Mohammed v. General Electric Company et al
Filing
23
MEMORANDUM DECISION denying 13 Motion for Summary Judgment. See Order for details. Signed by Judge David Sam on 2/13/13. (jmr)
THE UNITED STATES DISTRICT COURT FOR THE DISTRICT OF UTAH
CENTRAL DIVISION
****************************************************
)
Case No. 2:11CV542 DS
FAZLULLAH MOHAMMED,
Plaintiff,
)
MEMORANDUM DECISION
vs.
)
ON MOTION FOR
SUMMARY JUDGMENT
)
METROPOLITAN LIFE INSURANCE
COMPANY,
)
Defendants.
)
****************************************************
I. INTRODUCTION
Mr. Mohammed contends that lifting some heavy objects at work on April 20, 2004
caused such a severe injury to his left shoulder that he suffered the permanent and total loss of
use of his left shoulder and hand. Mr. Mohammed submitted a claim for the alleged injury under
the Accidental Death and Dismemberment Plan (“AD&D Plan”) of his former employer.
MetLife is the claim administrator of the AD&D Plan. MetLife reviewed Mr. Mohammed’s
claim, and concluded that he had not suffered a covered loss. After three administrative appeals,
all of which were denied, the claim was brought before this court. The Employee Retirement
Income Security Act (“ERISA”) governs the AD&D Plan. After carefully considering the parties
briefs and the administrative record, the Court finds that MetLife provided a full and fair review
of Mr. Mohammed’s claim for AD&D benefits, and that MetLife reasonably determined that
Mohammed was not entitled to receive AD&D benefits relating to his left shoulder and left hand.
Mr. Mohammed has not provided medical evidence of an injury constituting the permanent and
total loss of function in his left shoulder or left arm due to an accidental injury as required by the
AD&D Plan. The Court therefore denies Mr. Mohammed’s motion for summary judgment.
III. STANDARD OF REVIEW
A. Standard of Review Relating to Summary Judgment Under F.R.Civ.P. 56
Mr. Mohammed has filed a motion for summary judgment and supporting memorandum.
However, in the context of an ERISA case, “summary judgment is merely a vehicle for deciding
the case; the factual determination of eligibility for benefits is decided solely on the
administrative record, and the non-moving party is not entitled to the usual inferences in its
favor.”1 The Court will enter final judgment based on the evidence in the administrative record.
B. Standard of Review Under ERISA
Mr. Mohammed correctly notes that the standard of review for cases involving denial of
ERISA benefits is de novo unless there is language in the documents that govern the ERISA plan
granting discretion to a fiduciary of the plan to interpret the terms of the plan documents and to
determine eligibility for benefits.2 In this case, there is such language. MetLife is the insurer and
the payor of benefits under the General Electric Accidental Death or Dismemberment Insurance
Welfare Plan.3 MetLife is a “benefits administrator,” because it is an “insurance company . . .
that had been designated by [General Electric] to pay claims and/or administer a benefit plan on
[General Electric’s] behalf.”4 MetLife in its capacity as the benefits administrator and insurer of
benefits “has the authority and responsibility to interpret the provisions” of the AD&D Plan.5
1
Bard v. Boston Shipping Association, 471 F.3d 229, 235 (1st Cir. 2006).
2
Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115, 109 S.Ct. 948, 103 L.Ed.2d 80
3
Rec. 85.
4
Rec. 90.
5
Rec. 65.
(1989).
2
Therefore the Court will consider MetLife’s claim and appeal determinations under the arbitrary
and capricious standard of review.6
Under the arbitrary and capricious standard of review, the Tenth Circuit has held that:
‘[t]he Administrator[‘s] decision need not be the only logical one nor even the
best one. It need only be sufficiently supported by the facts within [its]
knowledge to counter a claim that it was arbitrary and capricious.’7
The Court’s “responsibility lay[s] in determining whether the administrator’s actions were
arbitrary and capricious, not in determining whether [the claimant] was, in the district court’s
view, entitled to disability benefits.”8 The Court “will uphold an administrator’s decision so long
as it is predicated on a reasoned basis.”9
IV. DISCUSSION
Mr. Mohammed claims that prior to April 20, 2004, he had no pre-existing conditions or
damage to the nerve and cartilages of the shoulders. In support of this claim, he provides
statements from his treating providers. Dr. Backman states that Mohammed “had no significant
injury prior to 4/20/04 to my knowledge. This injury was directly responsible for his injury and
issues he is still dealing with.” Dr. Backman also stated that Mr. Mohammed “has had a
6
The Court notes, however, that even under the de novo standard of review, the outcome
would have been the same. The evidence in the administrative record shows that MetLife correctly
denied Mohammed’s AD&D claim.
Kimber v. Thiokol Corp., 196 F.3d 1092, 1098 (10th Cir. 1999) (quoting Woolsey v. Marion
Laboratories, Inc., 934 F.2d 1452, 1460 (10th Cir. 1991)).
7
Sandoval v. Aetna Life & Cas. Ins. Co., 967 F.2d 377, 381 (10th Cir. 1992); see also
Hancock v. Metropolitan Life Ins. Co., 2008 WL 2996723 (D. Utah Aug. 1, 2008), aff’d, 590 F.3d
1141 (10th Cir. 2009).
8
Graham v. Hartford Life & Acc. Ins. Co., 589 F.3d 1345, 1357 (10th Cir. 2009) (quotation
omitted), cert denied, 130 S.Ct. 3356 (2010).
9
3
permanent loss of function that has been greater than one year.”10 Another treating physician said
that Mohammed
sustained an injury on April 20, 2004 that resulted in a hernia, left and right
shoulder pain. The left shoulder injury directly occurred due to the injury that he
sustained while he was at work. The patient reports that he had no pre-existing
dysfunction localized to his left shoulder before. While I have no x-rays or MRI
studies of his left shoulder before this injury, I presume that his left shoulder was
normal, given the fact that the patient had no previous history of pain.11
Notes from UUHN Westridge Medical Center state that the injury to his left shoulder occurred
“while lifting a heavy object almost two weeks ago.”12 Dr. Smoot opined about 5 months later
that Mohammed could “no longer perform the duties required of him at his present work.”13
Unfortunately, Mr. Mohammed submitted very limited medical evidence in support of these
statements.
Mr. Mohammed had an obligation to provide evidence establishing (i) the accident on
April 20, 2004, (ii) the injury resulting from that accident, and (iii) the permanent and total loss
of function in his left shoulder and left hand as a result of that accidental injury. Mohammed
failed to meet his burden of proof during the claim and appeal reviews.
The limited medical records that Mr. Mohammed submitted did not record any injury to
his left shoulder or left hand.14 However, x-ray reports of May 3, 2004 and May 13, 2004
showed severe osteoarthritis in Mohammed’s left shoulder. On October 14, 2004, one of
Mohammed’s treating physicians, Dr. Coleman, described the May 13, 2004 x-ray as revealing
10
Rec. 198.
11
Rec. 208.
12
Rec. 210 &221 (Gelman, MD., Medical Notes, dated May 3, 2004).
13
Rec. 223 (Medical Notes, dated September 29, 2004).
14
Rec. 283-303.
4
“severe left glenohumeral arthritis and moderate posterior subluxation of humeral head” in
Mohammed’s left shoulder.15 Dr. Amy Geroso, who examined Mr. Mohammed shortly after the
April 20, 2004 lifting accident, stated that her musculoskeletal examination indicated “pain back
and shoulder.” She did not report the complete loss of function of Mohammed’s left shoulder or
hand.16 She excused him from work from 04/21/04 to 04/26/04, later extending it to 05/03/04.
Dr. Geroso’s statements about Mohammed’s anticipated ability to return to work indicate that
she did not feel he had suffered a permanent or total loss of function in his left shoulder or left
hand.
MetLife had the medical evidence submitted by Mohammed, reviewed by two
independent physicians. Dr. Del Valle conducted the first review, and stated that an injury on
April 20, 2004 could not possibly have caused the “advanced osteoarthritic changes as noted in
the May 2004 x-rays.”17 Dr. Getz, a Board Certified Orthopedic Surgeon, provided the second
independent review. He also noted the pre-existing nature of the osteoarthritis in Mohammed’s
left shoulder.18 Neither doctor found any medical evidence that would support a finding of the
April 20, 2004 lifting incident as having caused Mohammed to suffer the permanent and total
loss of function in his left shoulder and left hand. MetLife denied Mohammed’s AD&D claim,
finding that there was substantial evidence that he had not suffered the permanent and total loss
of function in his left shoulder of left hand due to an accidental injury on April 20, 2004.
15
Rec. 294
16
Rec. 302.
17
Rec. 275.
18
Rec. 265.
5
In connection with his first administrative appeal, Mohammed submitted a number of
documents, including letters and office notes from his doctors, the previously submitted May 13
x-ray report, an MRI report, and an EMG report. None of these support the existence of a
permanent and total loss of function in Mohammed’s left shoulder and left hand due to an
accidental injury on April 20, 2004. Dr. Tashijian stated that, “[w]hile I have no x-rays or MRI
studies of his left shoulder before this injury, I presume that his left shoulder was normal given
the fact that the patient had no previous history of pain.”19 Mohammed’s physician’s assistant,
Ms. Macy, retracted her previous description of the April 20, 2044 lifting incident as having
caused an “exacerbation” of Mohammed’s left shoulder pain, but again did not cite any medical
evidence of a specific injury arising out of the incident. She identified the only conditions
affecting Mohammed’s left shoulder as “bilateral mild carpal tunnel symptoms, osteoarthritis of
left glenohumeral joint with associated rotator cuff syndrome.”20 Again, these conditions could
not have developed in the short interval between the accident on April 20, 2004 and the taking of
the May 3, 2004 x-ray.
The August 11, 2009 MRI of Mohammed’s left shoulder confirmed the severity of the
osteoarthritis.21 The findings were consistent with the x-rays, and the MRI did not reveal any
injury attributable to the April 20, 2004 lifting incident. The other letters and documents talked
about Mr. Mohammed’s condition, but failed to provide any medical evidence linking that
condition to the April 20, 2004 accidental injury.
19
Rec. 248-49.
20
Rec. 254.
21
Rec. 252.
6
MetLife referred Mohammed’s appeal submissions to Dr. Getz for review. He again
found no evidence of the total loss of function in Mohammed’s left shoulder or left hand.22 Dr.
Getz reiterated that “[a]ll radiographic findings reveal long-standing pre-existing conditions,”
and observed that “[t]here is no objective evidence of acute injury.”23 MetLife upheld the claim
denial in the first appeal.
In Mohammed’s second appeal, his lawyer submitted an argumentative letter and copies
of previously submitted documents to MetLife.24 As part of its review of the second appeal,
MetLife obtained the report of a third independent physician, Dr. Trotter, another Board Certified
Orthopedic Surgeon. He also concluded that the medical evidence did not support the existence
of an accidental injury on April 20, 2004 responsible for the total loss of function in
Mohammed’s left shoulder or left hand.25 Metlife upheld the claim denial in the second appeal.
The documents submitted in support of the third appeal were more of the same. They
contained general references to left shoulder pain and osteoarthritis, but provided no evidence
linking the osteoarthritis to the April 20, 2004 lifting incident, and providing no objective
analysis of the medical evidence. Two statements from different doctors discuss “marginal
improvement in the mobility of [Mohammed’s] left shoulder joint,” and recommend “[s]uitable
changes in his job pattern . . . so as to help him continue [to] earn his livelihood.”26 Both of these
22
Rec. 230-33.
23
Rec. 232.
24
Rec. 196-223
25
Rec. 180-85.
26
Rec. 161-62
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comments provide evidence that Mohammed had not suffered a permanent and total loss of
function in his left shoulder and left hand.
V. CONCLUSION
For the foregoing reasons, the Court finds that MetLife provided a full and fair review to
Mohammed’s claim for AD&D benefits. Based on the terms of the AD&D Plan and substantial
evidence in the administrative record, MetLife reasonably determined that Mohammed was not
entitled to receive AD&D benefits relating to his left shoulder and left hand. Therefore, the
Court denies Mr. Mohammed’s motion for summary judgment.
SO ORDERED.
DATED this 13th day of February, 2013.
BY THE COURT:
DAVID SAM
SENIOR JUDGE
U.S. DISTRICT COURT
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