OSOBKA v. Metropolitan Life Insurance Company
OPINION AND ORDER DENYING 9 Plaintiff's Motion to Reverse Defendant's Benefits Determination and GRANTING 10 Defendant's Cross-Motion to Affirm. Signed by District Judge Terrence G. Berg. (AChu)
UNITED STATES DISTRICT COURT
EASTERN DISTRICT OF MICHIGAN
Case No. 16-12311
Hon. Terrence G. Berg
OPINION AND ORDER DENYING PLAINTIFF’S
MOTION TO REVERSE DEFENDANT’S BENEFITS
DETERMINATION AND GRANTING DEFENDANT’S
CROSS-MOTION TO AFFIRM (Dkt. 9, 10)
Plaintiff Kristina Osobka challenges Defendant Metropolitan
Life Insurance Company’s (“MetLife’s”) denial of her long-term
disability benefits application. Plaintiff is a former Comcast Corporation (“Comcast”) customer service representative who contends she suffered from chronic fatigue syndrome (“CFS”) and was
unable to work. She filed for benefits under Comcast’s long-term
disability plan, which Defendant administered. After Defendant
denied both her initial application and her appeal, Plaintiff filed
this lawsuit under the Employee Retirement Income Security Act
(“ERISA”), 29 U.S.C. § 1132(a)(1)(B).
Before the Court are two motions: (1) Plaintiff’s motion to reverse Defendant’s denial of her long-term disability (LTD) benefits
application, and (2) Defendant’s cross-motion to affirm its denial.
The dispositive question is whether Defendant abused its discretion in crediting the opinions of independent physician consultants
rather than those of Plaintiff’s treating physicians. For the reasons outlined below, the Court finds that Defendant was within its
discretion in denying Plaintiff’s application for long-term disability benefits. Therefore, Plaintiff’s motion to reverse Defendant’s
decision must be DENIED, and Defendant’s motion to affirm
must be GRANTED.
Plaintiff worked for Comcast as a customer service representative from June 23, 2013 until August 6, 2014. At Comcast, she
participated in the Comprehensive Health and Welfare Benefit
Plan (“the Plan”), a long term disability policy that Defendant
provided and administered.
Defendant makes initial eligibility determinations on claims for
disability benefits under the Plan. If denied, employees may appeal to Defendant for further review of their claim. Plaintiff
claimed she suffered from various viral infections, which caused
chronic fatigue syndrome (CFS), rendered her disabled, and forced
her to take leave from her job at Comcast on August 6, 2014. On
July 13, 2015, Defendant denied Plaintiff’s initial application for
LTD benefits and on May 25, 2016, Defendant denied Plaintiff’s
1. MetLife’s LTD Plan
The Plan defines “disability” as the inability to earn more than
eighty percent of prior earnings in one’s occupation due to sickness
or injury. Dkt. 6-1, Pg. ID 47. To qualify for LTD benefits, a claimant must first continuously meet this definition for 180 days (the
“Elimination Period”). Dkt. 6-1, Pg. ID 47. Plaintiff stopped working at Comcast on August 7, 2014. Thus in order to qualify for
LTD benefits she must have been disabled from August 7, 2014, to
February 8, 2015. Dkt. 6-5, Pg. ID 354.
The Plan also excludes pre-existing conditions from LTD coverage if the claimant has not been “Actively at Work” for 12 months.
Dkt. 10-2, Pg. ID 2056. Pre-existing conditions are defined as any
“sickness or accidental injury” for which a claimant received care,
or experienced symptoms “that would cause a person to seek diagnosis, care or treatment,” in the 3 months before claimant’s coverage took effect. Dkt. 10-2, Pg. ID 2056.
The Summary Plan Description, a document that explains a
claimant’s rights and obligations under the Plan, designates Defendant as the Plan administrator and delegates to Defendant the
“sole discretion to interpret plan provisions and to determine
questions of fact and eligibility for benefits.” Dkt. 6-3, Pg. ID 145.
2. Initial Denial of LTD Benefits
As a Comcast customer service representative, Plaintiff worked
at a desk and communicated with clients who were dissatisfied
with Comcast’s telecommunications services. Dkt. 7-6, Pg. ID
1786. Claiming she could no longer perform these tasks, Plaintiff
took leave from Comcast beginning on August 7, 2014. Dkt. 6-6,
Pg. ID 362. Plaintiff then applied for LTD benefits with Defendant. Dkt.7-5, Pg. ID 1636–52. Additionally, Plaintiff applied for
and was denied Social Security Disability Insurance Benefits. Dkt.
7-6, Pg. ID 1774.
As part of its LTD benefit determination, Defendant requested
medical records from Plaintiff’s treating physicians. Dkt. 7-2, Pg.
ID 1287–88, 1292–93; Dkt. 7-5, Pg. ID 1603–32. Dr. Brian Massaro’s records indicate that Plaintiff was diagnosed with anxiety in
or prior to 2011 and chronic fevers and fatigue since November
2013. Dkt. 6-6, Pg. ID 453. Plaintiff visited CFS specialist Dr.
Martin Lerner on September 29, 2014. Dkt. 6-6, Pg. ID 496. Dr.
Lerner’s October 21, 2014, report informed Defendant that Plaintiff was unable to perform any sedentary work and noted that
Plaintiff had been diagnosed with life-altering fatigue caused by
viral infections. Dkt. 6-6, Pg. ID 496–98.
On May 22, 2015, Defendant referred Plaintiff’s claim file with
the records received from her treating physicians to two Independent Physician Consultants (“IPCs”). Dkt. 6-6, Pg. ID 418; Dkt.
6-6, Pg. ID 424.
First, Defendant referred Plaintiff’s claim file to Dr. Abdulhamid Alkhalaf, an IPC certified in infectious diseases. Dkt. 6-6, Pg.
ID 424–31. Dr. Alkhalaf issued a Peer Review Report that concluded functional impairments were not supported by information
in Plaintiff’s claim file. Dkt. 6-6, Pg. ID 428–30. Around June 4,
2015, Dr. Alkhalaf provided an addendum to his report after contacting Dr. Lerner, who advised Dr. Alkhalaf that Plaintiff was
suffering from CFS. Dkt. 6-6, Pg. ID 406. Dr. Alkhalaf affirmed
his opinion that Plaintiff was not disabled, explaining that “the
medical community has not yet come to a consensus regarding the
existence of [CFS]” and that he was “on the side of questioning
[CFS].” Dkt. 6-6, Pg. ID 407.
Second, Defendant referred Plaintiff’s claim file to Dr. Enrique
Molina, an IPC certified in internal medicine with a subspecialty
in gastroenterology. Dkt. 6-6, Pg. ID 418–23. Dr. Molina issued a
report concluding that Plaintiff was not “continuously impaired”
and thus not considered “disabled” under the Plan. Dkt. 6-6, Pg.
ID 422. Defendant forwarded Dr. Molina’s report and opinion to
Dr. Lerner for comment. Dkt. 6-6, Pg. ID 417. Dr. Lerner replied
and expressed his disagreement with Dr. Molina’s conclusions. Dr.
Lerner explained that Plaintiff had “severe incapacitating lifealtering fatigue” resulting from viral infections. Dkt. 6-6, Pg. ID
On July 13, 2015, Defendant issued its initial adverse benefit
determination. Dkt. 6-6, Pg. ID 361–64. Based on review of IPC
reports and medical records from Plaintiff’s physicians, Defendant
concluded Plaintiff was not functionally impaired throughout the
180-day Elimination Period after her last day working at Comcast.
Dkt. 6-6, Pg. ID 363. Plaintiff thus did not qualify as “disabled”
under the Plan and was deemed ineligible for LTD benefits.1 Dkt.
6-6, Pg. ID 363.
3. Plaintiff’s Unsuccessful Appeal
Plaintiff appealed Defendant’s initial denial. Dkt. 7-7, Pg. ID
1943. For consideration on appeal, Dr. Molina submitted an additional report on August 10, 2015. Dkt. 6-6, Pg. ID 394–95. After
Defendant also points out that several of Plaintiff’s medical conditions were
ineligible for LTD coverage because they met the Plan’s definition of “preexisting conditions”; that is, Plaintiff had not worked for the company for 12
consecutive months prior to claiming disability, and was treated for these
conditions within 3 months of the date that her benefits became effective.
See Dkt. 10-2, Pg. ID 2056 (Plan definition and exclusion of pre-existing conditions), and Dkt. 15-1 (Exhibit W, Chart Listing Pre-existing Conditions).
While such pre-existing conditions could have justified denying Plaintiff LTD
coverage for some of her conditions, both parties agree that not all of her conditions were pre-existing under the Plan’s definition. Nonetheless the denial
of Plaintiff’s LTD for all of her complained of conditions was properly based
on her evaluating doctors’ medical opinion evidence as discussed below.
speaking with Dr. Lerner, Dr. Molina stated that his communications with Dr. Lerner changed his original recommendation; Dr.
Molina explained that he now felt that Plaintiff’s viral infections
would result in her being disabled. Dkt. 6-6, Pg. ID 394–95.
Defendant also solicited several IPC reports from Sedgwick
Claims Management Services (“Sedgwick”), Comcast’s short-term
disability benefits claim administrator.2 Dr. Michael Rater, an
IPC certified in psychiatry, reviewed Plaintiff’s medical file and
issued two reports solely from a psychiatric perspective. Dkt. 7-7,
Pg. ID 1900–06; Dkt. 7-7, Pg. ID 1869–78. Dr. Rater concluded in
both reports—including in the second report he issued after speaking with Plaintiff’s nurse practitioner Sherry Russell—that Plaintiff was not disabled from a psychiatric perspective. Dkt. 7-7, Pg.
ID 1905; Dkt. 7-7, Pg. ID 1876. Dr. Olufemi Aboyeji, an IPC certified in infectious diseases, also issued two reports on behalf of
Sedgwick. Dkt. 7-7, Pg. ID 1891–99; Dkt. 7-7, Pg. ID 1880–87. Dr.
Aboyeji concluded in both reports that test results merely suggested Plaintiff had prior viral infections, not that she had ongoing viral infections that could cause disability. Dkt. 7-7, Pg. ID 1898;
Dkt. 7-7, Pg. ID 1885–87.
Sedgwick denied Plaintiff’s claim for short-term disability benefits on September 23, 2014. Dkt. 6-7, Pg. ID 502.
In addition to the two short-term disability IPCs, Defendant referred Plaintiff’s claim to a third IPC, Dr. John Brusch, who is certified in internal medicine with a specialty in infectious diseases.
Dkt. 7-6, Pg. ID 1765. Dr. Brusch prepared two reports. He wrote
his second report after discussing his first report with Plaintiff’s
physician Dr. Susan Levine.3 Dkt. 7-6, Pg. ID 1759–65; Dkt. 7-6,
Pg. ID 1746–47. Dr. Brusch’s first report concluded Plaintiff was
not disabled. Dkt. 7-6, Pg. ID 1763. Dr. Brusch explained that
CFS is diagnosed by excluding other sources of fatigue. Dkt. 7-6,
Pg. ID 1764. Behavioral health issues like depression, Dr. Brusch
reasoned, were more likely the source of Plaintiff’s fatigue. Dkt. 76, Pg. ID 1764. Dr. Brusch provided his report to Dr. Levine for
Dr. Levine responded on April 15, 2016, and expressed her disagreement with Dr. Brusch’s report. Dr. Levine explained that she
and Dr. Lerner were experts in the CFS field. Dkt. 7-6, Pg. ID
1751. Dr. Levine detailed the disabling effects of CFS and her disagreement with Defendant’s adverse determination despite her
and Dr. Lerner’s medical opinions. Dkt. 7-6, Pg. ID 1751. Defend-
On January 11, 2015, Plaintiff’s counsel informed Defendant that Dr. Lerner had died and that Plaintiff would seek treatment from other physicians.
Dkt. 7-7, Pg. ID 1932.
ant forwarded Dr. Levine’ response to Dr. Brusch for his consideration.
Dr. Brusch’s second report reiterated that he disagreed with
Dr. Levine because behavioral health issues were more likely the
cause of Plaintiff’s symptoms than CFS. Dr. Brusch cited two reasons in support of his opinion: (1) since diagnosing CFS is a process of exclusion, behavioral health issues such as depression or
personality disorder should be ruled out before concluding Plaintiff has CFS; and (2) Dr. Levine misinterpreted the medical diagnostic testing as indicating ongoing viral infections (Epstein-Barr
virus, cytomegalovirus, and human herpes virus 6) when Plaintiff’s diagnostic tests only supported prior viral infection. Dkt. 7-6,
Pg. ID 1746.
Defendant affirmed its initial denial of Plaintiff’s LTD claim on
May 25, 2016. Dkt. 7-6, Pg. ID 1740–45. Defendant explained
Plaintiff’s medical diagnostic testing supported prior but not persistent viral infections. Dkt. 7-6, Pg. ID 1743. “[Plaintiff] had old
self-contained infections that had no bearing on her current symptoms.” Dkt. 7-6, Pg. ID 1743. Defendant also noted that CFS is diagnosed by ruling out other potential causes for overwhelming fatigue. Dkt. 7-6, Pg. ID 1743. Defendant concluded that behavior
health issues such as depression, which had not been ruled out as
a cause of Plaintiff’s fatigue, were more likely the source of Plaintiff’s symptoms.
III. Standard of Review
The Employee Retirement Income Security Act (“ERISA”) provides a cause of action for participants or beneficiaries of certain
LTD plans to challenge benefit determinations. 29 U.S.C. §
1132(a)(1)(B). The Supreme Court has held that generally, “a denial of benefits challenged under section 1132(a)(1)(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 and Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989); accord Frazier v. Life Ins. Co. of N. Am., 725 F.3d 560, 566 (6th Cir.
2013). Here, the parties agree that the Plan vests the administrator with discretionary authority to determine eligibility for benefits. Dkt. 9, Pg. ID 1964; Dkt. 10, Pg. ID 1998; Dkt. 14, Pg. ID
2285. Accordingly, the Court will review the Trustees' decision
under the deferential arbitrary and capricious standard.4
Under the arbitrary and capricious standard of review, a policy
administrator’s decision must be upheld if it is “rational in light of
the plan's provisions.” Smith v. Ameritech, 129 F.3d 857, 863 (6th
Cir. 1997). Administrators’ decisions are upheld under this standard “[w]hen it is possible to offer a reasoned explanation, based on
the evidence” for that particular outcome. Shaw v. AT&T Umbrella Ben. Plan No. 1, 795 F.3d 538, 547 (6th Cir. 2015) (quoting Davis v. Ky. Fin. Cos. Retirement Plan, 887 F.2d 689, 693 (6th Cir.
1989)). An administrator's decision can be overturned “upon a
showing of internal inconsistency, bad faith, or some similar
ground.” Magdziak v. Metro. Life Ins. Co., 920 F. Supp. 2d 782,
790 (E.D. Mich. 2013). For example, “an administrator abuses its
discretion when it engages in a ‘selective review of the administrative record’ to justify a decision to terminate coverage.” Dockery v.
USG Corp. Retirement Plan, No. 08–13249, 2009 WL 2960471, at
While Mich. Admin. Code R. 500.2202(b) bars grants of discretion in certain
insurance policy documents delivered within Michigan, the statute does not
alter the standard of review here. Because the grant of discretion was contained in the Summary Plan Description, Dkt. 6-3, Pg. ID 145–46, §
500.2202(b) does not bar it. The arbitrary and capricious standard is therefore the appropriate standard of review. See Rose v. Liberty Life Assurance
Co. of Bos., No. 3:15-cv-28-DJH-CHL, 2016 WL 1178801, at *3–4 (W.D. Ky.
Mar. 23, 2016); Markey-Shanks v. Metropolitan Life Ins. Co., No. 1:12–CV–
342, 2013 WL 3818838, at *5–7 (W.D. Mich. July 23, 2013); Hess v. Metropolitan Life Ins. Co., 91 F. Supp. 3d 895, 901–02 (E.D. Mich. 2015).
*11 (E.D. Mich. Sept. 11, 2009) (quoting Moon v. Unum Provident
Corp., 405 F.3d 373, 381 (6th Cir. 2005)).
Plaintiff argues that Defendant’s determination was arbitrary
and capricious because Defendant improperly credited the opinions of IPCs over Plaintiff’s treating physicians, including Drs.
Lerner and Levine. Dkt. 9, Pg. ID 1965. Plaintiff further argues
that Defendant’s decision not to conduct its own physical examination of Plaintiff compounded this deficiency in its evaluation of
Plaintiff’s claim. Dkt. 9, Pg. ID 1966. Finally, Plaintiff claims, it
was an abuse of discretion for Defendant to rely on Dr. Alkhalaf’s
opinion after Dr. Alkhalaf stated he did not recognize CFS as a
medical condition. Dkt. 14, Pg. ID 2286–87.
Defendant responds that it relied on five qualified IPCs in making its determination and offered reasons for its disagreement
with Plaintiff’s treating physicians. Dkt. 15, Pg. ID 2297. Drs.
Alkhalaf, Aboyeji, and Brusch, each of whom is certified in or specializes in infectious diseases, concluded that the objective medical
evidence of Plaintiff’s diagnoses did not support continuous disability during the 180-day Elimination Period after Plaintiff’s last
day at Comcast. Accordingly, Defendant asserts, the decision to
deny Plaintiff’s LTD claim was neither arbitrary nor capricious.
Defendant acted within its discretion in relying on IPCs rather
than Plaintiff’s treating physicians. To withstand review under
the arbitrary and capricious standard a plan administrator must
offer reasons for rejecting the opinions of a claimant’s treating
physicians—rather than rejecting them summarily. See Shaw, 795
F.3d at 548–49. Here, the IPCs considered Plaintiff’s treating physicians’ opinions. Each IPC gave his report to either Dr. Lerner or
Dr. Levine for comment. And each IPC then issued either a second
report or addendum to their first report, specifically addressing
Dr. Lerner’s and Dr. Levine’s concerns. Drs. Lerner and Levine interpreted Plaintiff’s medical diagnostic results as indicating she
had CFS as the result of viral infections. Drs. Aboyeji and Brusch
interpreted these same results differently and concluded they only
indicated Plaintiff once had viral infections—not that these infections were ongoing.5
Dr. Brusch also reasoned that diagnosing CFS was a process of
exclusion, and behavioral health issues such as depression or per
Defendant does not specifically address its disagreement with Dr. Molina,
who issued an addendum to his report after speaking with Dr. Lerner. Dr.
Molina reversed his opinion after concluding medical diagnostic testing indicated Plaintiff would be considered “disabled” under the Plan. Although Defendant does not discuss Dr. Molina’s addendum in its appeal decision, it does
address Dr. Molina’s interpretation of Plaintiff’s medical diagnostic results.
Furthermore, it was not an abuse of discretion for Defendant to credit the
opinions of IPCs who opined from an infectious diseases perspective, since
Plaintiff claimed her CFS resulted from viral infections and Dr. Molina wrote
solely from a gastroenterological and internal medicine perspective.
sonality disorder were more likely the cause of Plaintiff’s fatigue.
Thus, Dr. Brusch concluded, further evidence was required to diagnose Plaintiff with CFS. Defendant noted these reasons in its
May 25, 2016 appeal determination letter. Because Defendant
documented these medical disagreements and its reasons for crediting Dr. Aboyeji’s and Dr. Brusch’s opinions over those of Plaintiff’s treating physicians, Defendant’s LTD benefits claim denial
was not arbitrary and capricious.
Moreover, contrary to Plaintiff’s assertion, Defendant was not
required to give special weight to the opinions of Plaintiff’s treating physicians over those of IPCs hired by Defendant. See Black &
Decker Disability Plan v. Nord, 538 U.S. 822, 834 (2003) (“[C]ourts
have no warrant to require administrators automatically to accord
special weight to the opinions of a claimant's physician; nor may
courts impose on plan administrators a discrete burden of explanation when they credit reliable evidence that conflicts with a
treating physician's evaluation.”); Balmert v. Reliance Standard
Life Ins. Co., 601 F.3d 497, 504 (6th Cir. 2010) (“Reliance on other
physicians is reasonable so long as the administrator does not totally ignore the treating physician's opinions.”). Unlike claims for
Social Security insurance disability benefits, the “treating physician rule” does not apply to disability determinations under employee benefits plans covered by ERISA. Black & Decker Disability
Plan, 538 U.S. at 825. It was therefore not an abuse of discretion
for Defendant to credit the opinions of the IPCs rather than those
of Drs. Lerner and Levine.
Finally, Defendant was not required to conduct its own physical
examination of Plaintiff. While it is preferable for a LTD plan administrator to conduct its own physical exam of a claimant, it is
not required. See Helfman v. GE Grp. Life Assurance Co. 573 F.3d
383, 393 (6th Cir. 2009) (“[W]hile this court has found that an administrator is not barred from engaging in a file review in lieu of a
physical exam, ‘the failure to conduct a physical examination . . .
may, in some cases, raise questions about the thoroughness and
accuracy of the benefits determination.’”) (quoting Calvert v.
Firstar Fin., Inc., 409 F.3d 286, 295 (6th Cir. 2005)).
Here, instead of a physical examination, Defendant considered
the opinions of five IPCs, three of whom discussed Plaintiff’s condition with her treating physicians. Three of the IPCs were certified or specialized in infectious diseases, which Dr. Lerner cited as
the cause of Plaintiff’s CFS. While Defendant’s failure to physically examine Plaintiff is a relevant consideration in evaluating the
thoroughness of Defendant’s review of Plaintiff’s claim, here Defendant relied on IPCs with specialized knowledge who reviewed
Plaintiff’s medical file and directly consulted with Plaintiff’s treat-
ing physicians. These steps indicate Defendant thoroughly reviewed Plaintiff’s claim.
In sum, Defendant acted within its discretion in denying Plaintiff’s LTD benefits claim. Although several of Defendant’s IPCs rejected the opinions of Plaintiff’s treating physicians, they thoroughly considered them. And Defendant provided the reasons for
the denial in its appeal determination letter. Thus, because Defendant was not required to give deference to Plaintiff’s treating
physicians, or physically examine Plaintiff, the Court finds that
that Defendant’s denial of LTD benefits under the Plan was not
arbitrary and capricious.
For the foregoing reasons, Plaintiff’s motion to reverse Defendant’s ERISA determination and grant long-term disability benefits
is DENIED, and Defendant’s motion to affirm its benefit denial
decision is GRANTED.
Dated: August 25, 2017
s/Terrence G. Berg
TERRENCE G. BERG
UNITED STATES DISTRICT JUDGE
Certificate of Service
I hereby certify that this Order was electronically filed, and
the parties and/or counsel of record were served on August 25,
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