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McGann v. Travelers Property Casualty Corp.

September 21, 2007

ELIZABETH MCGANN, PLAINTIFF,
v.
TRAVELERS PROPERTY CASUALTY CORP. WELFARE BENEFIT PLAN AND TRAVELERS PROPERTY CASUALTY CORP. IN ITS CAPACITY AS PLAN ADMINISTRATOR OF TRAVELERS PROPERTY CASUALTY CORP. WELFARE BENEFIT PLAN, DEFENDANTS.



The opinion of the court was delivered by: Hurley, Senior District Judge

MEMORANDUM AND ORDER

Plaintiff Elizabeth McGann ("Plaintiff") brings this action seeking to recover long-term disability benefits under her employer's benefit plan. Both Plaintiff and defendants Travelers Property Casualty Corp. ("Travelers") and Travelers Welfare Benefit Plan (the "Plan") (collectively, "Defendants") have moved for summary judgment pursuant to Federal Rule of Civil Procedure ("Rule") 56. For the reasons stated below, both motions are denied without prejudice to renew upon the completion of limited discovery.

BACKGROUND

The material facts, drawn from the Complaint and the parties' Local 56.1 Statements, are undisputed unless otherwise noted.

Plaintiff's Injury at Work

Plaintiff was employed as an automobile no-fault insurance claims representative for Travelers. On May 10, 2004, Plaintiff suffered a back injury at work while lifting a claim file. She returned to work after a short absence but left again on October 6, 2004, after allegedly re-injuring her back. She received short-term disability benefits for the maximum period, through January 5, 2005. On December 14, 2004, Plaintiff filed a claim for long-term disability benefits provided for under the Plan. Plaintiff also filed a Workers' Compensation ("WC") claim with St. Paul Travelers, her employer's WC carrier.

The Plan

Travelers established and maintains the Plan to provide long-term disability benefits to its eligible employees. The Plan is an employee welfare benefit plan governed by the Employee Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. §§ 1001 et seq. Metropolitan Life Insurance Company ("MetLife") is the Plan's claim administrator and also funds Plan benefits through a group policy of insurance. The Plan grants MetLife "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." (R. at 0247.)*fn1

The Plan defines "Disability" and "Disabled" as:

[D]ue to sickness, pregnancy or accidental injury, you are receiving Appropriate Care and Treatment from a Doctor on a continuing basis[] and during the Elimination Period and the next 24 month period, you are unable to perform all of the material duties of your Own Occupation for any employer in your Local Economy. (Id. at 0209.) After the Elimination Period and the first 24 months of benefits, the definition of disability becomes stricter:

[Y]ou are unable to perform all the material duties of any gainful occupation for which you are reasonably qualified taking into account your training, education, experience and Predisability Earnings.

(Id.)

The Plan requires that a claimant provide documented proof of disability "satisfactory to [MetLife]." (Id. at 0230.) As claim administrator, Met Life is responsible for initially reviewing claims and determining benefits eligibility. If a claim is denied, the claimant may appeal to MetLife. (Id. at 0245-47.)

MetLife's Denial of Long-Term Benefits

By letter dated January 4, 2005, MetLife denied Plaintiff's claim for long-term disability benefits, relying, in part, on the report of Dr. Andrew Miller, an independent orthopedic surgeon, who examined Plaintiff at the bequest of Travelers' WC carrier. In his report dated November 24, 2004, Dr. Miller diagnosed Plaintiff with "lumbar spine sprain/strain" and concluded as follows: "There is evidence of mild disability in regards to the lower back. [Plaintiff] is capable of working and performing the activities of daily living with restrictions to be placed on heavy lifting and carrying over 15 lbs." (Id. at 077.)

MetLife's denial letter was written by K. Ryan Conklin ("Conklin"), Disability Case Manager, and provides, in pertinent part, as follows:

Based on the extensive review of your claim we have determined that you do not meet the definition of disability per your employer's plan.

In reference to your disability claim indicated above, a review of your file indicates that you have been out of work from your position as a Claims Representative since October 6, 2004. During this period you had a diagnosis of lumbar intervertebral disc displacement. The Independent Medical Examiner's (IME) report stated that you have a mild disability of the lower back, but that you are capable of working and performing the activities of daily living with the restriction of not lifting over 15 pounds. Your job does not require you to lift objects over 15 pounds.

It is concluded that the information does not substantiate the presence of any functional impairment resulting in your inability to perform the basic work-related functions of your own occupation as ...


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