Plaintiff Jonnie Mae Robinson claims that Metropolitan Life Insurance Company ("MetLife"), the Skadden, Arps, Slate, Meagher & Flom, LLP ("Skadden") Plan and its Plan Administrator denied her application for long-term disability benefits in violation of the Employee Retirement Income Security Act ("ERISA"), 29 U.S.C. § 1001 et seq.
Both sides move for summary judgment pursuant to Rule 56 of the Federal Rules of Civil Procedure.
While the parties dispute whether the standard of review should be de novo or "arbitrary and capricious," the administrator's conclusion cannot be upheld under either.
ERISA states that every employee benefit plan shall "afford a reasonable opportunity to any participant whose claim for benefits has been denied for a full and fair review by the appropriate named fiduciary on the decision denying the claim."
Pursuant to 29 U.S.C. § 1135, the Department of Labor delineated the claims procedures that a disability benefits plan shall follow in order to provide a claimant "with a reasonable opportunity for a full and fair review of a claim and adverse benefit determination." 29 C.F.R. 2560.503-1(h)(4). These procedures include:
Provide that, in deciding an appeal of any adverse benefit determination that is based in whole or in part on a medical judgment, including determinations with regard to whether a particular treatment, drug, or other item is experimental, investigational, or not medically necessary or appropriate, the appropriate named fiduciary shall consult with a health care professional who has appropriate training and experience in the field of medicine involved in the medical judgment.
29 C.F.R. 2560.503-1(h)(3)(iii). Citing this provision, Ms. Robinson argues that MetLife mistakenly referred her appeal to Dr. J.W. Rodgers, an internist and pulmonary specialist, rather than to a neurologist or neurosurgeon.
Among the documents Ms. Robinson submitted in support of her claim were forms in which she and Dr. Robert Holtzman, her neurosurgeon, explained the basis for her claim that she was eligible for long-term disability benefits. The medical conditions they cited as forming the basis of Ms. Robinson's claim were almost entirely neurological in nature. In her initial claim form, Ms. Robinson stated that she was prevented from performing the duties of her job because of: "no control of left arm shoulder-no feeling, pain in spine, paralicist [sic] of left side vocal cord, head aches, equalibrium, [sic] weakness [illegible] leg." December 12, 2005 Affidavit of Karin T. Mohry, Ex. B, Vol. I, ML 0036.*fn1 Similarly, in her "Personal Profile," Ms. Robinson listed as physical limitations related to her return to work: "vocal cords don't move on left side causes breathing problems, problem with balance, pain in spine, headaches, pain left arm, shoulder, lost [sic] of feeling on left side weakness on left side head to toe." Id., ML 0064. Dr. Holtzman diagnosed her with Syringomyelia*fn2 and Arnold Chiari Malformation*fn3 and noted his objective findings as: "Pain/loss of sensation & control L arm, shoulder, pain in spine, L sided paralysis of vocal cords, HA's [head aches?]." Id., ML 0036. Dr. Holtzman stated that he had advised Ms. Robinson not to return to work because "Pt has extreme difficulty travelling to & from work, difficulty with prolonged sitting, standing and walking. All activities have been limited due to multiple problems co-morbidities." Id., ML 0041.
MetLife contends that Ms. Robinson had "multiple diagnoses and complaints," and it was therefore appropriate for her claim to be referred to an internist because "broad medical expertise was required to assess a wide range of diagnoses." February 3, 2006 Def. Opp. Mem. at 4-5. In addition, MetLife classified Ms. Robinson's primary problem as "breathing difficulty associated with the vocal cord paralysis and sleep apnea," requiring consultation with a pulmonary specialist like Dr. Rodgers. Id. at 5. While her medical file includes those complaints, they are not her "primary problems" as enumerated in her claim forms and the forms submitted by Dr. Holtzman.
More significantly, those particular ailments are not the basis of her claim for long-term disability. Rather, Ms. Robinson and Dr. Holtzman identify alleged neurological conditions that disable her, including loss of sensation and control and weakness on the left side of her body, pain in her spine and headaches. In her "Request for Claim Review," Ms. Robinson specifically requested that her appeal be reviewed by a doctor who could properly assess her neurological conditions:
If possible can my claim be reviewed by a certified license Doctor who knows or would take the time to look up Syringomyelia Arnold Chiar I Malformation, because the problems I suffer with now is after having an operation to eliminate the pressure ...