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Ahmed Mohamed v. Metropolitan Life Insurance Company

February 2, 2012

AHMED MOHAMED, PLAINTIFF,
v.
METROPOLITAN LIFE INSURANCE COMPANY, DEFENDANT.



The opinion of the court was delivered by: P. Kevin Castel, District Judge:

MEMORANDUM AND ORDER

Plaintiff Ahmed Mohamed seeks judicial review of a final decision by defendant Metropolitan Life Insurance Company ("MetLife") denying his application for long-term disability benefits. The Employee Retirement Income Security Act of 1974 ("ERISA") gives district courts original jurisdiction over actions to recover insurance benefits under a policy issued as part of an employee welfare benefit plan. 29 U.S.C. §§ 1132(a)(1)(B), (e)(1). Defendant seeks equitable restitution for income plaintiff received during the benefits period under section 502(a)(3) of ERISA. 29 U.S.C. §§ 1132(a)(3). Both parties have moved for summary judgment based on the administrative record. For the reasons discussed below, plaintiff's motion is granted and defendant's motion is denied. The matter will be remanded to MetLife, the plan administrator, to consider additional evidence. Defendant has also moved for summary judgment to recover overpayments made to the plaintiff. That motion is granted.

BACKGROUND

I. Procedural History

In March 2007, Mohamed was employed as an Assistant Vice President in

Application Architecture and Development at Credit Suisse First Boston ("Credit Suisse"). (145, 436)*fn1 Mohamed's job consisted of computer programming that required him to sit and type at a computer for five to eight hours a day. (852) As an employee, he was eligible for and enrolled in Credit Suisse's group short-term and long-term disability plans, which are administered by MetLife. (63-108) MetLife also funds the long-term disability plan. Mohamed's last day of work was March 8, 2007. (145) In March 2007, Mohamed applied for and began receiving short-term disability benefits. (113-116, 860) He received these benefits for the maximum six-month period before applying for and receiving long-term disability benefits for an additional year and three months. (153, 615, 842) The plans use the same definition of disability which is: due to sickness, pregnancy or accidental injury, you are receiving Appropriate Care and Treatment from a Doctor on a continuous basis and you are unable to earn more than 80% of your Predisability Earnings or Indexed Predisability Earnings at your Own Occupation for any employer in your Local Economy. (319)

On or about December 8, 2008, MetLife informed Mohamed that his long-term disability benefits would be terminated as of that date because an independent medical examiner found that he had the functional ability to perform his own job. (617) Mohamed appealed the decision, and MetLife upheld the termination of his long-term disability benefits on or about June 3, 2009. (296-299) Mohamed filed this action against MetLife on September 21, 2010 seeking to recover long-term disability benefits allegedly due to him under Credit Suisse's plan.

II. Medical History

a. Prior to Short-Term Disability Benefits

Mohamed was thirty-nine years old on his last day of work in March 2007. (843) He had complained of neck and back pain as well as numbness and weakness in his hands since early 2006, but x-rays taken at that time were negative. Although Mohamed tried various workplace accommodations to make working more comfortable, they did not sufficiently reduce his pain. (112-116) A January 25, 2007 magnetic resonance image ("MRI") of Mohamed's cervical spine showed disc herniation and canal stenosis. (881) A February 7, 2007 MRI of Mohamed's lumbar spine showed scoliosis, disc herniation and other conditions. (879-880) A March 12, 2007 electromyography exam ("EMG"), which detects the electrical potential produced by muscle cells, showed mild carpal tunnel syndrome in Mohamed's right hand and cervical radiculopathy, commonly known as a pinched nerve. (868, 875-876) Dr. Ali E. Guy treated Mohamed for multiple injuries during this time and expected that his impairments would last for six months. (865) These treatments included trigger point injections, physical therapy, chiropractic care, and pain medication. (843) After internally evaluating Mohamed's medical information and concluding that he could not safely perform his job duties, on March 23, 2007, MetLife approved short-term disability benefits lasting for approximately one month. (116, 860)

b. During Short-Term Disability Benefits

Mohamed flew to Cairo, Egypt, where his parents live, on April 17, 2007. (117, 140-141, 852) When, two weeks earlier, he informed MetLife of his plans to travel, MetLife contacted Dr. Guy to ask about Mohamed's ability to fly to and continue treatment in Egypt. (119) Dr. Guy does not appear to have responded to this inquiry. (MetLife Mem. at 6) Mohamed continued to complain of back and neck pain as well as weakness and numbness in his right hand that were exacerbated by sitting at a desk and typing. (852) On April 28, 2007, Dr. Mohamed Ismail examined Mohamed and the earlier MRIs and EMG. (851) As the result of his clinical examination, Dr. Ismail concluded that Mohamed had injuries to the cervical and lumbar regions of his spine, suffered from arthritis and carpal tunnel syndrome and had a limited range of motion and noticeable weakness in his right arm. (851)

During the first week of May, MetLife conducted a second internal evaluation of Mohamed's medical information and approved a one-month continuation of short-term disability benefits because Mohamed was unable to sit and type for eight or more hours and was at risk for increased pain, nerve damage, or loss of function. (130-131, 850) The nurse who conducted the evaluation suggested a twelve-week recovery period and concluded that Mohamed's condition was too severe for vocational rehabilitation. (130-131) Mohamed saw Dr. Ismail again on May 26, 2007 and was told to continue physical therapy and pain medication. (848) MetLife extended short-term disability benefits by one month on July 5, 2007. (845)

During a third visit on August 1, 2007, Dr. Ismail found that Mohamed's arthritis and range of motion limitations continued and that his carpal tunnel condition and neck and back pain had worsened. Dr. Ismail prescribed pain medication. (843) On August 16, 2007, MetLife conducted a third internal evaluation of Mohamed's medical information and extended short-term disability benefits to September 6, 2007, exhausting the maximum period allowed under the short-term disability plan. (147, 842) MetLife concluded that Mohamed's hand, wrist, shoulder, neck and back pain made him unable to perform his job duties. (147) Mohamed's claim was then referred to long-term disability claim management. (842) On September 6, 2007, a MetLife "claims ...


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