The opinion of the court was delivered by: Hon. Glenn T. Suddaby, United States District Court Judge
This action was filed pursuant to the Employee Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. §§ 1001 et seq. Generally, in his Complaint, David Magin ("Plaintiff") alleges that Cellco Partnership d/b/a Verizon Wireless ("Verizon"), Verizon Wireless and Managed Disability Plan, and Met Life Corporation ("Defendants") denied Plaintiff Long Term Disability benefits and Short Term Disability benefits to which he was entitled under the Plan pursuant to 29 U.S.C. § 1132(a)(1)(B). (See generally Dkt. No. 1 [Plf.'s Compl.].)
On April 5, 2006, Defendants filed a motion to dismiss this action pursuant to Fed. R. Civ. P. 12(b)(1) and 12(b)(6). (Dkt. No. 9.) On February 23, 2007, Chief Judge Norman A. Mordue issued an Order denying Defendants' motion to dismiss. (Dkt. No. 21.) However, in the Order, Judge Mordue (1) effectively dismissed Plaintiff's state common law claims of breach of contract and negligence by recharacterizing the claims as ERISA causes of action, and (2) indicated that, "[i]f plaintiff can demonstrate that he applied for [Long Term Disability] benefits and that defendants failed to take action on the application, he may be entitled to de novo review of his request for [Long Term Disability] benefits." (Dkt. No. 21.)
Currently pending are Defendants' motion for summary judgment and Plaintiff's motion for summary judgment, both pursuant to Fed. R. Civ. P. 56. (Dkt. Nos. 29 and 30.) For the reasons that follow, Defendants' motion for summary judgment is granted, Plaintiff's motion for summary judgment is denied, and his Complaint is dismissed in its entirety.
A. Undisputed Material Facts
The following facts, which are taken from the parties Rule 7.1 Statements and Responses, are undisputed. (See Dkt. No. 29, Part 3; Dkt. No. 30., Part 3; and Dkt. No. 34.)
During the relevant time period, Plaintiff was employed as a Retail Sales Manager by Verizon Wireless, the sponsor of the Verizon Wireless and Managed Disability Plan (the "Plan"). The Short Term Disability ("STD") component of the Plan was self-funded by Verizon Wireless. The Long Term Disability ("LTD") component of the Plan was insured by MetLife. MetLife was the claims administrator for both the STD and LTD components of the Plan.
On February 5, 2004, Plaintiff stopped working. On February 9, 2004, he saw Nurse Practitioner Karen Wickert, who diagnosed him with depression, anxiety, Post-Traumatic Stress Disorder and shingles. On February 9, 2004, Plaintiff notified his employer that he had been taken out of work by his medical provider, and filed a claim for STD benefits under the Plan. Plaintiff's primary care physician's office provided MetLife with the medical report drafted by Nurse Wickert on February 9, 2004. This "Acute Care/Follow Up" form was the only document that Plaintiff submitted to MetLife to support his STD claim. This form stated that Plaintiff presented "for follow-up on stressful situation," a rash on his side, and blood in his stool. The form also stated that Plaintiff has "very low self esteem, feelings of failure, feeling overwhelmed, can't concentrate, [and] insomnia." The form concluded that Plaintiff would be out of work until March 8, 2004, and would continue some type of counseling.
After receiving Plaintiff's claim, MetLife telephoned Plaintiff to obtain additional information. Plaintiff did not answer the telephone and did not return MetLife's telephone call. When Plaintiff failed to respond, MetLife moved forward with considering his claim.
On February 27, 2004, MetLife notified Plaintiff in writing that his claim for STD was denied because the medical evidence he submitted did not provide evidence sufficient to entitle Plaintiff to STD benefits. Specifically, MetLife stated that "[t]here was no report of the frequency or severity of any symptoms or any description of how they might prevent you from performing the duties of your job."
On March 18, 2004, Plaintiff spoke with his MetLife claim manager and the claim manager's supervisor regarding the initial denial of his claim. During both conversations, Plaintiff was informed of his right to appeal the denial. In addition, Plaintiff was advised that he should submit information "from his therapist and/or any other treating provider for his current condition indicating how he is unable to work."
On March 26, 2004, Plaintiff appealed MetLife's decision. On the Appeal Request Form, Plaintiff stated that additional information would be submitted to support his claim. On April 12, 2004, MetLife acknowledged receiving Plaintiff's appeal letter. On April 13, 2004, MetLife received a letter from Karen Wickert in support of Plaintiff's benefits claim. The letter stated that Plaintiff was being treated for "generalized anxiety disorder and post traumatic stress disorder." The letter further stated that "[t]hese conditions currently make him unable to work because his job is very stressful and he has interpersonal conflict at work."
In response to Plaintiff's appeal, MetLife requested an independent medical opinion from Dr. Leonard Kessler, a board-certified psychiatrist. On May 12, 2004, a MetLife case manager referred Plaintiff's file to Dr. Kessler for review. The MetLife case manager requested that Dr. Kessler comment specifically on whether the medical information submitted by Plaintiff supported a finding of a significant psychiatric impairment as of February 6, 2004.
On May 12, 2004, Dr. Kessler attempted to contact Plaintiff and Ms. Wickert to set up a telephone conference. Dr. Kessler was unable to contact either Plaintiff or Ms. Wickert, and neither party returned his telephone calls.
On that same day (May 12, 2004), at 3:34 p.m., after reviewing the limited information provided by Plaintiff and his health care provider(s), Dr. Kessler responded to the MetLife case manager in the form of a report. The report provided the following observations and opinions:
This 38 year old . . . married man left work, as a Retail Store Manger (sic), on 2/5/04 and has alleged disability based upon diagnosed Post Traumatic Stress Disorder and Generalized Anxiety Disorder. There is no support, in terms of history and mental status findings, for these diagnoses consistent with DSM IV criteria. Ms. Wickert has reported that '[h]is job is very stressful and he has interpersonal conflict at work.' She did not provide a treatment plan to address this interpersonal conflict but reported counseling which has not been documented in terms of onset, frequency, duration, and response. Attempts to reach the claimant and Mrs. Wickert, for telephone conferences, were not successful with no return calls by either. This claim would appear to represent a primary work conflict. There is insufficient information to support a psychiatric diagnosis, as consistent with DSM IV criteria. There is inadequate information to assess the presence of any significant functional limitations from 2/6/04. Lacking is a comprehensive psychiatric history, objective mental status examination, sustained DSM IV diagnosis, treatment plan, and evidence of functional limitations.
On May 24, 2004, based upon the medical records submitted by Plaintiff and Dr. Kessler's opinion, MetLife denied Plaintiff's claim. MetLife's decision letter advised Plaintiff that he had exhausted his administrative remedies under the Plan, and that MetLife would consider no further administrative appeals. The denial letter also informed Plaintiff that he would be provided with a copy of the documents, records and other information relevant to his claim upon request. In addition, the letter advised Plaintiff of his right to bring a civil action under Section 502(a) of ERISA. The letter concluded by stating that "there is lack of information submitted in your file that would suggest you were unable to perform the usual duties of your job because of an impairment for which there is material medical evidence."
On June 4, 2004, Plaintiff wrote a letter to MetLife, requesting copies of the documents used to deny his claim. On October 1, 2004, Plaintiff's then-attorney sent a letter to MetLife requesting the exact same materials. The parties dispute whether MetLife subsequently provided the documents. However, there is no dispute that Plaintiff never filed a claim for LTD benefits.
B. Relevant Language of the Plan
1. Qualification for STD Benefits
In order to qualify for STD benefits under the Plan, a participant in the Plan must meet the applicable definition of "disability."
An employee is considered disabled under the STD component of the Managed Disability Plan when the employee is absent from work because of impairment for which there is material medical evidence that the employee cannot perform the Essential Functions of his or her job at Verizon Wireless. The employee must not be engaged in any other job/occupation or earns any self employment income during ...