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Suren v. Metropolitan Life Insurance Co.

August 29, 2008

MIRTA SUREN, PLAINTIFF,
v.
METROPOLITAN LIFE INSURANCE COMPANY, DEFENDANT.



The opinion of the court was delivered by: John Gleeson, U.S.D.J.

MEMORANDUM AND ORDER

JOHN GLEESON, United States District Judge

Plaintiff Mirta Suren filed this action against defendant Metropolitan Life Insurance Company ("MetLife"), alleging that MetLife improperly denied her long term disability benefits in violation of the Employee Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. § 1001 et seq. MetLife counterclaimed to recover an overpayment arising out of a retroactive award of benefits to Suren by the Commissioner of Social Security. Both MetLife and Suren have moved for summary judgment. For the reasons set forth below, I grant MetLife's motion for summary judgment on Suren's claim for disability benefits and on MetLife's claim for reimbursement of overpayments. Plaintiff's motion for summary judgment is denied.

BACKGROUND

A. The Plan

Lehman Brothers Holdings, Inc. established and maintains the Lehman Group Benefits Plan to provide long-term disability ("LTD") benefits to its eligible employees. Def.'s Ex. B, ML 330-52.*fn1 That long term disability plan is referred to here as "the Plan." The Plan is governed by ERISA, and MetLife both administers the claims and funds the Plan benefits. ML 338, 346. MetLife has the "discretionary authority to make all decisions in connection with the administration of the [Plan], including, but not limited to, decisions concerning . . . any benefits to which a participant or beneficiary is entitled." ML 348; see also ML 325 ("In 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."). As plan administrator, MetLife is the final authority concerning the Plan. ML 348.

The Plan provides that to be eligible for LTD benefits, a participant must be unable "to perform all the essential duties of [her] occupation." ML 340. Furthermore, to be considered disabled, the claimant must be receiving "appropriate care and treatment from a doctor on a continuing basis" and must be unable to earn more than 80% of her pre-disability earnings at her original occupation. This loss of earnings must be a direct result of the claimant's condition. ML 288.

To obtain benefits, the Plan requires the claimant to submit proof of disability to MetLife. MetLife then determines whether the claimant qualifies for LTD benefits, and if so, for how long. ML 340-44. MetLife also makes the final determination of a claimant's appeal. In determining disability benefits on appeal, MetLife is obligated to consider all comments, documents, records and other information submitted by the claimant. 29 C.F.R. § 2560.503-1.

The Plan provides that monthly LTD benefits are to be reduced by other disability income received by the claimant, including Social Security Disability Income ("SSDI benefits"). ML 342. Any overpayment of LTD benefits due to retroactive receipt of SSDI or other disability benefits must be refunded to MetLife. ML 294.

B. Suren's Alleged Disability

Suren, 50, was employed by Lehman as an administrative coordinator. This position was a sedentary position, though the job did require her to occasionally stand, walk, bend, and kneel. ML 9, 12.*fn2 Suren stopped working on February 4, 2005 because she claimed to be disabled after she was diagnosed with hepatitis and autoimmune disease with fatigue. ML 3-4, 246-47. Suren and MetLife dispute the date of the onset of disability.

In March 2005, Suren applied for disability benefits. ML 1. In support of her claim, she submitted evaluations conducted by two doctors: Dr. Babu Duddempudi, an internist, and Dr. Placido Morano, a rheumotologist. According to Duddempudi, Suren was hospitalized from February 4, 2005 through February 16, 2005, but would be ready to return to work by April 15, 2005.*fn3 ML 247.

Laboratory tests from February 2, 2005 indicate that Suren had high alkaline phosphates, high GGT, high AST, high ALT, high LD, low iron, and a low platelet count.*fn4 ML 242-43. A urinalysis indicated high specific gravity, high squamous epithelial cells, and trace leukocyte esterbase. ML 242-44. Suren's ANA screen was positive. ML 245. An MRI of the brain conducted on February 8, 2005 revealed "[r]ight frontal lobe developmental venous anomaly" and "[n]onspecific frontal deep white matter signal abnormalities." ML 226. The MRI was normal in all other respects, and the effect of the MRI's abnormal findings upon Suren's functional capacity was not evaluated or explained. Laboratory data from February 14, 2005 indicated the presence of RNP antibodies. ML 241. None of Suren's doctors have addressed the significance of these laboratory tests.

On March 8, 2005, Suren was examined by Dr. Morano, who indicated that Suren suffered from autoimmune hepatitis with fatigue and arthralgia*fn5 and concluded that Suren was "unable to function well with daily physical activities." ML 225.

In a report dated April 19, 2005, Dr. Duddempudi indicated that Suren was incapacitated and could not perform work of any kind. ML 249. In May 2005, Duddempudi concluded that Suren had suffered a significant loss of psychological, physiological, personal and social adjustment skills. ML 221. He diagnosed her with autoimmune disease, hepatitis and hypothyroidism with symptoms of general weakness and difficulty walking. ML 220. As for physical limitations, he noted that Suren was able to sit and stand for only two hours intermittently, walk for one hour intermittently, and lift up to 20 pounds occasionally. She could not climb, twist, bend, stoop, reach above her shoulder level, or operate a motor vehicle. ML 221.

On June 14, 2005, MetLife approved Suren's claim for short-term disability benefits through August 2005 (the maximum duration for such benefits) based on her documentation of hepatitis and severe fatigue. ML 12. After satisfying the Elimination Period of 180 days, MetLife reviewed the medical evidence and approved Suren for LTD benefits through November 3, 2005, to commence on August 3, 2005. ML 12, 215-217.

On July 23, 2005, Suren stated in her personal profile evaluation that she suffered from Lupus*fn6 , a blood clot in her right lung, depression, a thyroid problem, headaches, muscle pain, forgetfulness, dizziness, weakness, and difficulty breathing and sleeping. ML 205-210. She also stated that she was unable to care for her personal needs due to severe muscle pain, and required assistance from her husband for simple activities like getting dressed and bathing. She stated that she could no longer perform any household chores due to her weakness, joint and muscle pain, dizziness, and headaches. Her fatigue and inability to concentrate prevented her from driving. ML 208. MetLife received a psychiatric evaluation dated July 19, 2005 from Suren's psychiatrist, Dr. Sudharam Idupuganti, diagnosing her with "major depression, single episode, severe with melancholia" based on her symptoms of insomnia, anxiety, impaired concentration and memory and sad feelings. ML 15. Idupuganti had been treating Suren with psychotherapy for about two months, and he had prescribed her anti-depressant medications.

After approving Suren's LTD claim, MetLife periodically requested additional updated information, including office notes and test results from her treating physicians. ML 183, 162-63. In compliance with these requests, in September and October 2005, Suren submitted supplemental reports from Dr. Duddempudi and Dr. Miran Salgado, a neurologist, as well as EMG and nerve conduction studies ("NCS") and a radiology exam. In his October report, Duddempudi listed a primary diagnosis of pulmonary embolism and a secondary diagnosis of hypothyroidism. ML 167-71. He indicated that Suren could not work due to "general weakness" and Lupus. Salgado examined Suren on October 10, 2005, and he reported that Suren was alert and oriented and that her "recall and past memory were well-preserved." He also indicated that the Lupus diagnosis was questionable. Salgado noted that although Suren complained of fatigue and muscle weakness, on examination she had normal muscle tone and there was no evidence of "fatigueability or weakness on exertion." He suggested that she had myasthenia gravis*fn7 or myasthenia syndrome with "probable psychogenic*fn8 overlay" and recommended further testing. ML 159-60.

On October 11, 2005, a walk-up review of Suren's claim was held to determine whether her benefits would be extended. The nurse concluded that the medical information supported an extension through November 30, 2005. ML 17. The nurse indicated that additional medical information was needed for further benefits, as office visit notes suggested that Suren's pulmonary embolism was resolving and it was unclear what would continue to keep her out of work. ML 17.

An EMG study performed on October 17, 2005 revealed no evidence of polyneuropathy.*fn9 The study was suggestive but not diagnostic of a presynaptic neuromuscular joint disorder. ML 156-58. The NCS study findings were normal. ML 158. The radiology exam report dated September 14, 2005 revealed that Suren's pulmonary embolism condition had been resolved. ML 144. However, the exam revealed the presence of stable ill-defined nodular opacities in the lateral right middle lobe with tree-in-bud appearance. This finding was "suggestive of an indolent infectious/inflammatory process, such as bronchiolitis, endobronchial tuberculosis, or atypical infection" for which a clinical correlation was recommended. ML 145.

In a letter dated January 9, 2006, MetLife informed Suren that her LTD benefits were terminated effective December 20, 2005 due to insufficient medical evidence of continued disability. ML 146-148.*fn10 A nurse consultant retained by MetLife had reviewed Suren's file and concluded that the medical records showed that Suren's pulmonary and liver conditions had resolved and that, other than subjective complaints of fatigue and weakness, there was no medical evidence to support continued functional impairments such that Suren could not perform her job. ML 21-22. Suren contests the reliability of the nurse's opinion and questions her qualifications. Furthermore, Suren states that the nurse's opinion was not valid because it was contrary to the opinions of Suren's treating doctors, Pl.'s Rule 56.1 Counter-statement ¶ O, and the nurse failed to consider the significant psychological impairments that Dr. Idupuganti had outlined in his June 2005 evaluation. ML 193. MetLife contends that since Idupuganti evaluated Suren over six months before the nurse's review, his evaluation would not have provided recent information about improvements in Suren's physical condition. Def.'s Rule 56.1 Response 57.

MetLife's January 9, 2006 letter notified Suren of her right to appeal the termination of her LTD benefits. ML 146-148. The letter advised Suren to send a written request for appeal within 180 days, and asked that she include in the appeal letter the reasons she believed the termination was improper and "any additional comments, documents, ...


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