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Kandace Williams v. Metropolitan Life Insurance Company

January 11, 2011

KANDACE WILLIAMS, PLAINTIFF,
v.
METROPOLITAN LIFE INSURANCE COMPANY, A NEW YORK INSURANCE COMPANY, AT&T LONG TERM DISABILITY PLAN FOR OCCUPATIONAL EMPLOYEES, AN ERISA WELFARE BENEFIT PLAN, AND AT&T INTEGRATED DISABILITY SERVICE CENTER, DEFENDANTS.



The opinion of the court was delivered by: Judge Robert E. Blackburn

AMENDED*fn1

ORDER GRANTING DEFENDANTS' MOTION FOR SUMMARY JUDGMENT, AND DENYING PLAINTIFF'S MOTION FOR SUMMARY JUDGMENT, & RESOLVING RELATED MOTIONS

Blackburn, J.

This matter is before me on the following motions: (1) the AT&T Defendants' Motion for Summary Judgment on First and Second Claims [#66*fn2 (sealed version)], [#67 (redacted version)], & [#68 (public entry for [#66])] filed November 30, 2009; (2) the Plaintiff's Combined Cross-Motion and Brief in Support for Summary Judgment To Reverse Defendants' Decision To Terminate her Long-Term Disability Benefits [#72 (sealed version)], [#73 (redacted version)], & [#75 (public entry for [#72])] filed December 11, 2009; (3) the Plaintiff's Motion for Assessment of Penalties Against Defendant Metlife under 29 U.S.C. § 1132(c) [#77] filed December 21, 2009; (4) MetLife's Combined Motion and Brief for Summary Judgment [#83] filed January 8, 2010; and (5) the Plaintiff's Motion in Limine to Exclude Defamatory and Irrelevant Reference to Board Certification of Plaintiff's Treating Physician [#102] filed February 8, 2010. The parties filed responses [#66, #76, #88, #101, #104] and replies [#99, #100, #109] addressing two of the motions for summary judgment. Defendant, Metropolitan Life Insurance Company, filed a response [#84] to the motion for assessment of penalties, and the plaintiff filed a reply [#92] in support of her motion. Defendant, AT&T Long Term Disability Plan for Occupational Employees, filed a response[#108] to the motion in limine, and the plaintiff filed a reply [#110]. I grant the defendants' motions for summary judgment, and I deny the plaintiff's motion for summary judgment.*fn3 I deny the plaintiff's motion for assessment of penalties and the plaintiff's motion in limine.

I. JURISDICTION

I have jurisdiction over this case under 18 U.S.C. § 1331 (federal question) and 29 U.S.C. § 1132(e)(1) and (f) (ERISA).

II. FACTS

This lawsuit arises out of Defendant Metropolitan Life Insurance Company of America's ("MetLife") termination of the plaintiff's disability benefits under a long-term disability ("LTD") plan provided by the plaintiff's prior employer, AT&T, Corp., under the AT&T Long Term Disability Plan for Occupational Employees (Plan). The plaintiff, Kandace Williams, has been unable to return to her prior occupation since September 13, 2001. After leaving work , Ms. Williams made a claim for disability benefits under the Plan. MetLife, the Plan's claims administrator, certified Ms. Williams' LTD benefit for approximately three years and six months, from December 14, 2001 through May 31, 2005. MetLife terminated her disability benefits on May 20, 2005, stating that the medical information did not show a severity of disability that would preclude Ms. Williams from doing any other job for which she is qualified. Ms. Williams filed a timely appeal, and on August 1, 2005, MetLife upheld its adverse benefit determination. Ms. Williams subsequently provided additional information in support of her claim. On December 22, 2005, MetLife informed Ms. Williams that the information did not change its prior determination.

Ms. Williams' claims in this case arise under the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. §§ 1001 - 1461. Before her 2001 claim for disability benefits, Ms. Williams served as a Production Assistant with AT&T. In 2001, she sought disability benefits because she was no longer able to work due to several chronic medical conditions, including severe back pain resulting from a car accident in September of 2001. I describe her conditions only generally, because Ms. Williams has redacted from the public version of her motion for summary judgment the detailed description of her medical conditions. She has undergone several surgeries and her treatment has included substantial medication usage, including highly potent pain relievers. In addition to her back pain, Ms. Williams suffers from other conditions documented in the record. Ms. Williams contends that, due to the debilitating effect of these conditions, she has been unable to return to her prior occupation or any other occupation since September 13, 2001.

The AT&T Plan defines disability as follows: You're unable to do any job for any employer for which:

* You're qualified, or

* You may become reasonably qualified by training, education or experience, other than a job that pays less than 50% of your Eligible Base Pay at the time you became disabled.

Administrative record [#59 (sealed version)] & [#60 (public entry for [#59])], p. 1195. Hereafter, I will cite the administrative record as "Rec." with a page number.

The Plan is defendant AT&T Long Term Disability Plan for Occupational Employees. AT&T Corp. is the designated Plan Administrator and defendant Metropolitan Life Insurance Company (MetLife) was, at the relevant times, the designated Claims Administrator for the Plan. Rec., p. 1203. MetLife made the determination that Ms. Williams' disability benefits should be terminated. After Ms. Williams' benefits were terminated, defendant AT&T Integrated Disability Service Center became the Claims Administrator for the Plan.

Ms. Williams asserts three claims in her complaint. In her first claim for relief, she asserts a claim for benefits under the terms of the Plan. Under 29 U.S.C. § 1132(a)(1)(B), a plan beneficiary may assert a claim for benefits. Necessarily, this claim is asserted against defendant AT&T Long Term Disability Plan for Occupational Employees, the only source of Plan benefits. In her second claim for relief, Ms. Williams asserts a claim for breach of ERISA fiduciary duty against MetLife under 29 U.S.C. § 1104(a)(3). She contends that, as the Plan's claims administrator, MetLife breached its fiduciary duty to Ms. Williams when MetLife terminated Ms. Williams' disability benefits. In her third claim for relief, Ms. Williams asserts a claim against MetLife under 29 U.S.C. § 1132(c)(1). Ms. Williams alleges that MetLife failed timely to provide to Ms. Williams documents she requested from MetLife relevant to Ms. Williams' claim for benefits under the plan.

III. STANDARD OF REVIEW

ERISA provides a detailed and comprehensive set of federal regulations governing the provision of benefits to employees by employers. Under 29 U.S.C. § 1132(a), part of ERISA, a plan beneficiary has the right to federal court review of benefit denials and terminations. The statute does "not establish the standard of review for such decisions." Chambers v. Family Health Plan Corp., 100 F.3d 818, 824-25 (10th Cir.1996). In Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101 (1989), the Supreme Court established the basic framework for determining the standard of review in ERISA cases that challenge the denial or termination of benefits. "(A) denial of benefits challenged under § 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, 489 U.S. at 115. If the plan provides for such discretion, then the proper standard of review is abuse of discretion. Id. Ms. Williams concedes that the Plan at issue here gives the administrator or fiduciary discretionary authority to determine eligibility for benefits, and the abuse of discretion standard of review is applicable. Motion for summary judgment [#72 (sealed version)], [#73 (redacted version)] pp. 8 -9.

Under the arbitrary and capricious standard of review, the Plan's decision need not be the only logical decision nor even the best decision. Rather, the decision need only be sufficiently supported by facts known to the Plan to counter a claim that the decision was arbitrary or capricious. The decision will be upheld unless it is not grounded on any reasonable basis. Kimber v. Thiokol Corp., 196 F.3d 1092, 1098 (10th Cir. 1999). The reviewing court "need only assure that the administrator's decision fall[s] somewhere on a continuum of reasonableness - even if on the low end." Id. (quoting Vega v. National Life Ins. Serv., Inc., 188 F.3d 287, 297 (5th Cir. 1999)).

The United States Supreme Court recently outlined several considerations that are relevant to a reviewing court's application of the arbitrary and capricious standard. Metropolitan Life Ins. Co. v. Glenn, 554 U.S. 105, ___, 128 S.Ct. 2343, 2351 - 2352 (2008). These factors include: 1) any potential conflict of interest; 2) the quality and quantity of the medical evidence; 3) whether the plan or claims administrator provided greater emphasis to medical reports favoring a denial of benefits as opposed to those supporting a determination of disability; 4) whether the plan or claims administrator provided its reviewing physicians and other experts with all of the relevant evidence; 5) whether the plan or claims administrator "has taken active steps to remove bias and promote accuracy;" and 6) whether the plan or claims administrator considered any social security disability determination, including whether the administrator encouraged the claimant to apply for social security disability benefits, and then ignored a social security disability determination. Id. This list of considerations is not exhaustive.

In Glenn, the Court held that when an ERISA insurer holds a dual role in which it "both determines whether an employee is eligible for benefits and pays benefits out of its own pocket" that insurer has a conflict of interest. Metropolitan Life Ins. Co. v. Glenn, 554 U.S. 105, ___, 128 S.Ct. 2343, 2346 (2008). Ms. Williams does not claim that such a conflict of interest exists in this case. Ms. Williams argues, however, that all of the other factors weigh in favor of her contention that the defendants' termination of her disability benefits was arbitrary an capricious.

Generally, summary judgment is proper when there is no genuine issue as to any material fact and the movant is entitled to judgment as a matter of law. FED.R.CIV.P.56(c); Celotex Corp. v. Catrett, 477 U.S. 317, 322 (1986). In this case, the administrative record [#59 (sealed version)] & [#60 (public entry for [#59])] provides all of the relevant facts and there is no contention that the administrative record is incomplete or inaccurate. The undisputed and relevant facts are established, and the only remaining question is an evaluation of MetLife's benefits determination under the legal standard of review outlined above. After this review is complete, either the plaintiff or the defendants necessarily will be entitled to judgment as a matter of law.

IV. PLAINTIFF'S MOTION FOR SUMMARY JUDGMENT

For the purpose of applying the Glenn factors to the determination at issue in this case, I adopt, at least in a general sense, the plaintiff's statement of these factors, as stated in her motion for summary judgment.

A. MetLife's reviewing physicians were biased.

Ms. Williams contends that MetLife relied almost entirely on opinions rendered by reviewing physicians hired by MetLife. These physicians reviewed Ms. Williams medical records and opined that Ms. Williams is not disabled. These doctors never examined or spoke to Ms. Williams. Ms. Williams argues that MetLife's decision to credit the opinions of the reviewing physicians, and to disregard the opinions of her treating physicians, indicates an abuse of discretion by MetLife. Some of Ms. Williams' argument on this point implicates also Ms. Williams' claim that the reviewing physicians' did not review all of the evidence and that their analysis is flawed. I will consider here Ms. Williams' claim that the reviewing physicians were biased. I will consider below Ms.Williams' contentions that the reviewing physicians did not consider all of the evidence and used a flawed analysis.

Citing several other cases from other courts, Ms. Williams argues that two of MetLife's reviewing physicians, Dr Lumpkins and Dr. Marion, are biased. Both of these doctors are employed by Elite Physicians, a subsidiary of Network Medical Review (NMR). Citing evidence developed in other cases, Ms. Williams contends, for example, that in 2005, NMR derived over 25 percent of its revenue performing medical record reviews for MetLife. In essence, Ms. Williams claims that NMR, Dr. Lumpkins, and Dr. Marion have a financial incentive to make findings that the patients whose records they review are not disabled.

AT&T argues that the theory that reviewing physicians have an inherent bias or conflict in every case, because they are hired by a claims administrator, is not sufficient to alter the usual application of the arbitrary and capricious standard in an ERISA case. Davis v. Unum Life Ins. Co. of America, 444 F.3d 569, 575 (7th Cir. 2006). I agree with the Davis court that a showing of bias requires a plaintiff to show that the reviewing physicians had a specific incentive to derail the plaintiff's disability claim. No such incentive has been shown here. AT&T challenges the admissibility of much of the evidence cited by Ms. Williams in support of her claim of bias. I agree with AT&T that the admissibility of some of the evidence cited by Ms. Williams is, at best, questionable. However, I need not resolve this issue here because I conclude that the evidence cited by Ms. Williams is not sufficient to demonstrate that MetLife's reviewing physicians, Dr. Lumpkins and Dr. Marion, exhibited any significant bias in reviewing Ms. Williams' claim. Ms. Williams cites also claimed inconsistencies and flawed procedures in Dr. Lumpkins and Dr. Marion's reports as evidence of their bias. I analyze these contentions IV.C. of this order, below. I conclude that Ms. Williams has not shown inconsistencies or flawed procedures that show significant bias on the part of Dr. Lumpkins and Dr. Marion. This factor does not weigh in favor of a finding that MetLife abused its discretion.

B. MetLife ignored its own procedures.

Ms. Williams contends that MetLife ignored one of its procedures concerning tender of a reviewing physician's report to the employee's attending treating physician. The relevant MetLife procedure is contained in a sealed document filed with the court. Plaintiff's Combined Cross-Motion and Brief in Support for Summary Judgment To Reverse Defendants' Decision To Terminate her ...


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