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Wellman v. Metlife Insurance Co.

December 15, 2009

SARA WELLMAN, PLAINTIFF,
v.
METLIFE INSURANCE COMPANY, DEFENDANT.



The opinion of the court was delivered by: David G. Larimer United States District Judge

DECISION AND ORDER

Plaintiff Sara Wellman ("Wellman") filed this action against Metropolitan Life Insurance Co., Inc., ("MetLife"), the Plan Administrator of the Eastman Kodak Long-Term Disability Plan (the "Plan"), in which Wellman was a participant. Wellman alleges that MetLife wrongfully terminated her receipt of long term disability ("LTD") benefits, in violation of the Employee Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. § 1132(a)(1).

MetLife now moves for summary judgment (Dkt. #12), arguing that Wellman cannot satisfy her burden to show that MetLife's decision to terminate her LTD benefits was arbitrary and capricious.

I. Standard of Review

Where, as here, the terms of an ERISA Plan give its Administrator the sole and absolute authority to interpret the Plan and determine claimants' eligibility for benefits, the Administrator's determinations are subject to a deferential standard of review, which requires only that the Administrator's decision was not arbitrary or capricious. See Pagan v. Nynex Pension Plan, 52 F.3d 438, 441 (2d Cir. 1995); Firestone Tire and Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989); Darling v. DuPont deNemours & Co., 952 F.Supp. 162, 163 (W.D.N.Y. 1997). Under this standard, this Court may only overturn the final decision of the Administrator to deny benefits if it was "without reason, unsupported by substantial evidence or erroneous as a matter of law." Darling, 952 F.Supp. 162 at 165 (quoting Pagan, 52 F.3d 438 at 442. The reviewing court's ultimate focus is "whether the decision was based on a consideration of the relevant factors and whether there has been a clear error of judgment." Jordan v. Retirement Committee of Rensselaer Polytechnic Inst., 46 F.3d 1264, 1271 (2d Cir. 1995).

Although plaintiff urges the Court to review MetLife's determination de novo, the case law relied upon by plaintiff is inapposite in light of the facts presented here. While de novo review is appropriately applied in cases where a plan administrator is also the insurer and therefore is occupying dual, conflicting roles, no such conflict of interest exists in this case. See e.g., Metropolitan Life Ins. Co. v. Glenn, 128 S.Ct.. 2343 (2008) (where ERISA plan administrator is also the insurer of the plan, the resulting conflict of interest merits de novo review of the administrator's denial of coverage); Hobson v. Metropolitan Life Ins. Co., 574 F.3d 75 (2d Cir. 2009) (where plaintiff fails to establish that plan administrator was influenced by a structural conflict of interest, denial of her claim will be reviewed for abuse of discretion). Here, MetLife is the Plan Administer only. The Plan is self-insured, and thus there is no conflict justifying application of a heightened standard of review.*fn1

When a Plan Administrator makes a determination based upon evidence in the record before it, ERISA mandates only that the Plan procedures afford a reasonable opportunity for a full and fair review. See 29 U.S.C. § 1133(2). The existence of conflicting evidence, even a conflicting opinion from a claimant's treating physician, does not necessarily render the Plan Administrator's decision arbitrary and capricious. See Baker v. Broadspire National Services, Inc., 2007 U.S. Dist. LEXIS 5780 (W.D.N.Y. 2007). Furthermore, "courts have no warrant to require [ERISA Plan] administrators automatically to accord special weight to the opinions of a claimant's treating physician; nor may courts impose a discrete burden of explanation when they credit reliable evidence that conflicts with a treating physician's opinion." Black & Decker Disability Plan v. Nord, 548 U.S. 822, 830-831 (2003). See also Baker, 2007 U.S. Dist. LEXIS 5780 at *16 (same).

II. Plaintiff's Claims

Wellman was a Plan participant during her employment with Eastman Kodak as an optical engineer. In September 1991, Wellman ceased working and applied for disability benefits. She received LTD benefits from March 20, 1991, though September 30, 2003, on the basis of MetLife's determination that Wellman's diagnoses of fibromyalgia, chronic fatigue syndrome and multiple chemical sensitivity rendered her disabled pursuant to the terms of the Plan. Specifically, the Plan requires that in order for a participant to be eligible for disability benefits, the participant must be "totally and continuously unable to engage in any substantial Gainful Work for which he is, or becomes, reasonably qualified by education, training or experience [for a designated time period]." (Dkt. #18-3 at Wellman 00378-00393). In the case of LTD benefits, a participant is required to "[f]urnish proof of continuance of Disability, as required by [MetLife]." (Dkt. #18-3 at Wellman 00391). LTD benefits will terminate upon the participant's recovery, or in the event the participant fails to, inter alia, furnish proof that his disability is continuing. (Dkt. #18-3 at Wellman 00386).

On August 14, 2002, after receiving LTD benefits for more than a decade, Wellman informed MetLife that she had been pursuing a Master's degree in Biology at the State University of New York in Brockport ("Brockport"), and that Brockport had offered her a part-time position as a Teaching Assistant. On August 27, 2002, Wellman and MetLife entered into a vocational "Rehabilitation Plan," whereby Wellman would remain entitled to LTD benefits for an additional year, contingent upon her continued satisfaction of the Plan's definition of disability.

On June 9, 2003, Wellman's family physician completed an Attending Physician Statement of Functional Capacity ("Functional Capacity Statement") for MetLife, noting that Wellman could perform "light" work, but with a number of restrictions so significant that she remained totally disabled from any and all occupations. MetLife noted that this report was inconsistent with Wellman's self-reported participation in graduate school course work, and called Wellman to inquire. Wellman reported that she was continuing to pursue a master's degree, and had nearly completed all of her course work. She was preparing to begin a two-year research project on the effects of Lake Ontario shore pollution on the local mink population. In fact, Wellman had performed appreciable field research, including videotaping mink on the American side of Lake Ontario, where a mink population was not previously known to exist. She was expecting a grant of $12,000 for her research project, and also expected to pursue a part-time teaching career in the biological sciences at the college level.

Based on Wellman's description of her activities, including her academic course work, field work, and continued employment as a part-time teaching assistant at Brockport, MetLife began to review Wellman's file to determine whether she was still incapable of performing "any substantial Gainful Work." (Dkt. #18-3 at Wellman 00378-00393).

A July 14, 2003 Functional Capacity Statement completed by Wellman's treating physician identified her diagnoses as chronic fatigue syndrome, multiple chemical sensitivity and fibromyalgia. Objective findings were limited to low blood pressure and acne, and subjective symptoms consisted of fatigue. Wellman was to completely avoid assuming cramped or unusual positions, and operating vehicles and heavy equipment, and had "some limitation" in virtually every other physical category. She could lift and carry up to 30 pounds for 20% of the workday, and had no psychological problems which would interfere with her ability to work. (Dkt. #18-3 at Wellman 00391).

On July 31, 2003, based upon the July 14, 2003 Functional Capacity Statement, MetLife determined that the limitations described by Wellman's physician were largely inconsistent with her reported activities, including conducting outdoor lakeshore research projects. MetLife also noted that there was little clinical data in the file to support Wellman's symptoms, and that despite Wellman's family physician describing her conditions as severe, Wellman had never treated with a specialist for any of her allegedly disabling conditions. Taking account of the physical limitations identified by Wellman's physician, ...


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