KUNION v. METROPOLITAN LIFE INSURANCE COMPANY et al
OPINION. Signed by Judge Esther Salas on 3/31/14. (jd, )
NOT FOR PUBLICATION
UNITED STATES DISTRICT COURT
DISTRICT OF NEW JERSEY
METROPOLITAN LIFE INSURANCE :
COMPANY and INTERNATIONAL
CORPORATION DISABILITY PLAN, :
Civil Action No. 12-3675 (ES)(JAD)
SALAS, District Judge
This matter comes before the Court on Defendants, The Metropolitan Life Insurance
Company (“MetLife”) and the IBM Long-Term Disability Plan’s1 (“Plan”), (collectively, the
“Defendants”), motion for summary judgment. (D.E. No. 23). The Court has considered the
parties’ submissions in support of and in opposition to the instant motion, and decides the matter
without oral argument pursuant to Fed. R. Civ. P. 78(b). For the reasons set forth below,
Defendants’ motion for summary judgment is GRANTED.
This Court has subject matter jurisdiction pursuant to 28 U.S.C. § 1331 and the Employee
Retirement Income Security Act of 1974, as amended (“ERISA”), 29 U.S.C. §§ 1001 et seq.
Defendant was pled as “International Business Machines Corporation Disability Plan” but
identifies itself as “IBM Long-Term Disability Plan.”
Factual Background and Procedural History2
A. The IBM Long-Term Disability Plan and Policy
Plaintiff David Kunion seeks continued payment of his long-term disability (“LTD”)
benefits under the terms of the Plan, which was maintained by IBM to provide LTD benefits to
its employees and which was funded by a group policy issued by MetLife. (SUMF ¶¶ 1-2; D.E.
No. 1, Compl.). Pursuant to the plan, MetLife is the claims fiduciary responsible solely for “full
and fair review of claims denials,” and who “shall have discretionary authority to interpret the
terms of the LTD Plan and to determine eligibility for and entitlement to LTD Plan benefits.”
The Plan further provides that “[a]ny interpretation or determination made
(SUMF ¶ 3).
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.).
The Plan also provides, in pertinent part, as follows:
Disabled or Disability means that, due to Sickness or as a direct
result accidental injury:
You are receiving Appropriate Care and Treatment and
complying with the requirements of such treatment; and
You are, during the Elimination Period and the next 12
months of Sickness or accidental injury unable to perform
each of the material duties of Your Own Job; and
The facts recited here are, unless otherwise indicated, undisputed. (Compare D.E. No. 23-1,
Statement of Undisputed Material Facts (“SUMF”), with D.E. No. 26, Pl. David Kunion’s
Response in Opp. to Defs.’ Statement of Undisputed Material Facts (“Pl. Response to SUMF”)).
This Court further notes that Plaintiff admitted the majority of facts in response to Defendants’
Statement of Undisputed Material Facts, and did not submit his own statement of disputed facts.
The Court thus cites to Defendants’ Statement of Undisputed Material Facts, unless the specific
paragraph is disputed and material. The Court also does not cite to the underlying administrative
record upon which the parties rely.
You are, after such period unable to perform the duties of any
gainful occupation for which You are reasonably qualified
taking into account Your training, education and experience.
Proof means Written evidence satisfactory to Us that a person
has satisfied the conditions and requirements for any benefit
described in this certificate. When a claim is made for any benefit
described in this certificate, Proof must establish:
the nature and extent of the loss or condition;
Our obligation to pay the claim; and
the claimant's right to receive payment.
Proof must be provided at the claimant's expense.
We, Us and Our mean MetLife.
You and Your mean an employee who is insured under the Group
Policy for the insurance described in this certificate.
(Id. ¶ 4). Additionally, the Plan provides:
If You become Disabled while insured, Proof of Disability must be
sent to Us. When We receive such Proof, We will review the
claim. If We approve the claim, We will pay the Monthly Benefit
up to the Maximum Benefit Period shown in the SCHEDULE OF
BENEFITS, subject to THE DATE BENEFIT PAYMENTS END
(Id. ¶ 5). For disabilities due to mental or nervous disorders or diseases, the Plan
If You are Disabled due to a Mental or Nervous Disorder or
Disease, We will limit Your Disability benefits to a lifetime
maximum equal to the lesser of:
24 months; or
the Maximum Benefit Period.
This limitation will not apply to a Disability resulting
organic brain disease.
Mental or Nervous Disorder or Disease means a medical
condition which meets the diagnostic criteria set forth in the most
recent edition of the Diagnostic and Statistical Manual of Mental
Disorders as of the date of Your Disability. A condition may be
classified as a Mental or Nervous Disorder or Disease regardless
of its cause.
(Id. ¶ 6).
B. Pre-Initial Determination of April 19, 2011
Plaintiff became disabled as a result of his inability to concentrate under excessive stress,
and hence stopped working on February 5, 2008. (Id. ¶ 7). He received short-term disability
benefits for the maximum period between February 5, 2008, and August 5, 2008. (Id. ¶ 8).
Thereafter, Plaintiff applied to MetLife for LTD benefits under the Plan, which application was
supported by an Attending Physician Statement (“APS”) from his treating psychologist, Stephen
S. Craig, Ph.D., who described his diagnoses as “Major Depressive Disorder” and “Acute
Reaction to Stress.” (Id. ¶¶ 9-10). By letter dated August 5, 2008, MetLife approved Plaintiff’s
LTD benefits and informed Plaintiff that his diagnoses fell within the mental or nervous disorder
and that therefore, his benefits would be subject to a limited benefit period of 24 months, which
was set to expire on August 4, 2010, unless one of three exceptions applied. (Id. ¶ 11).
In March and June 2009, Dr. Craig updated MetLife with his diagnoses of “Major
Depressive Disorder,” “Generalized Anxiety Disorder,” and “Acute Stress Disorder.” (Id. at ¶¶
13, 15). Plaintiff’s psychiatrist, Ambrose Mgbako, M.D., also submitted a letter, indicating that
Plaintiff “suffers from severe persistent bipolar disorder, hypo manic type which disables him
from all occupations.” (Id. ¶ 14).
By letter dated July 7, 2009, MetLife informed Plaintiff that it would continue Plaintiff’s
LTD benefits based on “total disability from any occupation,” and reiterated that Plaintiff’s
primary diagnosis fell within the definition of mental or nervous disorder and was subject to a
24-month benefit period. (Id. ¶ 16). Thereafter, by letter dated February 1, 2010, David G.
Miller, M.D. submitted a letter to MetLife.
(Id. ¶ 17). Dr. Miller explained that Plaintiff
“suffer[ed] from a significant Depressive Disorder with Anxiety,” and stated that Dr. Mgbako
had diagnosed Plaintiff with “Bipolar Disorder” and that a neurologist, Dr. Marvin Ruderman,
“had performed a neurologic evaluation and MRI scan which revealed no focal abnormality.”
(Id.). By letter dated March 29, 2010, Thomas Lane, LCSW, notified MetLife that Plaintiff had
been attending an Intensive Outpatient Program three days a week since March 8, 2010, with a
diagnoses of “Bipolar Disorder” and “Anxiety Disorder.” (Id. ¶ 18).
Plaintiff also submitted medical records to establish an LTD benefits claim based on his
degenerative disc disease and spinal stenosis. Specifically, Scott D. Orenberg, D.O. submitted a
letter dated January 31, 2010, in which he reported that lumber spine x-ray revealed narrowing of
disc space at the L4-L5 level, that a lower extremity EMG was “suggestive of lumbosacral
radiculopathy and spinal stenosis L5-S1 and S1-S2 bilaterally,” and that Plaintiff was referred for
physical therapy three times a week for one month. (Id. ¶ 19). MetLife acknowledged receipt by
letter dated March 23, 2010, but noted that “physical exam findings and specific medically
supported restrictions and limitations were not provided.” (Id. ¶ 20).
In March and April 2010, Kenneth J. Rieger, M.D. also reported that Plaintiff’s imaging
studies and MRI indicated “severe degenerative disc disease at L4-L5 with moderate foraminal
Stenosis/Degenerative Disc Disease.” (Id. at ¶¶ 21, 23). Matthew Lipp, M.D. also reported that
an MRI showed that Plaintiff had “significant degenerative bulging and stenosis at the L5-S1
level” and recommended that Plaintiff “undergo a right a L5-S1 transforaminal epidural steroid
injection,” which was scheduled but aborted due to a change in heart rate. (Id. at ¶¶ 22, 24). By
letter dated June 8, 2010, MetLife informed Plaintiff that his 24-month maximum benefit period
due to his disabling mental condition was set to expire on August 4, 2010, but that his LTD
benefits would continue beyond this date due to “another disabling medical condition.” (Id. ¶
In response to MetLife’s request for additional medical information, in October 2010, Dr.
Craig submitted a fax with diagnoses of “Bipolar I Disorder,” “Generalized Anxiety Disorder,”
and “Acute Stress Disorder.” (Id. ¶ 27). On November 3, 2010, Dr. Craig submitted an APS
stating a primary diagnosis of “Acute Stress Disorder” and a secondary diagnoses of “Major
Dep. Disorder,” “Alteration of Consciousness,” and “Bipolar Disorder.”
(Id. ¶ 28).
November 12, 2010, Dr. Miller submitted a form questionnaire in which he diagnosed Plaintiff
with “Dementia” and “Mood Disorder,” but provided no support for the dementia diagnosis.3
(Id. ¶ 29). On October 25, 2010, MetLife also received an APS from an orthopedist, Kenneth J.
Plaintiff admits that his diagnosis was dementia, but states that MetLife did not request
documentation to support this diagnosis in the form questionnaire. In doing so, Plaintiff merely
cites to the form questionnaire and does not provide any evidence to suggest that Dr. Miller
supplemented this form. (Pl. Response to SUMF ¶ 29).
Kopacz, M.D., who diagnosed Plaintiff with “Spinal Stenosis – Lumber 4-5” and “Lumbar
Radiculopathy.” (Id. ¶ 30).
MetLife retained Elite Physicians Limited (“EPL”) to review Plaintiff’s entire file. (Id. ¶
EPL obtained an independent review by a specialist in clinical and forensic
neuropsychologist, Michael J. Perrotti, Ph.D. (Id.). In his report and opinion dated January 17,
2011, Dr. Perrotti stated that there was no psychological testing to support a diagnosis of
dementia and after reviewing the tests conducted by Dr. Craig, Dr. Perrotti concluded that those
results were inconsistent with a diagnosis of dementia. (Id. ¶¶ 31-33). On March 30, 2011, Dr.
Craig provided an APS that stated diagnoses of “Dementia, . . . Bipolar Disorder, . . . Alteration
of Consciousness, . . . [and] Acute Stress Disorder,” but provided no support for the dementia
diagnosis nor reason for the change from the previous diagnosis. (Id. ¶ 37).
Dr. Kopacz also submitted an office note and APS, which diagnosed Plaintiff with
“Lumbar Disc Degeneration” and stated that Plaintiff could “obviously work in a sedentary-type
position” with the ability to get up every hour or so to “get up out of his chair.” (Id. ¶¶ 34-35).
Dr. Kopacz submitted another APS on April 5, 2011, in which he repeated the diagnosis and
stated that Plaintiff could “return to work on April 20 with restrictions” for eight hours per day
with intermittent breaks to stand and walk. (Id. ¶ 38).
In March 2011, MetLife also sought an Employability Assessment and Labor Market
Analysis. (Id. ¶ 36). The vocational consultant concluded that Plaintiff had “the ability to work
at the [s]edentary level of physical exertion with restrictions and limitations” and “identified 3
occupations” for which Plaintiff was qualified in his geographical area. (Id. ¶ 36).
On April 19, 2011, MetLife notified Plaintiff that payment of his LTD benefits would be
terminated on May 19, 201, based on the entire review of the administrative record. (Id. ¶ 39).
The letter noted that Plaintiff was no longer disabled due to degenerative disc disease or spinal
stenosis, that his own doctors had found that he could return to “full-time sedentary demand
work with restrictions,” and that a labor market analysis had concluded that occupations existed
for which Plaintiff was qualified in his geographic area. (Id.). MetLife further acknowledged
Plaintiff’s psychiatric functional limitations; that Dr. Perrotti determined that that there was no
support for the diagnosis of dementia; and thus that Plaintiff did not qualify for an exclusion
from the 24-month maximum benefit period. (Id.).
C. Administrative Appeal and Subsequent Submissions
On May 4, 2011, MetLife received an APS from Sam Locatelli, M.D., which diagnosed
Plaintiff with “Lumbar radiculitis.” (Id. ¶ 40). Dr. Locatelli also stated that his office did not
advise Plaintiff to stop working and that an opinion on why Plaintiff was unable to perform job
duties was “not related to [Dr. Locatelli’s] therapy.” (Id.). Accordingly, by letter dated May 9,
2011, MetLife acknowledged receipt of additional medical records and informed Plaintiff that he
should follow appeals procedures outlined in the April 19, 2011 termination letter. (Id. ¶ 41).
In May 2011, Plaintiff and his attorney sought an administrative appeal of MetLife’s
determination. (Id. ¶¶ 42-45). By letter dated October 29, 2011, Plaintiff’s counsel submitted
additional medical documentation for MetLife’s consideration without further explanation. (Id. ¶
46). In an office note dated June 3, 2011, Dr. Rieger stated that Plaintiff had “progressive
disability due to his spinal stenosis and lower extremity pain,” would require an “L4-S1
laminectomy . . . when he is ready,” and could work 20 hours per week from home. (Id.). In Dr.
Rieger’s APS dated April 12, 2010, he repeated his diagnosis of spinal stenosis and degenerative
In a report dated June 9, 2011, Dr. Miller stated that Plaintiff was
“dramatically limited by his cognitive deterioration,” that “there was no evidence of significant
depression nor anxiety,” and that Plaintiff should remain “disabled from any job which would
require significant concentration, attention, or cognitive functioning.” (Id.).
Further, Plaintiff’s counsel also submitted a report from Dr. Craig dated June 17, 2011 in
which he concluded that Plaintiff “remains fully and completely disabled from any and all job
functions that would require even a minimal level of concentration, attention, or cognitive
function.” (Id.). A report from Saint Barnabas Imaging Center dated March 3, 2010 was also
submitted, which showed “[d]egenerative disc disease most pronounced at the L4-L5 level
without significant interval change.” (Id.). In a report dated May 17, 2011, Dr. Kopacz also
stated that Plaintiff “may return to work as long as he is restricted to a sedentary position with
the ability to stand or move positions every hour” and that Plaintiff could “work 20 hours at
home during the week and 20 hours in the office per week.” (Id.). Finally, Plaintiff’s counsel
submitted two office notes from Warren J. Bleiwess, M.D. dated December 7, 2010, and
September 20, 2011, in which he noted that Plaintiff had been treated with trigger point
injections and that Plaintiff’s “condition interferes with his ability to function and perform work
Following receipt of this medical documentation, MetLife obtained a second independent
review of Plaintiff’s entire file by a different neuropsychologist, Keven Anne Murphy, Ph.D.
(Id. ¶ 47). In her report and opinion dated November 19, 2011, Dr. Murphy stated that she
reviewed Plaintiff’s extensive medical records and that she agreed with Dr. Perrotti’s opinion
that “the results of psychological testing were more consistent with a psychiatric disorder than a
neurological disorder, such as dementia or organic brain disease.” (Id.). Dr. Murphy further
stated that Plaintiff’s own doctors had not referred Plaintiff “to a neurologist or for a
neuropsychological assessment” and that the testing performed by Dr. Craig “did not constitute a
neuropsychological evaluation and was of limited usefulness in the diagnosis of a dementia or
other organic brain disease.” (Id.). Dr. Murphy also noted that if Plaintiff’s condition “was
thought to have an organic basis,” it would be expected that Plaintiff would have been referred
back to Dr. Ruderman who referred Plaintiff initially to Dr. Craig or to another neurologist.
Finally, in response to an inquiry as to why the medical evidence does not support the
diagnosis of dementia, Dr. Murphy explained that “there was no significant decline in overall
intellectual functioning between” the two intelligence tests administered in 2008 and 2010, and
therefore the “variability in areas of improvement and decline was more consistent with a
psychiatric disorder than a progressive neurological disorder.” (Id. ¶ 48).
Sometime after Dr. Murphy’s November 2011 report was issued, Dr. Murphy spoke with
Dr. Craig. (Id. ¶ 49). On December 7, 2011, Dr. Murphy issued an addendum report in which
she stated that Dr. Craig informed her that he was still treating Plaintiff and that Dr. Murphy had
received a call from Plaintiff. (Id.). Plaintiff informed Dr. Murphy that he was under the care
and treatment of a new psychiatrist, Nirmal Sathaye, M.D.,4 who wanted to “work on one thing
at a time” and the “first step would be to get [Plaintiff’s] anxiety under control.” (Id.). Plaintiff
also told Dr. Murphy that he was “most bothered by his memory and anxiety” and “his back was
also bad.” (Id.). Dr. Murphy concluded that Plaintiff was “receiving appropriate care and
treatment for his psychiatric disorder,” and that Dr. Sathaye’s plan appeared to be the
“appropriate course of action,” but that the evidence supported that Plaintiff’s issues were
“psychiatric and not neurologic.” (Id. ¶ 50). As such, Dr. Murphy maintained her conclusions
stated in her initial opinion. (Id.).
At MetLife’s request, Dana B. Mirkin, a Board certified doctor in occupational medicine,
Dr. Murphy refers to Dr. Sathaye as “Dr. Satay” in her report. (Id.).
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on behalf of Reliable Review Services (“RRS”), also conducted an independent medical review
of Plaintiff’s back problems. (Id. ¶ 51). Dr. Mirkin issued a report dated November 28, 2011, in
which he concluded that Plaintiff had some physical limitations, but that he was “physically able
to resume his normal sedentary occupation.” (Id.).
Thereafter, MetLife also sent Dr. Murphy and Dr. Mirkin’s reviews and reports to
Plaintiff’s medical providers and counsel, requesting their comments. (Id. ¶ 52).
claims that it did not receive any comments from Plaintiff’s providers.5 (Id. ¶ 53).
By letter dated January 3, 2012, MetLife issued its determination upon review of
Plaintiff’s complete administrative claim file and concluded that the “medical information did
not support that [Plaintiff] had any evidence of the exclusionary diagnoses for his mental or
nervous disorder or disease limited benefit conditions” nor was Plaintiff “disabled as defined by
the Plan regarding his physical conditions.” (Id. ¶ 55). Therefore, MetLife upheld its initial
determination. (Id.). The letter also advised Plaintiff that he had exhausted his administrative
remedies and had the right to bring a lawsuit under ERISA. (Id. ¶ 56).
On June 18, 2012, Plaintiff filed a complaint, alleging one count for wrongful denial of
disability benefits against Defendants under Section 502(a)(1)(B) of ERISA, 29 U.S.C. §
1132(a)(1)(B), (“Count One”). (Compl. ¶¶ 6-16).
Defendants’ motion for summary judgment is now ripe for this Court’s adjudication.
Plaintiff claims that he does not have sufficient information to admit or deny this statement, but
does not raise a genuine issue of material fact. (Pl. Response to SUMF ¶ 53).
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A. Summary Judgment Standard
A court shall grant summary judgment under Rule 56(c) of the Federal Rules of Civil
Procedure “if the pleadings, the discovery and disclosure materials on file, and any affidavits
show that there is no genuine issue as to any material fact and that the movant is entitled to
judgment as a matter of law.” Fed. R. Civ. P. 56(c). On a summary judgment motion, the
moving party must show, first, that no genuine issue of material fact exists. Celotex Corp. v.
Catrett, 477 U.S. 317, 323 (1986).
The burden then shifts to the non-moving party to present evidence that a genuine issue
of material fact compels a trial. Id. at 324. In so presenting, the non-moving party must offer
specific facts that establish a genuine issue of material fact, not just “some metaphysical doubt as
to the material facts.” Matsushita Elec. Indus. Co., Ltd. v. Zenith Radio Corp., 475 U.S. 574,
586-87 (1986). Thus, the non-moving party may not rest upon the mere allegations or denials in
its pleadings. See Celotex Corp., 477 U.S. at 324. Further, the non-moving party cannot rely on
unsupported assertions, bare allegations, or speculation to defeat summary judgment.
Ridgewood Bd. of Educ. v. N.E. ex rel. M.E., 172 F.3d 238, 252 (3d Cir. 1999). The Court must,
however, consider all facts and their reasonable inferences in the light most favorable to the nonmoving party. See Pa. Coal Ass’n v. Babbitt, 63 F.3d 231, 236 (3d Cir. 1995). If the nonmoving
party “fail[s] to make a sufficient showing on an essential element of [his] case with respect to
which [he] has the burden of proof,” then the moving party is entitled to judgment as a matter of
law. Celotex Corp., 477 U.S. at 323.
B. ERISA Standard of Review
An ERISA benefits determination is reviewed under the de novo standard of review
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“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 the administrator is vested with discretionary authority,
this Court applies a “deferential standard of review,” limiting its analysis to whether the
administrator abused its discretion. Metro. Life Ins. Co. v. Glenn, 554 U.S. 105, 111 (2008).
Here, it is uncontested that the plan confers broad discretion on MetLife as the claims
administrator. (Pl. Response to SUMF ¶ 3; Pl.’s Mem. of Law in Support of Pl.’s Mot. in Opp.
of Defs.’s Mot. for Summ. J. (“Pl. Opp. Br.”) at 15-16).6 Thus, the Third Circuit has described
this deferential review as an arbitrary and capricious (or abuse of discretion) standard, 7 under
which the district court may “overturn a decision of the plan administrator only if it is without
reason, unsupported by substantial evidence or erroneous as a matter of law.” Doroshow v.
Hartford Life & Acc. Ins. Co., 574 F.3d 230, 234 (3d Cir. 2009) (citation omitted). In this
regard, courts must defer to an administrator’s findings of facts when they are supported by
substantial evidence, which the Third Circuit has defined as relevant evidence that reasonable
minds might accept as adequate to support a conclusion even if it is possible to draw two
inconsistent conclusions from that evidence. Fleisher v. Standard Ins. Co., 679 F.3d 116, 121
(3d Cir. 2012).
The Supreme Court has explained that when conducting a deferential review of a claims
determination of an administrator vested with discretionary authority, the reviewing court must
consider whether the plan administrator operated under a conflict of interest. Glenn, 554 U.S. at
Because Plaintiff filed his opposition papers as one ECF filing without page numbers for each
document, this Court refers to the ECF page number for citation purposes. (See D.E. No. 26).
The Third Circuit has noted that in the ERISA context, the “arbitrary and capricious standard”
and “abuse of discretion standard” are “practically identical.” Estate of Schwing v. The Lilly
Health Plan, 562 F.3d 522, 526 n.2 (3d Cir. 2009).
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108. The Glenn Court found that a conflict of interest may exist when the “plan administrator
both evaluates claims for benefits and pays benefits claims.” Id. at 112. As such, the Third
Circuit has applied Glenn by requiring that courts “apply a deferential standard of review across
the board” and “consider any conflict of interest as one of several factors in considering whether
the administrator or the fiduciary abused its discretion.” Estate of Schwing, 562 F.3d at 525.
The Court declined to adopt a bright-line rule on this conflict because “[b]enefit decisions arise
in too many contexts, concern too many circumstances, and can relate in too many different
ways to conflicts—which themselves vary in kind and in degree of seriousness—for us to come
up with a one-size-fits-all procedural system that is likely to promote fair and accurate review.”
Glenn, 554 U.S. at 116-17.
With this framework in mind, this Court will now turn to whether MetLife’s claim
determination was an abuse of discretion under the plan.
MetLife’s Purported Conflict of Interest
As an initial matter, Plaintiff argues that this Court “should consider a possible conflict of
interest” because MetLife operated both as the claims administrator and the payor of benefits.
(Pl. Opp. Br. at 15-16). However, Plaintiff fails to submit evidence of significant conflict or
bias, and has failed to raise a genuine issue of material fact. As the Glenn Court noted, some
conflicts based on the specific facts in the record will be less significant “(perhaps to the
vanishing point) where the administrator has taken active steps to reduce potential bias and to
promote accuracy, for example, by walling off claims administrators from those interested in
firm finances, or by imposing management checks that penalize inaccurate decisionmaking
irrespective of whom the inaccuracy benefits.” 554 U.S. at 117 (citation omitted). This Court
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finds that the evidence in the record demonstrates that MetLife has taken steps to reduce any
potential bias by keeping finances separate from claims and by not providing any incentive to
deny claims. (D.E. No. 23-2, Br. in Support of Mot. for Summ. J. (“Defs. Br.”) at 21 (citing D.E.
No. 23-3, Cert. of Laura Sullivan ¶¶ 4-6)). Thus, while the Court observes MetLife’s dual role, it
finds no evidence to confer special emphasis on this factor.
MetLife’s Determination Was Based On Substantial Evidence
MetLife argues that its adverse benefit determination was reasonable and based on
abundant evidence and therefore should be upheld. (Defs. Br. at 23). Specifically, it relies on
the substantial evidence including independent medical exams, Plaintiff’s own orthopedist that
cleared him for work, the expiration of the 24-month maximum benefit for his psychiatric
condition, and that there was no support for the conclusory diagnosis of dementia. (Id. at 27-29).
Plaintiff disagrees, arguing that MetLife’s decision was arbitrary and capricious, because he is
unable to work and the decision was not based on substantial evidence. (Pl. Opp. Br. at 15-20).
This Court has thoroughly reviewed the administrative record, and now concludes that
MetLife’s claim determination was reasonable, because it is supported by substantial evidence
and a reasonable person could accept the evidence as adequate to support the conclusion that
Plaintiff was not disabled.
Here, MetLife applied the express terms of the Plan and had
discretionary authority to determine Plaintiff’s eligibility for benefits. In August 2008, MetLife
granted Plaintiff’s claim for LTD benefits based on his diagnoses of Major Depressive Disorder
and Acute Reaction to Stress, and informed Plaintiff that this benefit expired in 24 months unless
one of three exclusions applied.
Two years later, in August 2010, MetLife approved the
continuation of LTD benefits because Plaintiff was also being treated for his severe back
problems, subject to periodic updates on his disabling medical condition.
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Thereafter, however, Plaintiff’s own orthopedist cleared him to return to work on April
20, 2011. MetLife also obtained a labor market analysis, which concluded that Plaintiff could
work in a sedentary position and that three jobs existed in his geographical area. Meanwhile,
Plaintiff’s psychiatrist, for the first time, diagnosed Plaintiff with dementia, but did not explain
his diagnosis or submit any evidence to explain the change in diagnosis. In fact, Plaintiff’s
neurologic evaluation performed by Dr. Ruderman had revealed “no focal abnormality.”
Consequently, MetLife sought an independent medical exam (“IME”) by a doctor that
specialized in neuropsychology. In his report dated January 17, 2011, Dr. Perrotti concluded that
there was no data to support a diagnosis of dementia.
Upon review of the entire claim file, including an independent review, a labor market
analysis and reports from Plaintiff’s own doctors that cleared him to return to work and did not
support their changed diagnosis of dementia, MetLife informed Plaintiff that he was no longer
disabled under the terms of the Plan and that his benefits would cease on May 19, 2011.
Following Plaintiff’s administrative appeal and submission of additional medical documentation,
MetLife obtained a second IME by licensed psychologist Dr. Murphy. Following a review of
extensive medical records, Dr. Murphy issued two reports and agreed with Dr. Perrotti’s
conclusion that Plaintiff’s mental disorder was “psychiatric not neurologic,” and that there was
no neurologic evidence to support the diagnosis of dementia.
Notably, Plaintiff’s doctors
diagnosed Plaintiff with dementia after the expiration of the 24-month benefit period in August
2010. Dr. Miller first diagnosed Plaintiff with dementia in November 2010 and then Dr. Craig
diagnosed dementia in March 2011. Neither Dr. Miller nor Dr. Craig supported their medical
conclusion with objective data and testing or offered an explanation for the new diagnosis.
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MetLife also obtained an IME from Dr. Mirkin who concluded that Plaintiff could return to a
Thus, MetLife reviewed the entire administrative file and obtained two IMEs in making
This Court finds that MetLife did not abuse its discretion because its
determination was based on substantial evidence. By relying on multiple independent medical
evaluations, as well as Plaintiff’s own doctor’s reports, to ultimately conclude that Plaintiff was
not disabled and was able to return to work, MetLife was not unreasonable. This Court finds that
there was adequate evidence that might cause a reasonable person to agree with the termination
of LTD benefits. Accordingly, this Court finds that no reasonable factfinder could find that
MetLife’s determination was arbitrary and capricious.
Plaintiff argues that his doctors have “remained steadfast that Plaintiff has dementia”
since October 2010, and that in 2011, Dr. Kopacz opined that Plaintiff could only work 20 hours
due to his back problems.
(Pl. Opp. Br. at 16, 18).
But, the Plan delegates to MetLife
discretionary authority to resolve any conflicts between the doctors. In light of MetLife’s
discretionary authority to determine Plaintiff’s eligibility for benefits, MetLife also had
discretion to resolve any factual disputes relating to his eligibility. Fleisher, 679 F.3d at 122
(finding that a grant of discretionary authority to the claims administrator to apply the plan also
“encompass[ed] the resolution of factual disputes”) (citation and quotation marks omitted).
MetLife’s findings of fact were amply supported and explained by evidence in the record. See
Abnathya v. Hoffman-LaRoche, Inc., 2 F.3d 40, 45 (3d Cir. 1993), abrogated on other grounds
by Glenn, 554 U.S. at 112 (finding that abuse of discretion is determined not by evaluating
whether the claim administrator’s determination was correct, but rather by evaluating whether
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the determination was reasonable and supported by the evidence). As such, this Court’s role is
limited to determining whether it reasonably resolved the conflicts, which it did.
Plaintiff also claims that because MetLife’s independent consultants only reviewed the
claim file and did not examine and treat Plaintiff, MetLife’s decision was arbitrary and
capricious. (Pl. Opp. Br. at 16-18). Here, too, Plaintiff’s argument is meritless. MetLife was
entitled to rely upon opinions of consulting doctors and not accord great weight to the treating
physicians’ opinions. See Black & Decker Disability Plan v. Nord, 538 U.S. 822, 834 (2003);
see also Nichols v. Verizon Commc’ns, Inc., 78 F. App’x 209, 211-12 (3d Cir. 2003) (claims
administrator could rely on opinions of consulting doctors); McCann v. Unum Provident, No. 113241, 2013 WL 1145422, at *15 (D.N.J. Mar. 18, 2013) (finding that “[b]oth the Third Circuit
Court of Appeals and district courts therein have concluded that a plan administrator that enjoys
discretionary authority to determine eligibility for benefits may (1) rely on the opinions of
nontreating physicians and, (2) accord those opinions greater weight that the opinions of treating
Plaintiff insists that the “arguable issue is whether Plaintiff is able to work with [his]
limitations.” (Pl. Opp. Br. at 19). But Plaintiff misses the point. The issue here is not whether
Plaintiff is not able to return to work and disabled, but rather whether MetLife’s termination of
LTD benefits was reasonable based on the evidence in the administrative record. Where, as here,
the administrative record contains substantial evidence that supports the determination, even with
evidence to the contrary, this Court must uphold the determination.
For the foregoing reasons, this Court does not find MetLife operated under a conflict of
interest in making the determination to terminate Plaintiff’s LTD benefits, and the Court finds
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that MetLife relied on substantial evidence in deciding to terminate Plaintiff’s LTD benefits.
Viewing these factors as a whole, the Court concludes that MetLife’s decision was not arbitrary
and capricious. Accordingly, Defendants’ motion for summary judgment is granted. An Order
accompanies this Opinion.
Esther Salas, U.S.D.J.
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