Searching over 5,500,000 cases.

Buy This Entire Record For $7.95

Official citation and/or docket number and footnotes (if any) for this case available with purchase.

Learn more about what you receive with purchase of this case.


United States District Court, S.D. New York

June 6, 2005.


The opinion of the court was delivered by: PETER LEISURE, District Judge


Plaintiff Sharon Klecher brings this action under the Employee Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. § 001 et seq., and specifically under 29 U.S.C. § 1132(a)(1)(B), challenging the termination of Long-Term Disability ("LTD") benefits under her employer's benefit plan. Plaintiff brings this suit against defendants, the Metropolitan Life Insurance Company ("MetLife") and The Oxford Health Plans, Inc. Employee Welfare Plan ("the Plan"). On June 11, 2002, the parties cross-moved for summary judgment pursuant to Rule 56 of the Federal Rules of Civil Procedure. This Court granted in part defendants' motion and denied in part plaintiff's motion on June 5, 2003. Klecher v. Met. Life Ins. Co., No. 01 Civ. 9566, 2003 U.S. Dist. LEXIS 9572 (S.D.N.Y. June 5, 2003). On July 9, 2003, plaintiff sought leave to amend her Complaint under Rule 15 of the Federal Rules of Civil Procedure. On August 27, 2004, the Court denied plaintiff's request to file her proposed amended complaint but granted her request to file an amended complaint with the limited changes of adding Oxford Health Plans, Inc. ("Oxford") as a named defendant and repleading her claim for breach of fiduciary duty as to MetLife as one for improper denial of benefits under 29 U.S.C. § 1132(a)(1)(B). Klecher v. Met. Life Ins. Co., 331 F. Supp. 2d 279 (S.D.N.Y. 2004). Plaintiff filed her amended complaint on November 4, 2004, pleading the ERISA violation but apparently not adding Oxford as a defendant. Defendant now moves for renewed summary judgment under Rule 56 and plaintiff moves for judgment on the pleadings under Rule 12(c), based on plaintiff's only remaining claim asserting that defendants violated 29 U.S.C. § 1132(a)(1)(B) in terminating her LTD benefits under the Plan. For the following reasons, defendants' motion is granted and plaintiff's motion is denied as there is no material issue of fact in dispute. BACKGROUND*fn1

  I. The Parties

  Plaintiff Sharon Klecher was actively employed by Oxford as a Director of Provider Operations from January 2, 1996 (AR 149, at 2)*fn2 until October 20, 1998 when she took disability leave due to back pain (Defendants' Rule 56.1 statement filed with its first motion for summary judgment on April 1, 2002 ("Defs.' 56.1") attached to Defendants' Notice of Motion, dated October 29, 2004, at Ex. B ¶¶ 5, 7). She has not returned to work and is currently receiving Social Security Disability benefits. (See AR 157-61.)

  Defendant MetLife is the issuer and administrator of the Plan, established and maintained by Oxford to provide eligible Oxford employees with LTD benefits. (Defs.' 56.1 ¶¶ 1-2.)

  II. Plaintiff's Medical History Prior to Receipt of Disability Benefits

  Plaintiff Sharon Klecher has suffered from lower back pain since as early as 1990. (AR 300.) In 1995, Magnetic Resonance Imaging ("MRI") showed that she suffered from a mild narrowing of her vertebral spinal disc and showed evidence of disc desiccation. (Id. 228-29.) This was treated with physical therapy, which improved the pain. (Id. 149, at 2.) In October 1998, plaintiff complained of reinvigorated back pain coinciding with her third pregnancy. (Id. 300.) On October 20, 1998, plaintiff began receiving short term disability benefits and, on April 21, 1999, she was granted LTD benefits pursuant to the Plan. III. The Plan

  The Plan authorizes LTD benefits for Oxford employees deemed disabled depending on the following pertinent criteria:

[D]ue to an Injury or Sickness, you require the regular care and attendance of a Doctor and:
1. you are unable to perform each of the material duties of your regular job; and
2. after the first 24 months of benefits, you must be unable to perform each of the material duties of any gainful work or service for which you are reasonably qualified.
(Declaration of Jeanne Rudell ("Rudell Decl.") Ex. A at 16, attached to Defendants' Notice of Motion, dated October 29, 2004.) The Plan also grants MetLife and other Plan fiduciaries:
discretionary authority to interpret the terms of the Plan and to determine eligibility for and entitlement to Plan benefits in accordance with the terms of the Plan. Any interpretation or determination made 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. at 39.)

  IV. Denial of Benefits and Appeals

  On May 19, 1999, Drs. Joseph P. Communale, Jr., M.D. and Edward Glenn, M.D. administered another MRI on plaintiff which revealed that she suffered from degenerative disc disease and central vertebral disc herniation (protrusion of the disc) without evidence of spinal stenosis (narrowing of the spinal column) or foraminal encroachment. (AR 250.)

  On July 1, 1999, Klecher's primary care physician, Dr. Eileen Korpi, in her Attending Physician Disability Claim Statement (id. 243-45), noted that plaintiff suffered from a herniated lumbar disc and severe back pain with radiculopathy (disease of the spinal nerve roots). (Id. 243.) The statement maintained that plaintiff had no ability to sit, stand, walk, carry, twist, bend, reach or operate a motor vehicle. (Id. at 245.) Based on these restrictions, Dr. Korpi surmised that plaintiff could not work at all. (Id.) The prognosis for improvement was "possibly after delivery in 6 months." (Id.) Dr. Korpi's patient notes from July 12, 1999 indicate that plaintiff's back pain had improved "six weeks postpartum" but, based on plaintiff's description of her normal work routine, Dr. Korpi strongly recommended that plaintiff not return to work for at least six months. (Id. 273.) On September 9, 1999, Dr. Korpi examined plaintiff again and noted that she was in pain and had a palpable (noticeable by touch) muscle spasm in her upper back. (Id.)

  On September 28, 1999, MetLife's "in house physician" (id. 298), Dr. Amy Hopkins, M.D., M.P.H., PhD,*fn3 reviewed plaintiff's medical history. (Id. 300.) Dr. Hopkins found it inconsistent that plaintiff's treatment plan for residual back pain consisted largely of maintaining a state of recline as "[t]here is no documentation that she is recumbent most of the day, which would not be the indicated tx [treatment] for back pain in any case." (Id.) Dr. Hopkins recommended that,

[s]ince EE's [employee plaintiff's] sx [symptoms] have improved since the birth of her child, and no neurologic deficits are documented, there does not appear to be any reason why EE cannot return to her regular duties which are described as sedentary to light. Her MRI findings are mild and would not preclude any specific type of work.
(Id.) Dr. Hopkins did not recommend any further testing because "the documentation supports the lack of significant functional impairment." (Id. 300-01.) MetLife, presumably concerned with the veracity of plaintiff's LTD benefits claim, employed InPhoto Surveillance, Inc. ("InPhoto") to observe plaintiff at her home for two days. On September 30, 1999, InPhoto observed plaintiff walking one of her children from her home to the curb for the school bus. (Id. 293.) In the afternoon, InPhoto observed and videotaped plaintiff walking for three minutes around the outside of her home "in a normal, unrestricted fashion." (Id. 294.) Approximately a half-hour later, plaintiff was observed entering her neighbor's house, but, "[d]ue to the brevity of this activity, it was not possible to obtain videotape." (Id.) Less than ten minutes later, plaintiff was videotaped walking back to her house "in a normal, unrestricted fashion." (Id.) Finally, at 3:20 p.m., InPhoto took videotape of plaintiff retrieving her mail from her mailbox, again walking normally. (Id.) InPhoto summarized that day's observations as follows:
Ms. Klecher was observed walking and carrying in a normal, unrestricted fashion. She does not appear to be physically handicapped or disabled, nor does she wear any visible back brace or cervical collar. We note that she does not utilize the support of a cane while moving about.
Approximately three minutes of videotape were obtained on this day.
(Id.) In Photo had surveilled plaintiff for a total of ten hours. InPhoto continued its surveillance on October 1, 1999, videotaping plaintiff carrying her infant child to and from her house without obvious restriction. (Id. 295.) Two minutes of videotape were obtained out of ten hours of observation. (Id. 296.) InPhoto supplied substantially the same summary as that for September 30, 1999. (Id.)

  A. Initial Termination of LTD Benefits

  By letter dated October 4, 1999, MetLife advised plaintiff that, based on an ongoing review of her eligibility, her LTD benefits were discontinued effective October 1, 1999. (Id. 298; Defs.' 56.1 ¶ 10.) MetLife reviewed medical records from Dr. Korpi and Spagnoli Physical Therapy and plaintiff's claim file in its entirety. (AR 298.) The file was also reviewed by Dr. Hopkins. (Id.) The letter stated that, though plaintiff "may experience some discomfort there is no medical documentation or clinical data presented" supporting a diagnosis prohibiting plaintiff from performing her sedentary to light job duties. (Id.) MetLife finally advised plaintiff that she could file a written request for review of her claim within sixty days of the letter, complete with new medical information and facts important to reconsideration. (Id.)

  B. First Appeal

  On January 23, 2000, plaintiff's legal counsel, Aba Heiman, Esq., submitted a letter requesting that MetLife review its decision to terminate plaintiff's LTD benefits. (Id. 195.) Mr. Heiman directed MetLife's attention to new medical information including: (1) a report and studies from Dr. Scott McWilliams, M.D., neurologist, conducted in December of 1999; (2) medical records from Drs. Eileen and Carl T. Korpi, M.D. encompassing December 14, 1994 through December 2, 1999; and, (3) a narrative medical report and testing from Dr. Susan Jacoby-Berlin, neurologist, dated November 19, 1999. (Id. 195-96.) Mr. Heiman pointed out that the electromyogram ("EMG"), which records the electrical activity in muscles, administered by Dr. McWilliams on December 30, 1999, found lumbar radiculopathy which was consistent with the May 19, 1999 MRI's evidence of disc herniation. (Id. 196.)

  On February 22, 2000, Dr. Hopkins reviewed plaintiff's case file again along with the new medical information and InPhoto's surveillance observations. (Id. 192-93.) Dr. Hopkins stated that plaintiff's radiculopathy had been present since 1995 without documented worsening and without impeding her ability to perform her job duties. (Id. 192.) She noticed further discrepancies between plaintiff's notation of symptoms and the medical data: "EE stated that she has difficulty walking, but her gait was WNL [within normal limits] on exam. She stated that she cannot lift, yet she was seen to be carrying her child without difficulty." (Id.) Further, Dr. Hopkins could not ascertain how plaintiff's loss of sensitivity and motor function in her leg had worsened or would impede her ability to work. (Id. 193.) Further, Dr. Hopkins found that Dr. Jacoby-Berlin's "statement that EE is totally, permanently disabled does not have medical and functional information to substantiate it." (Id.) Dr. Hopkins concluded that plaintiff's symptoms were out of proportion with Dr. Jacoby-Berlin's physical findings. (Id.) Thus, Dr. Hopkins recommended that plaintiff take a functional capacity evaluation ("FCE") in order to corroborate plaintiff's claimed impairments. (Id.)

  On February 23, 2000, MetLife requested that plaintiff be authorized to take the FCE. The FCE "is a means of testing a person's lifting, carrying abilities, positional tolerances, dexterity, general endurance levels and ability to lift specific weights to certain heights. The typical [FCE] requires 4-8 hours of testing over 1 or more days." (Id. 188.) On March 3, 2000, Dr. Eileen Korpi refused to authorize plaintiff's taking of the FCE, stating, "I do not believe Sharon Klecher is able to perform this activity. This would be detrimental to her health." (Id.)

  On March 14, 2000, MetLife sent Mr. Heiman a five-page letter detailing its reasons for withdrawing plaintiff's LTD benefits and stating that it continued to believe that withdrawal was appropriate despite the new medical information. (Id. 149-52.) The letter stated that,

[a]lthough Ms Klecher reported to her providers of record that her duties required extensive travel and thus met light to heavy work strength criteria (depending on the report read), the Human Resources Contact at the Policy Holder discloses her job does not include any travel and is sedentary in nature.
(Id. at 149, second unnumbered page.) The letter went on to define sedentary work as:
[e]xerting up to 10 pounds of force occasionally (Occasionally: activity or condition exists up to 1/3 of the time) and/or a negligible amount of force frequently (Frequently: activity or condition exists from 1/3 to 2/3 or more of the time) to lift, carry. [sic] push, pull or otherwise move objects, including the human body. Sedentary work involves sitting most of the time, but may involve walking and standing for brief periods of time. Jobs are sedentary if walking and standing are required only occasionally and all other criteria are met.
(Id. (quoting United States Department of Labor, Dictionary of Occupational Titles App. C (4th ed. Rev. 1991)).) MetLife again noted that plaintiff's symptoms had improved following the birth of her third child on May 15, 1999. (Id.) Regarding the new medical reports, MetLife acknowledged that Dr. McWilliams found "mild to moderate right lumbar radiculopathy" but stated that it was "unclear from the brief report of examination how and why Dr. Jacoby-Berlin was able to conclude that Ms Klecher was limited in these activities [sitting, standing walking, lifting, et al.] when all but the [EMG] revealed normal activity and ability." (Id.) MetLife explained that, while there was no evidence of documented medically necessary restrictions on plaintiff's movement, there was documented evidence of her walking normally while under surveillance. MetLife qualified this remark by stating,


[w]hile we do not suggest that the brief periods of walking and carrying her 5 month old infant indicate or support an ability to return to work, we do conclude that her reports of discomfort and inability to perform routine tasks is not corroborated by the test results, the clinical examination findings, or the observations of the surveillance investigators.
(Id.) MetLife elaborated on the purpose of the FCE and argued it was not dangerous to plaintiff's health. (Id. 150.) Finally, MetLife differentiated plaintiff's impairment as an irreversible medical condition from a disability justifying benefits, i.e. an inability to engage in gainful activity because of an impairment. (Id. 151.) MetLife found that the medical documentation of plaintiff's right lumbar radiculopathic symptoms did not support a finding of disability so severe as to preclude plaintiff's return to her sedentary job. (Id. 152.) Thus, MetLife concluded its denial of benefits was appropriate and its October 1, 1999 decision remained in effect.

  C. Second Appeal

  On November 6, 2000, Mr. Heiman wrote to MetLife requesting that it reopen plaintiff's claim for evaluation. (Id. 153.) Mr. Heiman enclosed new information consisting of (1) plaintiff's notice of award of Social Security benefits, dated October 16, 2000; (2) Report from Dr. Rashed Ayyub, M.D., orthopedist, dated March 23, 2000; (3) report of Dr. Eileen Korpi, dated April 11, 2000 and August 29, 2000; and (4) Klecher's own description of her job duties. (Id.) Mr. Heiman argued that the surveillance video was not dispositive of whether plaintiff should be denied benefits under the plan because "the patient isn't playing tennis or unloading trucks. Neither is she in a wheel chair or vegetating in a dark room, but that is of course not required to obtain benefits." (Id.) Based on the medical diagnoses of Klecher's condition and his characterization of her job duties as "Light" rather than "Sedentary," Mr. Heiman asked MetLife to reconsider the denial of benefits and pay Klecher's claim. (Id. 154.)

  The Social Security Administration's letter states that Klecher became disabled under that agency's rules on October 20, 1998. (Id. 157.)

  Dr. Ayyub's report notes that plaintiff does not require a cane or assistance to walk. The report states that plaintiff suffers from "a lot of tenderness and muscle spasm of the lumbosacral spine," and limited spinal flexibility. (Id. 164.) He diagnosed her with herniated intervertebral disc of the lumbosacral spine and bilateral sciatica. (Id.) This, practically speaking, defines plaintiff as moderately disabled "in sitting and standing continuously for more than a few hours without interruption and walking more than a few blocks without interruption. She also has moderate disabilities in lifting more than a few 1b [pounds] at present." (Id.) As far as plaintiff's prognosis for future treatment, Dr. Ayyub states that "claimant has reached maximum medical improvement." (Id.)

  Dr. Korpi's August 29, 2000 report indicates that plaintiff has a disorder of the spine, herniated disc with spinal stenosis, significant pain, muscle spasm, and limited motion, none of which are likely to improve. (Id. 173.) Dr. Korpi states that plaintiff "is unable to stand for more than twenty minutes at a time, she is unable to sit for more than fifteen minutes at a time, she is unable to do any lifting at all." (Id.) This, the doctor avers, is all confirmed by multiple medical evaluations, including those performed by neurosurgeon Dr. Raphael Davis and neurologist Dr. Jacoby-Berlin, along with the MRI and EMG results. (Id. 172.)

  Plaintiff's description of her job duties contends that, in her role as Director of Provider Operations at Oxford, she is required to visit several hospitals per week. (Id. 178.) Plaintiff lives in Stony Brook, New York and the Oxford home office is one hour by car in Melville, New York. (See id.) She also visits New York City, Edison, New Jersey, and Norwalk, Connecticut once per week. (Id.) At each site, she is required to sit for four to five hours. (Id.) Additionally, in New York City, she must walk five to ten blocks carrying her fifteen-pound computer, a briefcase, and personal items. (Id.) Often, though it is unclear exactly how often, plaintiff visits sites in Manhasset, White Plains, Staten Island, and Brooklyn, all in New York State. (Id.)

  On November 14, 2000, Dr. Hopkins again reviewed plaintiff's claim. (Id. 144.) Based on a review of Drs. Ayyub and Korpi's submissions and classifying plaintiff's work level as sedentary, Dr. Hopkins concluded that:

The findings of physical examination do not correlate with the degree of impairment that EE claims to have. In addition, surveillance documented that EE's level of functioning was far in excess of that claimed. Dr. Korpi did not provide any comment on the surveillance results. There was no evidence of spinal stenosis or foraminal encroachment on MRI. Dr. Korpi refused to authorize an FCE, so specifics of functional capacity could not be evaluated.
(Id.) Based on the above evaluation, Dr. Hopkins recommendation was that "[n]o physical impairment was documented in this record which precluded EE from RTW [returning to work], FT [full time], own occupation." (Id. 145.)

  On November 15, 2000, MetLife advised Mr. Heiman that the new information provided did not alter its decision to discontinue plaintiff's benefits. (Id. 142.) Following that final determination, plaintiff initiated the instant suit.


  I. Summary Judgment Standard

  A moving party is entitled to summary judgment if "the pleadings, depositions, answers to interrogatories, and admissions on file, together with the affidavits, if any, show that there is no genuine issue as to any material fact and that the moving party is entitled to judgment as a matter of law." Fed.R.Civ.P. 56(c); see Celotex Corp. v. Catrett, 477 U.S. 317, 322-23 (1986); Holt v. KMI-Cont'l Inc., 95 F.3d 123, 128 (2d Cir. 1996). The substantive law underlying a claim determines if a fact is material and "[o]nly disputes over facts that might affect the outcome of the suit under the governing law will properly preclude the entry of summary judgment." Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 248 (1986). When considering the motion, the Court should not "resolve disputed issues of fact but . . . assess whether there are any factual issues to be tried." Knight v. U.S. Fire Ins. Co., 804 F.2d 9, 11 (2d Cir. 1986).

  To determine whether genuine issues of material fact exist, the Court must resolve all ambiguities and draw all justifiable inferences in favor of the nonmoving party. See Anderson, 477 U.S. at 255; Holt, 95 F.3d at 129. The moving party bears the burden of demonstrating that no genuine issue of material fact exists. See Adickes v. S.H. Kress & Co., 398 U.S. 144, 157 (1970); Gallo v. Prudential Residential Serv. L.P., 22 F.3d 1219, 1223-24 (2d Cir. 1994). "[T]he movant's burden will be satisfied if he can point to an absence of evidence to support an essential element of the nonmoving party's claim." Goenaga v. March of Dimes Birth Defects Found., 51 F.3d 14, 18 (2d Cir. 1995). Once the moving party discharges its burden of demonstrating that no genuine issue of material fact exists, the burden shifts to the nonmoving party to offer specific evidence showing that a genuine issue for trial exists. See Celotex, 477 U.S. at 324. The nonmoving party "must do more than simply show that there is some metaphysical doubt as to the material facts." Matsushita Elec. Indus. Co. v. Zenith Radio Corp., 475 U.S. 574, 586 (1986). "A `genuine' dispute over a material fact only arises if the evidence would allow a reasonable jury to return a verdict for the nonmoving party." Dister v. Cont'l Group, 859 F.2d 1108, 1114 (2d Cir. 1988) (citing Anderson, 477 U.S. at 248). The Second Circuit reviews a District Court's disposition of a summary judgment motion de novo. Mario v. P & C Food Mkts., 313 F.3d 758, 763 (2d Cir. 2002) (quoting Morales v. Quintel Entm't, Inc., 249 F.3d 115, 121 (2d Cir. 2001)).

  II. Plaintiff's Claim That MetLife's Denial of Benefits Was Arbitrary and Capricious

  The only claim surviving the Court's first Opinion granting in part and denying in part the parties' motions for summary judgment is plaintiff's claim that defendants denied her LTD benefits in violation of ERISA. (See Plaintiff's Second Amended Complaint ("Second Amended Complaint") ¶ 49 (requesting relief for violation of ERISA, 29 U.S.C. § 1132(a)(1)(B)).) Title 29 section 1132 provides for civil enforcement of a person's right to employment disability benefits "to recover benefits due to him under the terms of his plan, to enforce his rights under the terms of the plan, or to clarify his rights to future benefits under the terms of the plan." 29 U.S.C. § 1132. In order to obtain relief under section 1132, plaintiffs "must first pursue any administrative means of redress provided by their benefit plans." Yoran v. Bronx-Lebanon Hosp. Ctr., No. 96 Civ. 2179, 1999 U.S. Dist. LEXIS 8679, at *23 (S.D.N.Y. June 10, 1999) (Leisure, J.) (citing Kennedy v. Empire Blue Cross & Blue Shield, 989 F.2d 588, 594 (2d Cir. 1993); Leonelli v. Pennwalt Corp., 887 F.2d 1195, 1199 (2d Cir. 1989)). "This exhaustion requirement is a jurisdictional prerequisite to a suit for benefits under ERISA." Id. (citing, inter alia, Ambris v. Bank of N.Y., No. 96 Civ. 0061, 1998 U.S. Dist. LEXIS 15801, *20 n. 7 (S.D.N.Y. Oct. 7, 1998); Barnett v. IBM Corp., 885 F. Supp. 581, 586-87 (S.D.N.Y. 1995)). Plaintiff has satisfied this requirement by submitting two requests to MetLife to review its decision to deny her benefits. MetLife twice refused to reverse its decision which "represented MetLife's final determination" of plaintiff's eligibility for LTD benefits. (AR 142.) This point is uncontested by the parties, thus, plaintiff's claim is properly before this Court.

  The Court did not dispose of plaintiff's remaining claim in the last Opinion because it was unclear whether the operative benefits plan conferred discretionary authority upon the plan administrator to determine plaintiff's eligibility. Klecher, 2003 U.S. Dist. LEXIS 9572, at *24-25 & n. 9. This issue has been resolved and is undisputed by the parties; both the 1998 and 1999 benefits plans contained a discretionary clause and were distributed to plaintiff. (Pl.'s Mem. at 3; Defs.' Mem. at 3.) Therefore, as stated in the last Opinion, the proper legal yardstick by which the Court should measure plaintiff's claim is whether MetLife's denial of plaintiff's benefits was an arbitrary and capricious decision. See Klecher, 2003 U.S. Dist. LEXIS 9572, at *27 (citing Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989)). In doing so, the Court may only look to the administrative record that was available to MetLife at the time of its decision. Id. (citing Miller v. United Welfare Fund, 72 F.3d 1066, 1071 (2d Cir. 1995)). Under this deferential standard, the Court may reverse MetLife's decision to deny plaintiff LTD benefits only if the decision was "without reason, unsupported by substantial evidence, or erroneous as a matter of law." Pagan v. NYNEX Pension Plan, 52 F.3d 438, 442 (2d Cir. 1995). The scope of the Court's power to review MetLife's decision as arbitrary and capricious is narrow. The Court cannot "substitute its judgment for that of the plan administrator as if the question of eligibility were being considered anew." Yoran, 1999 U.S. Dist. LEXIS 8679, at *31 (citing Pagan, 52 F.3d at 442). Moreover, the Court must let MetLife's denial of benefits stand if it was a reasonable decision. Sharkey v. Ultramar Energy Ltd., 70 F.3d 226, 229 (2d Cir. 1995); Jordan v. Ret. Comm. of Rensselaer Polytech. Inst., 46 F.3d 1264, 1273 (2d Cir. 1995). Following that, if there is a dispute as to the interpretation of the plan, the Court must side with the plan administrator's interpretation if it is reasonable. Pagan, 52 F.3d at 443; see also Jordan, 46 F.3d at 1273 (finding that where plaintiff's interpretation is "as reasonable as the interpretation adopted by the [plan administrator] the arbitrary and capricious standard" requires the Court "to defer to the interpretation of the [administrator]").

  Plaintiff claims that MetLife ignored evidence that she was disabled by relying solely on Dr. Hopkins' reports and the surveillance video. (Pl.'s Mem. at 14-15.) Further, plaintiff argues that Dr. Hopkins is not disinterested because she reviews over 500 claims per year for MetLife. (Id.) Finally, plaintiff argues that MetLife mistakenly characterized her job activity as sedentary where it should have been characterized as sedentary to light. (See id. at 12; Pl.'s Reply at 1-4.)

  Defendants claim that the plan administrator's decision was not arbitrary or capricious because it was based on plaintiff's medical records demonstrating she was no longer disabled to the extent it would prevent her from performing her sedentary job duties. Defendants support MetLife's decision with: (1) the May 20, 1999 MRI showing no evidence of spinal cord or nerve root compression (AR 317); (2) Dr. McWilliams' neurological report of normal gait, coordination and muscle power (id. 200-02); (3) InPhoto's surveillance video showing plaintiff walking with normal gait and holding her child (id. 274-75); (4) Dr. Ayyub's report finding plaintiff "ambulatory," walking without assistance (id. 163-65); and (5) Dr. Hopkins' three independent reviews of plaintiff's records concluding plaintiff was not sufficiently disabled (id. 144-45, 192-93, 300-01). (Defs.' Mem. at 4-5; Defs.' Reply at 4-5.) Defendants claim that this evidence contradicted the diagnoses of Drs. Korpi and Jacoby-Berlin finding that plaintiff is sufficiently disabled to receive LTD benefits. (Defs.' Reply at 6.) MetLife does not dispute plaintiff's underlying diagnosis; rather, MetLife only disputes that she was disabled to the point of being barred from performing her sedentary job functions. (Id. 6, 8 (citing MetLife's letter upholding its denial of plaintiff's benefits, dated March 14, 2000 (AR 186)).)

  Defendants' arguments are persuasive and carry the day. MetLife reviewed plaintiff's eligibility for LTD benefits three separate times. During the course of those reviews, MetLife reasonably resolved the doctors' conflicting opinions regarding the effect of plaintiff's health on her ability to work by relying on the factual findings in the MRI, the doctors' own reports, the surveillance observations, and Dr. Hopkins' independent opinion. This comports with the Supreme Court's decree on the subject:

Plan administrators, of course, may not arbitrarily refuse to credit a claimant's reliable evidence, including the opinions of a treating physician. But, we hold, courts 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.
Black & Decker Disability Plan v. Nord, 538 U.S. 822, 834 (2003); see also, Fay, 287 F.3d at 108 ("Despite [plaintiffs'] presentation of two qualified experts' opinions to the contrary, this Court cannot find Oxford's determination of medical necessity `without reason, unsupported by substantial evidence or erroneous as a matter of law.'" (quoting Pagan, 52 F.3d at 442)). Plaintiff's blanket assertion that Dr. Hopkins is biased toward MetLife's position finds no support in the Administrative Record. That the doctor regularly reviews MetLife's claims and is referred to as an "in house physician" (AR 298) does not automatically trigger a finding that she is predisposed to denying any benefits claims that crosses her desk. The same is true for the allusion that MetLife is inherently biased in its decision to deny benefits based on its potential to gain economically in that denial. (See Pl.'s Mem. at 16 n. 13); see, e.g., Rosenthal v. First UNUM Life Ins. Co., Nos. 02 Civ. 7661, 02 Civ. 7700, 04 Civ. 0845, 2005 U.S. App. LEXIS 4897, at *2 (2d Cir. Mar. 24, 2005); Fay, 287 F.3d at 108 (finding that no conflict of interest existed where the record did not support such a conclusion and defendant only had a monetary bias in denying the sought benefits). Further, MetLife's overview of the entire claim cures any deficiencies in Dr. Hopkins' reports, including her omission of Dr. Ayyub's diagnosis. (See Pl.'s Mem. at 14.) In fact, any allegation that Dr. Hopkins' determination was "arbitrary and capricious" is moot for Dr. Hopkins did not make the decision to terminate plaintiff's benefits; rather that was the sole province of the plan administrator, MetLife, and it is MetLife's decision that the Court reviews. (See id. at 15.) Nor is this a case where the plan administrator improperly relied solely on the surveillance video. (See Pl.'s Mem. at 6-7; see also Defs.' Reply at 10-11.) Rather, MetLife made a reasoned decision based on the complete, available record that plaintiff's health would not impair her conduct of the material duties of her job.

  Plaintiff's claim that MetLife mischaracterized her job as sedentary, too, must fail. First, the Court notes that Dr. Hopkins' initial recommendation that plaintiff's diagnosis did not justify LTD benefits was based on plaintiff's job being "sedentary to light." (AR 300.) However, to the extent that MetLife viewed plaintiff's job duties as solely "sedentary" in making its decision to continue to deny plaintiff's benefits, that view was not arbitrarily or capriciously held. Instead, MetLife characterized plaintiff's job based on her employer's human resource department's classification and plaintiff's personal job description. While the human resource classification may not have been sufficiently close to the source to reflect accurately plaintiff's job duties, plaintiff's own description certainly was. In it, plaintiff notes travel obligations requiring her to sit in a car for up to two and a half hours at a time, coupled with the necessity of walking several blocks with a laptop, briefcase, and personal items. (Id. 178.) As stated above, sedentary jobs involve sitting most of the time, and "exerting up to 10 pounds of force occasionally (Occasionally: activity or condition exists up to 1/3 of the time)." (Id. 149, at 2d unnumbered page (quoting United States Department of Labor, Dictionary of Occupational Titles App. C (4th ed. Rev. 1991)).) "Jobs are sedentary if walking and standing are required only occasionally and all other criteria are met." (Id.) It is the Court's view that MetLife's decision that plaintiff's job fell within the above definition was not arbitrary or capricious. Plaintiff's only non-sitting activity was the five to ten block walk once per week in New York City with the aforementioned items. That certainly would constitute walking "only occasionally" and it appears that "all other criteria are met." It is inapposite that her so-called "commute" to numerous cities were required under her job description (Pl.'s Reply at 1-3; Defs.' Reply at 3-4) for those commutes, too, are reasonably construed as sedentary in nature under the above definition.

  Finally, in the unlikely event that MetLife misconstrued plaintiff's job as "sedentary" when it was actually "light" based on plaintiff's notation that she was required to lift and carry her fifteen pound laptop, the mistake is not fatal. The lifting of the computer was not a material aspect of her job that plaintiff was unable to perform, thus justifying a grant of LTD benefits. The material aspects of her job as viewed from her own description, were sitting in a car or working at a desk. As stated above, MetLife reasonably determined plaintiff was capable of these activities based on its review of plaintiff's entire file and the video surveillance.*fn4


  The Court finds nothing in the record before it suggesting that MetLife's twice reviewed decision to discontinue plaintiff's LTD benefits was arbitrary and capricious. Therefore, defendants' motion for summary judgment pursuant to Federal Rule of Civil Procedure 56 is hereby GRANTED. Plaintiff's cross-motion for judgment on the Administrative Record pursuant to Federal Rule of Civil Procedure 12(c) is hereby DENIED.


Buy This Entire Record For $7.95

Official citation and/or docket number and footnotes (if any) for this case available with purchase.

Learn more about what you receive with purchase of this case.