The opinion of the court was delivered by: David G. Larimer, Chief District Judge
Plaintiff began working for Philips in 1983. Plaintiff worked in
several capacities over the years, and was employed as a parts assembler
and welder in April 1986, when he injured his back at work. In 1987,
plaintiff applied for and began receiving long term disability ("LTD")
benefits under the Plan. The Summary Plan Description ("SPD") for the
Plan in effect at the time that plaintiff applied for benefits states
that a Plan participant will be eligible for benefits when he suffers
from a "total disability," which the SPD defines as follows:
"Total disability" as used in this Plan means
inability, because of an injury or sickness, to engage
in any gainful occupation for which you are reasonably
fitted by education, training or experience. However,
for the first twelve months of your absence due to
disability, you will be considered totally disabled if
you are unable, because of illness or injury, to
perform any and every duty of your occupation. In
addition, you must be under the care of a physician
for any required treatment of your disability.
Declaration of Hope A. Webber (Docket Item 17) Ex. A at 10. The SPD also
states that no benefits will be paid "after the date you fail to furnish
satisfactory proof, as required by the insurance company, of the
continuance of total disability." Id. at 4.
After it began paying benefits to plaintiff, MetLife would periodically
review his claim to determine if plaintiff's condition continued to meet
the definition of "total disability." In January 1997, MetLife arranged
for plaintiff to be examined by Robert Siliciano, M.D., an orthopedic
surgeon. In his report, Dr. Siliciano opined that plaintiff "could
tolerate an occupation which would allow him to change positions from
sitting, standing and walking periodically. He should also refrain from
doing repetitive bending or lifting more than 10 lbs." Record at 18.*fn1
MetLife forwarded Dr. Siliciano's report to Dr. Manola Basa,
plaintiff's treating physician, and invited him to respond with any
comments or additional documentation. Record at 295. MetLife alleges, and
plaintiff does not dispute, that MetLife received no response.
MetLife then solicited a labor market survey from Stickney
Rehabilitation Services, Inc. ("Stickney"), which submitted a report on
March 17, 1997, listing eleven jobs within fifty miles of plaintiff's
home that, according to Stickney, were within plaintiff's work experience
and physical restrictions. Record at 291.
Plaintiff then agreed to participate in job placement. To that end,
MetLife retained CRA Managed Care, Inc. ("CRA"), which in a report dated
April 24, 1997, described plaintiff as "not financially motivated to
return to work." Record at 15. A final report dated June 4, 1997
indicated that plaintiff showed little or no interest in finding a job,
and that "further vocational assistance would not be indicated." Record
Also in June 1997, MetLife sent plaintiff a letter advising him that
"it has not been established that you continue to be totally disabled as
defined in Philip's [sic] LTD Plan. It appears that you are able to
perform some type of remunerative work. We must therefore advise you that
your claim for LTD benefits is being terminated effective July, 1, [sic]
1997." Record at 272.
Plaintiff then sought review of MetLife's decision to discontinue his
benefits. In the course of that review, MetLife accepted additional
medical documentation from plaintiff, and sent his entire file to Network
Medical Review Co. ("NMR"). In a report dated June 16, 1998, Dr. Robert
Petrie of NMR opined that plaintiff was "capable of performing job duties
within the parameters listed," which included some relatively moderate
physical restrictions on lifting, carrying, etc. Record at 11.
On June 23, 1998, MetLife forwarded Dr. Petrie's report to Dr. Basa,
plaintiff's treating physician, stating, "[i]f you are in agreement [with
Dr. Petrie's findings], please sign, date and return this notice to our
attention." Dr. Basa did so on June 24, 1998. Record at 190.
Plaintiff also submitted to MetLife a report dated July 10, 1998,
prepared by Dr. Robert Tiso of Office of Pain Management. Dr. Tiso did not
render an opinion as to whether plaintiff could work, but described
plaintiff's medical history and physical condition, and stated that Dr.
Tiso's "impression [wa]s that of Post laminectomy pain syndrome with a
severe reactive depression." Record at 184.
MetLife forwarded Dr. Tiso's report to Dr. Petrie, who stated that
"[a]fter reviewing the additional information, the previous opinion is
unchanged. Mr. Brooks has mild residual symptoms and deficits. . . . It
remains my opinion that he is capable of working within the parameters
indicated in the report dated June 16, 1998." Record at 7.
Based on these reports, MetLife upheld its prior determination to
discontinue plaintiff's benefits.
Plaintiff commenced the present action in January 1999. He alleges that
he remains totally disabled and that defendants' determination that he is
not disabled is arbitrary and capricious, and a breach of their fiduciary
duty. The first cause of action seeks benefits pursuant to
29 U.S.C. § 1132(a)(1)(B). The second cause of action seeks a
declaration that plaintiff is entitled to benefits, and the third cause
of action requests an award of attorney's fees under
29 U.S.C. § 1132(g)(1). The fourth cause of action appears to assert
claims under both ERISA and New York law. It alleges that defendants'
discontinuation of plaintiff's benefits constituted a breach of their
fiduciary duty and their implied covenant of good faith and fair
dealing, and that it was capricious, arbitrary and ...