The opinion of the court was delivered by: Joseph F. Bianco, District Judge
Plaintiff Barbara Aitkins ("plaintiff" or "Aitkins"), by Katherine Casillas ("Casillas"), plaintiff's daughter and attorney-in-fact, brought the instant action against defendants Park Place Entertainment Corporation Employee Benefit Plan (the "Plan") and Harrah's Operating Company ("defendants"), pursuant to the Employee Retirement Income Security Act of 1974, 29 U.S.C. § 1001 et seq. ("ERISA"), challenging the termination of her long term disability ("LTD") benefits under the Plan and requesting that the Court direct defendants to retroactively adjust the date upon which plaintiff became entitled to LTD benefits. Specifically, plaintiff alleges that the decision to terminate her benefits by the Plan's administrator, Metropolitan Life Insurance Company ("MetLife"), was arbitrary and capricious. Plaintiff also alleges that she did not receive a full and fair review of her claim during MetLife's appel late process. Defendant s counterclaimed, alleging that they were entitled to recover from Aitkins the overpayment of her LTD benefits that arose retroactively from her award of benefits from the Social Security Administration.
Plaintiff and defendants now move for summary judgment pursuant to Federal Rule of Civil Procedure 56 on all of plaintiff's claims and on defendants' counterclaim. For the reasons set forth below, the Court grants plaintiff's motion for summary judgment to the extent that MetLife's denial of her appeal is vacated, and on her claim for retroactive adjustment of her disability start date, but denies the motion on all other grounds. Defendants' motion is granted on their counterclaim, but denied on all other grounds.
The Plan is an employee welfare benefit plan governed by ERISA. (Summary Plan Description ("SPD") at "ERISA Information," "Statement of ERISA Rights".) Park Place Entertainment Corporation established and maintains the Plan to provide LTD benefits to eligible employees. (See SPD at i.) As the Plan's claims administrator, MetLife funds Plan benefits through a group policy of insurance. (SPD at i, "Erisa Information".)
(1) Discretionary Authority
The Plan provides that "[i]n carrying out their respective responsibilities under the Plan, the Plan administrator and other Plan fiduciaries shall have 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." (SPD at "Claims Information".)
(2) Eligibility for LTD Benefits
a. Definition of Disability
"Disabled" or "Disability" means that, due to sickness, pregnancy or accidental injury, you are receiving Appropriate Care and Treatment from a Doctor on a continuing basis; and 1. during your Elimination Period and the next 24 month period, you are unable to earn more than 80% of your Predisability Earnings or Indexed Predisab i li t y Earnings . . . ; or 2. after the 24 month period, you are unable to earn more than 60% of your Indexed Predisability Earnings . . . .
The SPD further states that
"Appropriate Care and Treatment" means medical care and treatment that meet all of the following:
1. it is received from a Doctor whose medical training and clinical experience are suitable for treating your Disability
2. it is necessary to meet your basic health needs and is of demonstrable medical value;
3. it is consistent in type, frequency and duration of treatment with relevant guidelines of national medical, research and health care coverage organizations and governmental agencies;
4. it is consistent with the diagnosis of your condition; and
5. its purpose is maximizing your medical improvement. (SPD at 7.)
The SPD defines an Elimination Period as "180 days of continuous Disability" (SPD at 2), which "begins on the day you become Disabled. It is a period of time during which no benefits are payable." (SPD at 6.)
The SPD further provides that "[y]ou may temporarily recover from your Disability during your Elimination Period. If you become disabled again due to the same or related condition, you may not have to begin a new Elimination Period." (SPD at 6.)
Specifically, "[i]f you return to work for 30 days or less during your Elimination Period, those days will count towards your Elimination Period. However, if you return to work for more than 30 days before satisfying your Elimination Period, you will have to begin a new Elimination Period. (SPD at 6.)
The Plan provides for a potential period of Temporary Recovery, defined as "your return to work for less than 6 months for each period of Temporary Recovery." (SPD at 6.) In particular, "[o]nce benefits become payable under This Plan, you may Temporarily Recover from your Disability. If you become Disabled again due to the same or related condition, you may not have to begin a new Elimination Period." (SPD at 14.)
The Plan provides that "[w]e have the right to recover from you any amount that we determine to be an Overpayment. You have the obligation to refund to us any such amount. Our rights and your obligations in this regard are also set forth in the reimbursement agreement you are required to sign when you become eligible for benefits under This Plan. . . . An Overpayment occurs when we determine that the total amount paid by us on your claim is more than the total of the benefits due under This Plan. This includes any Overpayments resulting from . . . retroactive award received from sources shown in the List of Other Income Benefits. . . ." (SPD at 20.) The List of Other Income Benefits includes benefits received under the Federal Social Security Act. (SPD at 10.)
(4) The Short Term Disability Benefit Plan
MetLife also administers a Short Term Disability Benefit ("STD") Plan. The maximum benefit duration of the STD Plan is 26 weeks, which follows an Elimination Period of 14 days. (STD Plan at 2.)
The STD Plan also provides for Temporary Recovery. Specifically, "[o]nce you have satisfied your Elimination Period, a period of Temporary Recovery is your return to work for less than 14 consecutive days for each period of Temporary Recovery. If your recovery lasts longer than 14 days, when you become Disabled again you will have to begin a new Elimination Period." (STD Plan at 7.)
B. Plaintiff's Disability
Aitkins began working as a blackjack dealer at the Caesar's Palace casino in Las Vegas in 1979. (Short Term Disability Eligibility Information (ML 0234).)
(1) Plaintiff's STD Benefits
Aitkins received STD benefits from MetLife in connection with the period February 17, 2003 through July 27, 2003, stemming from a hospitalization for bipolar disorder on February 17, 2003. (See Physician Consultant Review, dated December 19, 2003 ("The Case Management Summary from the Case Manager indicates this individual has had several prior claims with the same diagnosis of bipolar disorder. The Claimant was out of work for several months in 2001 and again from 03/02/03 through 7/27/03. She had a prior inpatient hospitalization on 2/17/03 to 05/05/03.") (ML 0218).)*fn2 Aitkins returned to work on July 28, 2003.
b. The Second STD Claim Aitkins also received STD benefits for bipolar disorder in connection with the period October 24, 2003 through April 11, 2004, stemming from plaintiff's stopping work on October 23, 2003. (Physician Consultant Review, dated May 13, 2004 (ML 0194).)*fn3
A Diary Entry dated November 4, 2003 states: "relapse prior claim 02/18 to 7/27. . ." (Diary Entries at 2 (ML 0066).) Another Diary Entry from that day states "possible recurrent claim." (Diary Entries at 3 (ML 0067).) However, a Diary Entry dated November 13, 2003 recounts a "CM[`s]" conversation with Casillas in which the CM informed her "that the claim is recurrent only if presented within 14 days of the prior claim." (Diary Entries at 3 (ML 0067).)
During an investigation related to plaintiff's second STD claim, MetLife received statements from Aitkins's treating psychiatrist, Dr. Robert Peprah ("Dr. Peprah"). For instance, in April 2004, Dr. Peprah diagnosed plaintiff with bipolar disorder with symptoms including depression, confusion, and delusions. (Attending Physician Supplementary Statement, dated April 16, 2004 (ML 0215).) Also in April 2004, Dr. Peprah assigned Aitkins a Global Assessment of Functioning Scale ("GAF") score of 50. (Mental/Behavioral Functioning Assessment (ML 0206).) Dr. Peprah stated that plaintiff was "permanently disabled" and could not return to work as a blackjack dealer. (Mental/Behavioral Functioning Assessment (ML 0209-210).)
1. Dr. Busch's 2004 Report
In addition, in conjunction with plaintiff's second STD claim, MetLife had Aitkins's file reviewed by an independent physician consultant, Kenneth Busch M.D. ("Dr. Busch"), a Board-certified psychiatrist. In a report in May 2004, Dr. Busch stated: "The medical information indicates this individual has been hospitalized psychiatrically two times during the year 2003. There was a psychiatric admission the early part of 2003 and another admission 10/30 to 11/08/03." (Physician Consultant Review (ML 0194).)
In his report, Dr. Busch found that plaintiff was "in appropriate care and treatment for her diagnosis." (Physician Consultant Review (ML 0196).) Specifically, Dr. Busch stated:
The Claimant was seeing Dr. Peprah through January 2004 at which time it appears Dr. Peprah recommended that she move to New York City to be with her daughter so the daughter could provide the necessary support. Dr. Peprah indicated in January 2004 that this individual was not able to care for herself. She remained psychotic. It appears the Claimant did benefit from the move to New York City and that her daughter has been supportive. The Claimant did not find a doctor in the New York City area due to the fact that she wanted to continue under Dr. Peprah's care. Although there was some question r egar di ng emergency treatment, the fact the Claimant was continuing with the medication, specifically mood stabilizers and antidepressant medication was the primary plan regarding her treatment. It appears the Claimant continued to take the medication which was supervised by her daughter and when she went back to see Dr. Peprah in April 2004 her Global Assessment of Function was improving. Hence, the care and treatment was appropriate for the diagnosis of bipolar disorder and she was cooperating with the overall treatment plan.
(Physician Consultant Review (ML 0196).)
With respect to Dr. Busch's recommendations for plaintiff's STD claim, he stated that "the updated medical information from Dr. Peprah from mid April 2004 indicates that this individual continues to suffer from significant and functional psychiatric impairments that would preclude the Claimant from concentrating on her job responsibilities as a 21 Card Dealer for Cesar's [sic] Entertainment thorough the max out date 05/12/04." (Physician Consultant Review (ML 0196).)
(2) Aitkins Receives LTD Benefits
On June 10, 2004, having satisfied the Elimination Period, plaintiff applied for LTD benefits. (Long Term Disability Claim Form Employee Statement (ML 0270).) In his Long Term Disability Claim Form Attending Physician Statement, dated June 18, 2004 and supplied in conjunction with Aitkins's application, Dr. Peprah recommended that plaintiff "continue with medications" and "supportive psychotherapy." (Long Term Disability Claim Form Attending Physician Statement (ML 0161).) He stated that she had "significant cognitive difficulties" and was "disabled total." (Long Term Disablity Claim Form Attending Physician Statement (ML 0162).)
By letter dated May 21, 2004, MetLife informed Aitkins that her LTD claim had been approved for the period beginning April 27, 2004. (Letter from MetLife dated May, 21, 2004 (ML 0198).)
(3) Information MetLife Received During the Course of Plaintiff's LTD Benefit Period
a. Initial Social Security Denial
In October 2004, MetLife received a report from the Social Security Administration denying Aitkins's claim for benefits because her "condition is not severe enough to keep you from working." (Explanation of Determination, dated October 19, 2004 (ML 0151).)
In March 2005, MetLife's nurse consultant, Joann Robinette ("Robinette"), wrote a report regarding the status of plaintiff's LTD claim. Robinette stated as a threshold matter that her findings were based on "very limited medical information." (Diary Detail dated April 6, 2005 (ML 0134).)
With respect to Aitkins's treatment, Robinette stated:
There is nothing to review to show the level of impairment. The symptoms submitted by unknown treater are subjective in nature and there has been no diagnostic testing done to support this claims [sic] of cognitive impairment. This associate isn't been [sic] treated on a regular basis (7/04 and 2/05) are the last two office visits. This associate was told over a year ago about seeking treatment w/ a NY provider. Her daughter is a social worker and could possible [sic] assist w/ finding a provider that could see her either "pro bono" or on a sliding scale.
(Diary Detail dated April 6, 2005 ...