaintiff returned to work following the surgery. (Doc. 16-8 at 85). However, on
July 21, 2007, the Plaintiff fell while climbing stairs and reinjured her back. She filed a
timely claim for short-term disability (STD) benefits under the Plan. (Doc. 17-2 at 3-4;
Doc. 16-1 at 5; Doc. 16-14 at 20-23). The Defendant agreed the Plaintiff was disabled,
and she received STD benefits from July 23, 2007, through January 20, 2008. During
this time period, the Plaintiff was examined by several doctors. The Plaintiff was
diagnosed with severe back pain and radiculopathy by Dr. Marcus Simmons. (Doc. 1614 at 18-19). Dr. Charles H. Richardson also documented the Plaintiff suffered from
“post lumbar discectomy and fusions with rods L5-S1.” (Doc. 16-13 at 93). Dr. Harvey
Jones diagnosed the Plaintiff with acute anxiety depression, herniated disc at L4-5,
status post lumbar laminectomy syndrome and status post cervical discectomy and
fusion. (Doc. 16-13 at 73-75, 78-79).
The Plaintiff began receiving long-term disability (LTD) benefits on January 21,
2008, when the STD maximum benefit period of 26 weeks expired. (Doc. 16-5 at 4).
The Defendant continued to agree that the Plaintiff was disabled, primarily because of
1

For reasons that will become apparent, the Defendant stresses that Novartis, not Metropolitan Life
Insurance Company, drafted the Plan. The Defendant only administers the Plan.

2

Because the relevant Plan documents and administrative record have been electronically filed at
Documents 16-2 through 16-14, this Order cites to the record by using the document number and
electronic screen page shown at the top of each page by the Court's CM/ECF software rather than the
administrative record cites.
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her diagnosis of post laminectomy syndrome with lumbar radiculopathy. (Doc. 16-7 at
11). In December 2009, the Defendant notified the Plaintiff that her LTD benefits would
terminate on January 20, 2010. The Defendant had determined that based on her
medical records the Plaintiff was disabled because of a “neuro-musculoskeletal or soft
tissue disorder,”3 and thus her LTD benefits were limited to 24 months. The applicable
Plan language is:
Benefit Payment Limit for Certain Conditions: Monthly LTD benefits
under this plan are payable for up to a maximum of 24 months during
your lifetime if you are disabled because of mental nervous disorder
or disease or neuro-musculoskeletal or soft tissue disorder, unless
the disability results from: schizophrenia, bipolar disorder, dementia,
organic brain disease.
(Doc. 16-4 at 7) (emphasis in original). Notably, the Plan does not contain any
exceptions to this limitation—coverage for any neuro-musculoskeletal disorder is limited
to 24 months. (Doc. 16-4 at 7). Nor does the Plan define the term neuromusculoskeletal.
The Plaintiff appealed the Defendant’s decision to terminate her benefits.4 The
Defendant then requested a review of the Plaintiff’s claim by an “Independent Physician
Consultant” or IPC. (Doc. 16-8 at 75-78). The IPC physician, Heidi Klingbeil, agreed
that the Plaintiff’s medical records supported her doctors’ conclusions regarding her
back problems. (Doc. 16-8 at 79-83). Dr. Klingbeil’s final assessment was:

3

Though both Parties and various claims documents occasionally refer to the Plan’s phrase “neuromusculoskeletal or soft tissue disorder” it is clear that the Plaintiff’s LTD benefits were limited because the
Defendant contends she was disabled due to a neuro-musculoskeletal disorder, not a soft tissue disorder.

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In the appeal the Plaintiff alleged that her disability was caused by a mental and nervous disorder.
(Doc. 16-1 at 13-14). This argument on appeal was apparently an attempt to bring her claim within one of
the Plan’s exceptions to a LTD benefits limitation on mental and nervous disorders. The Plaintiff has not
raised this argument before the Court. Instead, she argues that her physical conditions are not neuromusculoskeletal disorders. See infra II.E.
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Given [the] totality of clinical information, the claimant would be
considered functionally impaired and unable to safely perform any
occupations secondary to continued use of high dose oral
medications secondary to intractable pain.
(Doc. 16-8 at 51). Thus, Dr. Klingbeil agreed that, from a medical standpoint, the
Plaintiff was totally disabled.
The Defendant nevertheless denied the appeal. In its denial letter, the
Defendant acknowledged that the Plaintiff “has a failed back syndrome secondary to
previous fusion performed at L5-S1,” that the Plaintiff had not responded to medication,
physical therapy, and the implantation of a spinal cord stimulator to control pain, and
that because of these and other related conditions, the Plaintiff was “unable to safely
perform any occupations.” (Doc. 16-8 at 49-52). However, these conditions, the
Defendant concluded, were “neuromusculoskeletal in nature” and thus the Plaintiff was
not entitled to continued benefits. (Doc. 16-8 at 49-52). This action followed.
Both Parties have moved for judgment as a matter of law pursuant to Federal
Rule of Civil Procedure 52. (Docs. 16 and 17). Following a hearing, the Court ordered
the Defendant to submit portions of its claim manual and guidelines addressing the term
neuro-musculoskeletal disorder. The Court further requested the Parties submit
supplemental briefs on the potential applicability of New Jersey state law, because the
Plan eventually produced by the Defendant provides that the Plan “shall be interpreted,
construed, and administered in accordance with the laws of the State of New Jersey to
the extent such laws are not preempted by the law of the United States.” (Doc. 25-1 at
40).

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II.

DISCUSSION AND CONCLUSIONS OF LAW

A. Motion for Judgment as a Matter of Law Standard
Both Parties move, pursuant to Federal Rule of Civil Procedure 52, for judgment
as a matter of law. Here, the Parties agree that the Court’s review of this case is limited
to the administrative record, and when a decision is based on an agreed-upon
administrative record, findings of fact and conclusions of law pursuant to Rule 52 are
preferred. Adams v. Hartford Life & Accident Ins., Co., 694 F. Supp. 2d 1342, 1345 n. 1
(M.D. Ga. 2010). “In an action tried on the facts without a jury … the court must find the
facts specially and state its conclusions of law separately. The findings and conclusions
… may appear in an opinion or memorandum of decision filed by the court.” Fed. R.
Civ. Pro. 52(a)(1).
Accordingly, the Court bases its Findings of Fact and Conclusions of Law on the
administrative record available to the Defendant when it made its decision to deny
benefits. See Glazer v. Reliance Standard Life Ins. Co., 524 F.3d 1241, 1246 (11th
Cir.2008) (“When conducting a review of an ERISA benefits denial under an arbitrary
and capricious standard ..., the function of the court is to determine whether there was a
reasonable basis for the decision, based upon the facts as known to the administrator at
the time the decision was made.”) (internal quotations omitted)); Jett v. Blue Cross &
Blue Shield of Ala., Inc., 890 F.2d 1137, 1139 (11th Cir.1989) (same).
B. ERISA Analytical Framework
ERISA “permits a person denied benefits under an employee benefit plan to
challenge that denial in federal court.” Metro. Life Ins. Co. v. Glenn, 554 U.S. 105, 108
(2008) (citing 29 U.S.C. § 1132(a)(1)(B)). ERISA itself does not provide a standard for

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courts reviewing benefits decisions made by plan administrators or fiduciaries.
Blankenship v. Metro. Life Ins. Co., 644 F.3d 1350, 1354 (11th Cir. 2011) (citing
Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 109 (1989)). Based on guidance
from the Supreme Court in Glenn and Firestone, the Eleventh Circuit “established a
multi-step framework to guide courts in reviewing an ERISA plan administrator’s
benefits decisions.” Id. The steps are:
(1) Apply the de novo standard to determine whether the claim
administrator's benefits-denial decision is “wrong” (i.e., the court disagrees
with the administrator's decision); if it is not, then end the inquiry and
affirm the decision.
(2) If the administrator's decision in fact is “de novo wrong,” then
determine whether he was vested with discretion in reviewing claims; if
not, end judicial inquiry and reverse the decision.
(3) If the administrator's decision is “de novo wrong” and he was vested
with discretion in reviewing claims, then determine whether “reasonable”
grounds supported it (hence, review his decision under the more
deferential arbitrary and capricious standard).
(4) If no reasonable grounds exist, then end the inquiry and reverse the
administrator's decision; if reasonable grounds do exist, then determine if
he operated under a conflict of interest.
(5) If there is no conflict, then end the inquiry and affirm the decision.
(6) If there is a conflict, the conflict should merely be a factor for the court
to take into account when determining whether an administrator's decision
was arbitrary and capricious.
Id. at 1355 (internal citation omitted).
C. Burden of Proof
A claimant suing under ERISA has the burden of proving entitlement to plan
benefits. Horton v. Reliance Std. Life Ins. Co., 141 F.3d 1038, 1040 (11th Cir. 1998)
(internal citation omitted). However, “if the insurer claims that a specific policy exclusion

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applies to deny the insured benefits, the insurer generally must prove the exclusion
prevents coverage.” Id. (internal citation omitted). The Plaintiff argues that the Plan’s
LTD limitation is akin to a policy exclusion, and thus the Defendant carries the burden of
proving the applicability of the LTD benefit limitation it relied on when terminating the
Plaintiff’s benefits. The Defendant argues that “‘the limitation provision at issue is not
an exclusion from benefits, rather it merely limits the amount of benefits that may be
received once a claim has been granted.’” (Doc. 21 at 3) (quoting Doe v. Hartford Life &
Accident General Am. Life. Ins. Co., 2008 WL 5400984, *4 n.1 (D.N.J.)).
The Defendant further cites two Northern District of Georgia cases, Aleksiev v.
Metropolitan Life Insurance Co., No. 1:10-cv-3322-SCJ, (N.D. Ga. 2012) and Craig v.
Metropolitan Life Insurance Co., No. 1:10-cv-3231-CAP, (N.D. Ga. 2012), to support its
argument the burden of proof with regard to the 24-month limitation on LTD benefits for
neuro-musculoskeletal disorder rests with the Plaintiff. But, as the Defendant
acknowledges, Craig is currently pending before the Eleventh Circuit and the plaintiffappellant has raised this exact burden of proof issue. (Doc. 21 at 5 n. 2). The Eleventh
Circuit has scheduled oral argument in Craig for January 2013.
The Court declines to determine whether the Plaintiff or the Defendant has the
burden of proving that the Plaintiff is or is not disabled because of a limiting condition
because, regardless of who has this burden, the Defendant’s decision to deny the
Plaintiff coverage because she was disabled from a neuro-musculoskeletal disorder is
not de novo wrong.

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D. Potential Applicability of New Jersey Law
A supplement to the Plan submitted by the Defendant at the hearing states that
the Plan “shall be interpreted, construed, and administered in accordance with the laws
of the State of New Jersey to the extent such laws are not preempted by the law of the
United States.” (Doc. 25-1). The Defendant argues that New Jersey law does not
apply because “(1) ERISA is a law of the United States; and (2) ERISA preempts New
Jersey law.” (Defendant’s Supplemental Brief at 7). The Plaintiff, citing Buce v. Allianz
Life Insurance Co., 247 F.3d 1133 (11th Cir. 2001) and Capone v. Aetna Life Insurance
Co., 592 F.3d 1189 (11th Cir. 2010), argues that, because of the Plan’s choice of law
provision, New Jersey state law should be used to define the term neuromusculoskeletal.
First, the Court agrees with the Plaintiff’s contention that, because the Plan has a
choice of law provision, if there were applicable New Jersey law that did not conflict with
ERISA, then the application of the law to this case could be appropriate. However, New
Jersey law does not address the issue here: Whether Novartis can write a Plan
effectively limiting disability coverage for any type of neck, back and spinal condition to
24 months of LTD benefits.
The Plaintiff cites New Jersey cases supporting her primary argument—that
neuro-musculoskeletal disorders are related to chiropractic and osteopathic treatment.
The validity of this argument is addressed more specifically below.5 But, briefly, the fact
that New Jersey cases generally have referred to neuro-musculoskeletal disorders in
this context sheds no light on the issue before this Court. Therefore, although the Plan
contains a choice of law provision, because New Jersey law does not address the issue
5

See infra II.E.
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the Court faces, no New Jersey state law is applicable.
E. The Defendant’s Decision to Terminate the Plaintiff’s LTD Benefits Was Not
De Novo Wrong
“A decision is wrong if, after a review of the decision of the administrator from a
de novo perspective, the court disagrees with the administrator’s decision.” Glazer v.
Reliance Standard Life Ins. Co., 524 F.3d 1241, 1246 (11th Cir. 2008) (internal
quotations and citation omitted). The Court “must consider, based on the record before
the administrator at the time its decision was made, whether the court would reach the
same decision as the administrator,” and “[i]f the [C]ourt determines that the plan
administrator was right, the analysis ends and the decision is affirmed.” Id. at 1246-47
(internal citation omitted).
As discussed above, the Plaintiff’s physicians and the Defendant’s IPC agree
that the Plaintiff is unable to work, primarily because of post laminectomy syndrome or
failed back syndrome as the Defendant called it. Nevertheless, the Defendant
determined that the Plaintiff’s disabling conditions were neuro-musculoskeletal
disorders. The Plan specifically limits LTD benefits if a plan participant is disabled
because of a neuro-musculoskeletal disorder, and the Plan provides no exceptions to
this broad limitation. (Doc. 16-4 at 7).
The Plaintiff argues that her disabling conditions should not be classified as
neuro-musculoskeletal disorders. First, the Plaintiff contends no medical provider
specifically diagnosed her with a neuro-musculoskeletal disorder. The Plaintiff argues
“[t]he term neuro-musculoskeletal is rarely used in mainstream medicine,” and that the
term is used “in the context of osteopathy.” (Doc. 20 at 5). According to the Plaintiff,
neuro-musculoskeletal disorders are premised on dysfunctions of the “body as a whole”
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or an “imbalance between the nervous system, blood vessels, musculature and skeletal
framework of the body.” (Doc. 20 at 8).
The real problem with Novartis’ neuro-musculoskeletal disorder limitation is not
that it is difficult to figure out what it means. It is neither vague nor ambiguous. Courts
have had little difficulty in deciphering its meaning.6 The problem is its breadth. It
includes within its reach any neck or back injury no matter how certain it is that a
Novartis employee is truly disabled. Even an employee who is a paraplegic because of
spinal cord compression suffers from a neuro-musculoskeletal disorder and therefore
would not be entitled to continued benefits under Novartis’ Plan.
Examination of other plans containing similar limitations reveals that their
legitimate purpose is to limit coverage for neuro-musculoskeletal conditions that cannot
be confirmed by “objective evidence.” See e.g. Iley v. Metro. Life Ins. Co., 261 Fed.
App’x 860, 862 (6th Cir. 2008) (“The relevant limitation here limits benefits to twentyfour months if the beneficiary suffers from a neuromusculoskeletal or soft tissue
disorder, unless the beneficiary has “objective evidence” of radiculopathy.” (emphasis
added)); McClenahan v. Metro. Life Ins. Co., 631 F. Supp. 2d 1135, 1146 (D. Colo.
2009) (“[D]isability benefits are limited to 24 months during the claimant's lifetime if the
claimant is disabled due to a: Neuromusculoskeletal and soft tissue disorder, … unless
the Disability has objective evidence of a. seropositive arthritis; b. spinal tumors,
malignancy, or vascular malformations; c. radiculopathies; d. myelopathies; e. traumatic
spinal cord necrosis; or f. musculopathies.”); Iliff v. Metro. Life Ins. Co., 2012 WL
709234, * 2 (E.D. Mo.) (same).

6

See infra footnote 7.
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Apparently, as best the Court can determine, the neuro-musculoskeletal
limitation is a common feature of plans drafted by Metropolitan Life Insurance Company.
Fairly frequently, it seems, plan participants sue Metropolitan when it relies on this
limitation to deny benefits. Generally, the allegedly disabling condition in those cases is
a neck or back injury. Again, in every case the Court could find the neuromusculoskeletal limitation was limited to neuro-musculoskeletal disorders that could not
be confirmed by objective evidence. 7 Under the typical Metropolitan plan, the Plaintiff
almost certainly would be considered disabled because there is sufficient objective
evidence of her disabling neuro-musculoskeletal conditions. See (Doc. 16-9 at 16).
Novartis, however, apparently has modified Metropolitan’s standard neuromusculoskeletal limitation. It has removed the objective evidence exception to the
neuro-musculoskeletal limitation. Whether this is fair is a legitimate question. If
Novartis’ plan were an insurance policy, it is likely that state law and state insurance
regulators would frown on such an attempt to deprive totally disabled insureds of their
coverage.
However, as unfair as Novartis’ Plan may seem, the Plaintiff cites no law, and the
Court has found none, that bars Novartis from drafting its Plan any way it chooses, so
long as it complies with ERISA requirements. The fact that the Plan is a contract of
adhesion or that Novartis employees would be surprised to learn that their disability
coverage is not what a reasonable employee would think, is of no consequence.
7

O’Callaghan v. SPX Corp., 442 Fed. App’x 180 (6th Cir. 2011); Noland v. Heald College, 551 F.3d 1148
(9th Cir. 2009); Brien v. Metro. Life Ins. Co., 2012 WL 4370677 (D. Mass.); Sedens v. Metro. Life Ins. Co.,
2012 WL 748373 (D. Mass.); Lanier v. Metro. Life Ins. Co., 692 F.Supp. 2d 775 (E.D. Mich. 2010);
Meiringer v. Metro. Life Ins. Co., 2009 WL 1788588 (D. Or.); Wright v. Metro. Life Ins. Co., 618 F. Supp.
2d 43 (D.D.C. 2009); Dennison v. Metro. Life Ins. Co., 2009 WL 77216 (W.D. N.C.); Warden v. Metro. Life
Ins. Co., 574 F. Supp. 2d 838 (M.D. Tenn. 2008); Halladay v. Metro. Life Ins. Co., 2008 WL 1751965
(S.D. Tex.); Wilson v. Metro. Life Ins. Co., 2006 WL 3702635 (E.D. Pa.).

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Novartis is the master of its plan and no ERISA provision bars it from excluding
coverage for neuro-musculoskeletal disorders.
Accordingly, the Defendant’s decision was not de novo wrong. The Plaintiff’s
lumbar spine disorders clearly are neuro-musculoskeletal conditions. Neither the fact
that Metropolitan agrees she is unable to work nor the fact that objective evidence
confirms her disabling conditions helps the Plaintiff. Novartis’ Plan provides no
coverage for neuro-musculoskeletal conditions after the payment of two years of LTD
benefits.
Because the Court concludes that the Defendant’s decision was not de novo
wrong, the analysis of the denial of the Plaintiff’s LTD benefits ends here. Accordingly,
the Plaintiff’s Motion is DENIED, and the Defendant’s Motion is GRANTED.
SO ORDERED, this 3rd day of January, 2013.
S/ Marc T. Treadwell
MARC T. TREADWELL, JUDGE
UNITED STATES DISTRICT COURT

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