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Karen Novick v. Metropolitan Life Insurance Company and Metlife and

February 14, 2011


The opinion of the court was delivered by: Richard J. Holwell, District Judge



Before the Court is defendants' Metropolitan Life Insurance Company ("Metlife") and Metlife Options and Choices Plan No. 512 (the "Plan") (collectively the "Metlife defendants") motion to dismiss [14] plaintiff Karen Novick's claims for denied and unpaid benefits under the Employee Retirement Income Security Act, 29 U.S.C. §§ 1001, et seq. ("ERISA"). In February 2007, Novick, employed by Metlife, applied for Short Term Disability ("STD") benefits pursuant to the Plan after receiving a tick bite and developing symptoms of Lyme disease. In March of that year Metlife approved benefits. In July 2007, however, Metlife terminated the STD benefits; and in February 2008, Metlife upheld that decision on appeal. In May 2009, Novick applied for Long Term Disability ("LTD") benefits under the Plan, but the Metlife defendants never issued a formal decision responding to that application. Then in August 2009, Novick filed this action. The Metlife defendants now move to dismiss under Federal Rule of Civil Procedure 12(b)(6), arguing that Novick's claim for STD benefits is untimely and that her claim for LTD benefits fails because she did not receive twenty-six weeks of STD benefits, a condition precedent to her reception of LTD benefits. Novick responds that the Metlife defendants' letter upholding their termination of her STD benefits on appeal violated the applicable ERISA regulations, and that the alleged condition precedent to receipt of LTD benefits did not actually exist in the relevant documents. For the reasons stated below, the Court DENIES defendants' motion in its entirety.


The following facts, taken as true for the purposes of the present motion, are relevant to this opinion.

A. The Disability Benefits Plans

In January and February 2007, Karen Novick was employed by Metlife as a Business Systems Analyst in Metlife's Information Technology department. (Compl. ¶¶ 9-10.) As part of her employment, Novick was a participant in the Plan, an Employee Welfare Benefit Plan provided by Metlife and established pursuant to ERISA. (Id. ¶ 5.) Under ERISA, Metlife was the Plan's fiduciary and administrator. (Id. ¶ 6.) The Plan granted Novick, inter alia, STD and LTD insurance coverage. (Id. ¶ 8.)

1. STD Benefits

STD benefits were summarized in Metlife's Short Term Disability Summary Plan Description ("STD SPD").*fn1 That document contained thirty-nine pages of text discussing the Plan's purpose, benefits, obligations, and procedures. The text was separated into several sections including one titled "OTHER PROVISIONS." (Hallford Decl. Ex. A ("STD SPD") at 26.) Within that section was a subsection titled "Claim Review and Appeal Procedures." (Id. at 30.) That subsection explained that after receipt of benefit claims, Synchrony, the Plan's "Claims Administrator," and Metlife would approve or deny STD claims normally within forty-five days. (Id.) If the claim was denied, the plan participant could file an appeal within 180 days of the denial decision. (Id.) Those appeals would also be decided normally within forty-five days. (Id.) The subsection concluded: "All decisions are final and are not open to further administrative appeal. . . . No civil action can be brought challenging the denial of the claim on appeal more than 6 months following the issuance of the final written decision on appeal." (Id.)

2. LTD Benefits

LTD benefits were summarized in Metlife's Long Term Disability Summary Plan Description ("LTD SPD"). The parties dispute whether that document required an LTD claimant to collect twenty-six weeks of STD benefits before being eligible for LTD benefits; and the LTD SPD contained numerous clauses potentially going towards the issue. For example, the section "HIGHLIGHTS" stated: "The [LTD] Plan is intended to replace some of your income if you continue to be Disabled and unable to work after receiving compensation continuance and/or temporary disability benefits for 26 weeks." (Hallford Decl. Ex. B ("LTD SPD") at 5.)*fn2 The same section went on to state: "Benefits begin after you've been Disabled beyond the period of time covered by compensation continuance and/or temporary disability benefits." (Id.) The LTD SDP defined "Disabled" as, inter alia, being unable to earn more than eighty percent of pre-disability income during and after "the first 12 months of disability, including the period of short term disability." (Id. at 8.) Additionally, the section "HOW THE PLAN WORKS" stated that the Plan pays benefits if the claimant "continue[s] to be Disabled beyond the expiration of STD benefits." (Id. at 10.) That section continued: "If you remain Disabled after 26 (or 27) weeks after receiving all of your compensation continuance and/or temporary disability benefits, LTD benefits may commence." (Id.)*fn3 The "FILING A CLAIM FOR BENEFITS" section directed the claimant to Synchrony and stated: "You should file the claim after four months of disability." (Id. at 19.) Finally under the "TERMS YOU SHOULD KNOW" section, the LTD SPD explains, in defining "Pay," that "[y]our LTD benefit is always based on your Pay immediately preceding your date of Disability, even though LTD payments do not begin until you have received STD benefits for 26 weeks." (Id. at 27.)

B. Novick's Tick Bite and Benefits Claims

Novick was bitten by a tick on January 6, 2007. (Compl. ¶ 9.) She subsequently developed symptoms of Lyme disease*fn4 and was forced to leave work due to those symptoms on February 6 of that year. (Id. ¶¶ 9-10.) Also in February Novick applied for STD benefits under the Plan. (Id. ¶ 14.) Though Metlife initially approved Novick's STD benefits in March 2007, (id. ¶ 15), Metlife terminated those benefits on July 23, 2007, alleging that Novick had not submitted sufficient documentary medical proof that her claimed Lyme disease prevented her from performing her job. (Id. ¶ 17.) The termination letter informed Novick that she could file additional documentation attesting to her "functional impairment," and that she could appeal the termination internally. (Compl. Ex. 1 at 1-2.) The letter also stated, "In the event your appeal is denied in whole or in part, you will have the right to bring civil action under Section 502(a) of [ERISA]." (Id. at 2.) The letter did not mention any limitations period for bringing that action.

Novick did internally appeal the termination of STD benefits, and included in the materials she provided Metlife two letters from one Dr. Richard I. Horowitz, then Vice President of the International Lyme and Associated Disease Society.*fn5 (Compl. ¶¶ 18, 24; Compl. Exs. 2 at 1; 4 at 4.) Those letters described how Novick's symptoms of "chills, sweats, . . . fatigue, joint pains, stiffness, muscle twitching, burning pains/neuralgia and electrical sensations . . . lightheadedness and poor balance, . . . cognitive problems including brain fog, confusion, difficulty thinking, difficulty with concentrating and reading, and poor memory, and an excessive . . . need for sleep," (Compl. Ex. 4 at 3), were "consistent with neurologic Lyme disease as well as with the conditions of fibromyalgia*fn6 and chronic fatigue symptoms," (id. at 1), explained that Novick "remains severely symptomatic and is still disabled," (id. at 3), and concluded that Novick "is disabled by her current symptoms and is not capable of returning to her previous job." (Id. at 4.)

Based in part on an opinion by an "Independent Physician Consultant" (Compl. Ex. 6 at 1), explaining that "no objective findings [exist] that would necessitate the placement of restrictions and limitations on activities whether it be related to fibromyalgia and/or Lyme disease . . . [and] that [Novick] is capable of unrestricted work," (Compl. Ex. 5 at 2),*fn7 Metlife upheld its prior termination of benefits by letter dated February 12, 2008. (Compl. Ex. 6 at 1). That letter stated, "the available information does not demonstrate that [Novick] was unable to perform the essential duties of her occupation." (Id. at 2.) The letter concluded, "You also have the right to bring a civil action under Section 502(a) of [ERISA]. You have exhausted your administrative remedies under the plan, therefore no further appeals will be considered." (Id. at 2.) Like the initial termination letter, the letter denying Novick's appeal did not mention any time limits applicable to any civil action.

Novick alleges that the Metlife defendants' termination of her STD benefits was improperly intended to "insulate[] defendants against [her] anticipated claim for LTD benefits." (Compl. ¶ 29.) She further alleges, "[o]n several occasions," the Metlife defendants told her, "she is not permitted to file her claim for LTD benefits . . . until she had received all of her STD benefits." (Id. ¶ 31.) Regardless, relying on the LTD SPD's language directing a claimant to file her claim after four months of disability, Novick submitted a claim for LTD benefits on May 26, 2009. (Id. ¶¶ 32-33.) The Metlife defendants never issued any decision in response, (id. ¶ 40), which Novick contends is a "deemed denial" of her claim as a matter of law. (Id. ¶ 41.)

Novick filed this action on August 3, 2009. Her single claim, brought pursuant to 29 U.S.C. § 1132(a)(1)(B), is that the Metlife defendants violated ERISA by improperly terminating her STD benefits and improperly denying her LTD benefits. (Compl. ¶ 45.) She claims that the Metlife defendants arbitrarily and capriciously failed to investigate her claims, refused ...

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