Plaintiff Jonnie Mae Robinson ("Robinson") claims that Metropolitan Life Insurance Company ("MetLife"), the Skadden, Arps, Slate, Meagher & Flom, LLP Plan ("the 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.
This case was previously before this Court under Case Number 05-cv-1534. On May 12, 2006, the Court found that MetLife erred in referring Robinson's claim to an internist and pulmonary specialist because the medical conditions underlying Robinson's claim "were almost entirely neurological in nature." May 12, 2006 Opinion and Order p. 2-3, 5. The Court stated, "there is no basis for granting Ms. Robinson's claim and directing MetLife to provide her with long-term disability benefits. The record evidence is insufficient to compel the finding that a reasonable fiduciary must grant her claim. A neurological specialist might conclude otherwise." Id. at 5. The Court remanded Robinson's claim to MetLife to reconsider after consultation with a neurological specialist.
On June 14, 2006 MetLife referred Robinson's claim to Joseph J. Jares, III, M.D., a Board-certified neurologist. Dr. Jares concluded that "From a neurological perspective, she has, based upon the most recent documentation, mild residual left-sided weakness, numbness, and pain. However, records suggest her to be otherwise fairly intact and do not indicate what would prevent Ms. Robinson from performing sedentary work in an office type setting." July 16, 2007 Affidavit of Cindy S. Broadwater ("Broadwater Aff."), Ex. A, R70-71.*fn1 MetLife affirmed its denial of Robinson's claim on July 14, 2006 (after its June 23, 2006 notification that it needed an additional 45 days to review Robinson's claim), but rescinded the denial on August 17, 2006 after discovering that it had not supplied Dr. Jares with all of Robinson's medical records.
MetLife then sent the entire claim file to a third-party vendor, Elite Physicians, Ltd., with instructions to have it evaluated by a neurologist. Dr. Patrick R. Parcells, a Board-certified neurologist, evaluated the records. In his report dated September 1, 2006, Dr. Parcells stated that "There is no medical information on file to support the inability to perform the duties of her job." Id. at R46.
MetLife realized that Elite Physicians had not forwarded the entire file to Dr. Parcells, so it instructed Elite Physicians to send the entire file back to Dr. Parcells for supplemental review. In his supplemental report dated September 29, 2006, Dr. Parcells stated that the additional materials were predominantly not related to any neurological problem (R39) and did not change his opinion. Id. at R40:
In review of these extensive records, the further information does not change my original determination.
From the neurological perspective, based on my review of all material provided, the claimant's level of functionality and abilities is for sedentary work. From a neurologic perspective, medical information does not support a continuing disabling condition from August 16, 2002, through present.
On September 21, 2006, Robinson commenced this suit and on October 19, 2006 MetLife denied Robinson's claim.
Both sides move for summary judgment pursuant to Rule 56 of the Federal Rules of Civil Procedure.
Robinson concedes that the Plan gives the decision-maker discretionary authority to determine benefit eligibility. When plans grant such discretion, courts do not disturb the administrator's ultimate conclusion unless it is "arbitrary and capricious."
However, Robinson argues that an exception under Nichols v. Prudential Ins. Co. of Am., 406 F.3d 98 (2d Cir. 2005) requires that the decision be reviewed de novo. In Nichols, the Second Circuit held that failure to render a timely decision rendered a claim "deemed denied" under ERISA and therefore subject to de novo review. However, "[t]he holding of Nichols is limited to those cases where the administrator fails to respond at all, not those cases where the response is tardy. Where the response is merely procedurally tardy, the denial is still owed deference." Morgenthaler v. First Unum Life Ins. Co., 2006 U.S. Dist. LEXIS 62688 (S.D.N.Y. August 22, 2006). "[T]he case law in this Circuit indicates that where the administrator communicates with the claimant regarding the status of her appeal, acts in good faith, and does not delay its decision unreasonably, its failure to comply with the regulation deadlines may be excused." Pava v. Hartford Life & Accident Ins. Co., 2005 U.S. Dist. LEXIS 41753 (E.D.N.Y. Aug. 24, 2005).
In this case, although MetLife did not issue a decision within the time prescribed by ERISA, its tardiness was not in bad faith. MetLife remained in contact with Robinson's attorney, informed him of the reasons for its delays, and took steps to ensure a full and fair review of Robinson's ...