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Hobson v. Metropolitan Life Insurance Co.

July 29, 2009

DEBORAH HOBSON, PLAINTIFF-APPELLANT,
v.
METROPOLITAN LIFE INSURANCE COMPANY, DEFENDANT-APPELLEE.



SYLLABUS BY THE COURT

Plaintiff-Appellant Deborah Hobson appeals from an order of the United States District Court for the Southern District of New York (Alvin K. Hellerstein, Judge) dismissing her complaint challenging the denial by her ERISA plan administrator, Metropolitan Life Insurance Co., of her claim for long-term disability benefits. Because we find that the plan administrator acted within its discretion in denying Plaintiff-Appellant's claim, the district court's judgment is AFFIRMED.

The opinion of the court was delivered by: John M. Walker, Jr., Circuit Judge

Argued: October 30, 2008

Before: WALKER, B.D. PARKER, and RAGGI, Circuit Judges.

Plaintiff-Appellant Deborah Hobson ("Hobson") is a member of an employer-provided health care plan (the "Plan") that is governed by the provisions of the Employee Retirement Income Security Act, 29 U.S.C. §§ 1001-1461 ("ERISA"), and for which claims for benefits are administered by Defendant-Appellee Metropolitan Life Insurance Co. ("MetLife"). Hobson brings this appeal from an order of the United States District Court for the Southern District of New York (Alvin K. Hellerstein, Judge) dated December 12, 2006, granting summary judgment to MetLife, denying Hobson's cross-motion for summary judgment, and dismissing the complaint. Hobson v. Metro. Life Ins. Co., No. 05 CV 7321, Tr. at 29 (S.D.N.Y. Dec. 12, 2006).

Hobson alleges that MetLife's conflict of interest as both evaluator and payor of benefit claims influenced its decision to deny her claim for benefits, requiring this court to review MetLife's determination de novo. She contends that, in any event, MetLife's decision was arbitrary and capricious because it was not supported by substantial evidence. She also avers that MetLife abused its discretion by not affording her a full and fair review of her claim, as required by sections 404(a) and 503 of ERISA, 29 U.S.C. §§ 1104, 1133.

Finding that Hobson failed to establish that MetLife was influenced by its structural conflict of interest, we decline to accord this factor any weight in our review of MetLife's denial of Hobson's benefits claim for abuse of discretion. Because we find that substantial evidence supported MetLife's denial of Hobson's benefits claim, and that MetLife afforded her a full and fair review of her claim, we conclude that the district court properly determined that MetLife acted within its discretion as plan administrator in denying the claim. We therefore affirm.

BACKGROUND

Hobson worked for KPMG, LLP ("KPMG") from 1998 to February 12, 2001 as a tax technician, a sedentary position which involved sitting at a work-space and using a computer. She challenges MetLife's denial of her claim for long-term disability ("LTD") benefits.

Hobson's Health Insurance Plan

Under KPMG's group health insurance policy with MetLife, MetLife has the "discretionary authority" to interpret the Plan's terms and determine a claimant's eligibility for, and entitlement to, Plan benefits. An employee is eligible for LTD benefits under the Plan beginning twenty-five weeks after becoming "disabled." The Plan considers the employee "disabled" (1) for the next thirty-six months, if she cannot perform the "material and substantial duties of [her] [o]wn [o]ccupation," and (2) after this period, if she cannot perform "any job for which [she is] qualified or... may become reasonably qualified...." Hobson's Claims History

Initial Benefits Claim

After becoming disabled in February 2001, Hobson filed a claim for short-term disability and LTD benefits under the Plan, claiming that she was unable to work. Hobson allegedly suffers from asthma, severe tremors, migraines, depression, ulcerative colitis ("colitis"), ileostomy skin problems, seizures, thyroid cancer, fibromyalgia, sleep apnea, severe fatigue, heaviness in her arms and legs, herniated disks in her lower back and neck, arthritis, and Dercum's disease ("Dercum's"). Hobson initially submitted medical examination reports from three doctors. The first, rheumatologist Dr. Sandra L. Sessoms, diagnosed Hobson with fibromyaglia*fn1 -- a disease impairing cognitive functioning -- and opined that Hobson was unable to work. The second, gastroenterologist Dr. D. Keith Fernandez, diagnosed Hobson with colitis, which involves acute or chronic inflammation of the tissue lining the gastrointestinal system, but stated that Hobson could return to work on August 22, 2001. The third, neurologist Dr. Randolph W. Evans, submitted a report indicating that Hobson had mild lumbar spine abnormalities and no neurological abnormalities, and expressing no opinion as to her ability to work.

MetLife consulted an independent rheumatologist and internal medicine specialist, Dr. Jefrey D. Lieberman, who opined that the evidence Hobson submitted did not demonstrate that she suffered from fibromyalgia or that she could not return to work. Dr. Lieberman contacted Dr. Sessoms, who stated that she was no longer treating Hobson and was not sure if Hobson currently was being treated for fibromyalgia. MetLife approved Hobson's claim for short-term benefits, but on November 5, 2001, denied her claim for LTD benefits.

Hobson appealed MetLife's denial of her LTD benefits claim. Hobson clarified that she continued to be a patient of Dr. Sessoms and was about to undergo treatment for fibromyalgia. Hobson also submitted an evaluation from Dr. Sessoms reiterating her diagnosis that Hobson was unable to work, had limited mobility, and suffered from various medical conditions, including symptoms "consistent with fibromyalgia," colitis, hypertension, insomnia, lung disease, anemia, and depression. Hobson also submitted another report from Dr. Fernandez, which indicated that Hobson was being treated for colitis and that other medical conditions made her "feel much worse."

MetLife referred Hobson's file to Dr. Joseph M. Nesta, an independent physician specializing in internal medicine and gastroenterology, who concluded that Hobson's colitis "appear[ed] to be stable," that her fibromyalgia was not disabling, and that the MRIs of her spine, which showed only "mild" abnormalities, did not indicate that she was unable to work. In March 2002, MetLife upheld its denial of Hobson's claim for LTD benefits.

LTD Benefits for Colitis, Rectal Bleeding, and Anemia

In August 2002, after Hobson submitted additional information regarding her colitis, rectal bleeding, and anemia, MetLife approved her LTD benefits claim. In April 2003, after consulting a physician trained in internal and occupational medicine, who reported that Hobson's colitis and anemia were under control, and that she could perform "most jobs as long as there was ready access to a bathroom," MetLife terminated Hobson's LTD benefits.

LTD Benefits for Colitis-Related Surgery

On June 13, 2003, after Hobson underwent two surgical procedures relating to her colitis, MetLife reinstated her LTD benefits. At the time, a MetLife nurse consultant disagreed with the reinstatement and recommended that Hobson's benefits be discontinued because her colitis had been corrected by the surgery, and her medical records did not indicate that she was physically or psychologically impaired.

Hobson submitted a physician's report indicating that she had a yeast or fungal infection, and suffered from a "major depressive disorder" whereby she was "unable to engage in stress[ful] situations" or "interpersonal" interactions, and her "emotional and adaptive functioning ma[d]e [returning to work] unfeasible." MetLife's nurse consultant concluded that "the submitted medical findings do not document a significant severity of condition or provide evidence of a functional impairment that would preclude [Hobson] from performing the duties of her sedentary job."

On July 20, 2004, Dr. Nesta, the physician who reviewed Hobson's file upon her initial appeal, reevaluated her case and again concluded that her alleged impairments did not preclude her from working. On July 27, 2004, Hobson's treating internist responded to the reevaluation, stating that he "disagree[d] with [MetLife's] [r]eview due to insufficient data," and expressing concern about Hobson's "possible systemic yeast infection." In August 2004, MetLife terminated Hobson's LTD benefits for the second time.

LTD Benefits for Thyroid Cancer Surgery

In September 2004, after Hobson underwent surgery to treat thyroid cancer, MetLife reinstated her LTD benefits for "a closed period of time," until November 12, 2004. The physician who performed the surgery recommended that Hobson return to work in January 2005. MetLife informed Hobson that by this time, over thirty-six months had passed from her initial claim for benefits, meaning that in order to be "disabled" under the Plan, she was required to show that she could not perform the duties of any job "reasonably fitted by [her] education, training, and experience," and not only the duties of her actual occupation.

LTD Benefits for Dercum's

In appealing MetLife's termination of her LTD benefits in 2004, Hobson enclosed an updated report from Dr. Sessoms, which explained that Hobson had some difficulty standing, walking, and sitting. Hobson also included a report from Dr. Paul Subrt, a dermatologist, who diagnosed her with Dercum's, which is a "rare, chronic condition" whose symptoms include "painful adipose tissue, extreme weakness and fatigability, chronic generalized pain, fibromyalgia, epilepsy, cognitive dysfunction and depression," has no effective treatment, and "can lead to lifelong debilitating disabilities."

MetLife had two independent consultants review Hobson's file, both of whom concluded that none of Hobson's alleged impairments rendered her unable to work. The first, an internist, explained that the Dercum's diagnosis was not well-documented or supported, and that Hobson had not been given a treatment plan. The second, a neurologist and psychiatrist, concluded that although Hobson had "a number of chronic medical problems which are severe," she appeared to be "functional" and was "able to work without any difficulty" at her sedentary job. In March 2005, MetLife upheld its denial of Hobson's claim for LTD benefits.

MetLife granted Hobson's request for additional, discretionary review of the claim denial and referred her file to two more independent physicians. The first, a psychiatrist, explained that "[t]here [we]re no complete psychiatric evaluations in the documentation or any complete mental status examinations." This consultant also determined that Hobson "herself had submitted numerous letters [to MetLife which we]re... very well written and contain[ed] no hints of any cognitive impairment." The second consultant, a dermatologist, opined that the Dercum's "diagnosis actually was made by Ms. Hobson, not by her doctor," and "found that she made it according to information... on the Internet." Dr. Subrt, the physician who authored the brief, one-paragraph letter diagnosing Hobson with Dercum's, told MetLife's consultant that he "d[id] not feel that Ms. Hobson [wa]s disabled and d[id not] understand why she c[ould] not do her job, which is sedentary." The second consultant also concluded that, aside from Hobson's subjective reports of pain, no objective finding confirmed that she was unable to work. On May 5, 2005, MetLife informed Hobson that it upheld its denial of her benefits claim and would not consider any further appeals, because Hobson had "exhausted [her] administrative remedies under the [P]lan."

Hobson then submitted two letters to supplement her claim. The first, authored by Dr. Subrt, explained that although he did not "discern" any dermatologic disability, he was not qualified to opine on whether she otherwise suffered disabilities. The second, a letter from her treating psychologist, stated that Hobson's depression had since worsened to the point of "severe despondent episodes" of "sufficient severity that [she wa]s unable to function consistently enough to sustain employment." In letters dated May 11 and 19, 2005, MetLife informed Hobson that her additional submissions had not persuaded it to reconsider the denial of her benefits claim.

The ERISA Action

On August 18, 2005, Hobson responded to Metlife's denial of her administrative appeals by instituting this action. Her complaint alleges that MetLife was influenced by its conflict of interest as both the evaluator and payor of benefit claims, warranting de novo review, and that, in any event, it abused its discretion in denying her claim for LTD benefits. The parties then filed cross-motions for summary judgment.

On December 12, 2006, the district court granted MetLife's motion and denied Hobson's, concluding that MetLife did not act arbitrarily and capriciously in denying Hobson's claim for benefits, because, inter alia, MetLife "reasonably took up each and ...


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