Summary
noting two independent medical reviews
Summary of this case from Laser v. Provident Life Accident Ins. Co.Opinion
Civil No. JFM 00-1018
February 6, 2001
MEMORANDUM
Now pending before the court is the Defendants' Motion for Summary Judgment. Carol A. Adamson ("Adamson") works for Raytheon Company ("Raytheon") as a principal software engineer. Adamson has had medical problems dating to the mid-1990's involving pain in her right hand, right arm, right shoulder, neck and back. She has undergone operations for carpal tunnel syndrome and shoulder problems. During the relevant time period, Raytheon provided disability plans for its employees. Beginning in March 1997, Adamson received benefits under Raytheon's short-term disability plan, which was administered and insured by Metropolitan Life Insurance Company ("MetLife"). After receiving benefits under this plan, she went on long-term disability in June 1997. At the time, Adamson was under the care of Dr. William Tham, a physical medicine specialist. Dr. Tham referred Adamson to Dr. Thomas Dennis, an orthopedic physician, in the summer of 1997. On October 30, 1997, Dr. Dennis operated on Adamson's shoulder and, on December 11, 1997, cleared Adamson for work. On the basis of Dr. Dennis' opinion, MetLife terminated Adamson's long-term disability benefits on December 22, 1997 (retroactive to December 11th). Adamson requested a review of the determination and sent MetLife a letter explaining that her shoulder surgery had not resolved her back and arm pain, for which Dr. Tham had been treating her. MetLife also received a note from Dr. Tham, who stated that he had seen Adamson on January 5th and January 16, 1998. He concluded that Adamson's problems with fibromyaglia and myofascial pain in her arm and neck still disabled her from working. MetLife upheld its original determination on appeal. After further requests for review, it commissioned an independent medical review by Network Medical Review Company ("NMR"); the NMR physician concluded that Adamson was not disabled from working.
On August 14, 1998, Adamson sought benefits under Raytheon's short-term disability plan; MetLife administered the claim but did not insure the plan. MetLife believed Adamson's requested disability period ran from July 29th to August 13th. MetLife denied benefits under this plan, stating that Adamson had not submitted adequate evidence that she was disabled during this time period.
On February 2, 1999, Adamson filed for benefits under a different Raytheon short-term disability plan, which MetLife administered and insured. Adamson submitted medical records from Dr. Tham, Dr. Angela Calle (her family physician), and Dr. Sassan Hassassian (a pain management specialist at the University of Maryland). MetLife denied her claim because it did not contain sufficient objective evidence of disability. MetLife subsequently upheld its determination. During the process, it commissioned independent medical reviews from NMR. Two NMR physicians concluded that there was a lack of evidence from which to conclude that Adamson was disabled from her position.
Adamson brings suit to recover the benefits that MetLife denied her. She states seven claims under state law and one under section 1132(a)(1)(B) of the Earned Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. § 1001 et seq.
I.
The defendants have moved for summary judgment on counts I — VII, which allege claims under state law, on the ground that ERISA pre-empts them. Adamson has responded to their motion by moving to dismiss these claims without prejudice. The defendants argue that these claims should be dismissed with prejudice.
Fed.R.Civ.P. 41(a) covers voluntary dismissal of "actions." The rule does not allow the plaintiff to dismiss individual claims from a multi-claim complaint. Bragg v. Robertson, 54 F. Supp.2d 653, 660 (S.D.W. Va. 1999) (noting that Rule 41(a)(2) "is an appropriate mechanism only when a plaintiff seeks to dismiss an entire action as against a defendant"); Loutfy v. R.R. Donnelley Sons, Co., 148 F.R.D. 599, 602 (N.D.Ill. 1993) (same); Paglin v. Saztec Int'l, Inc., 834 F. Supp. 1184, 1189 (W.D.Mo. 1993) (same). Courts thus treat motions to dismiss fewer than all the claims in a suit as motions to amend the complaint under Fed.R.Civ.P. 15(a). Bragg, 54 F. Supp.2d at 660; Loutfy, 148 F.R.D. at 602; Paglin, 834 F. Supp. at 1189. Under Rule 15(a), leave to amend the complaint "shall be freely given when justice so requires." See Foman v. Davis, 371 U.S. 178, 182 (1962) (the mandate in Fed.R.Civ.P. 15(a) "is to be heeded"). Leave should be denied only when "the amendment would be prejudicial to the opposing party, there has been bad faith on the part of the moving party, or the amendment would be futile." Edwards v. City of Goldsboro, 178 F.3d 231, 242 (4th Cir. 1999) (citation omitted).
Here, granting Adamson's motion to dismiss without prejudice her state law claims would be futile. Its only purpose would be to permit her to assert those claims in a subsequent motion. However, there is no point in permitting that to occur since Adamson's state law claims are pre-empted by ERISA. Accordingly, her motion to dismiss is denied, and defendants' motion for summary judgment as to counts I through VII is granted.
II.
In count VIII, Adamson alleges that the defendants violated ERISA by denying her disability benefits.
The framework for deciding employee benefits cases under ERISA is well-established. If an employee benefit plan gives the plan administrator discretion to construe uncertain terms or to determine eligibility for benefits, the court reviews the administrator's decision for an abuse of discretion; if not, the court's review is de novo. Booth v. Wal-Mart Stores, Inc. Assocs. Health Welfare Plan, 201 F.3d 335, 340-41 (4th Cir. 2000); Firestone Tire Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989). Under the abuse of discretion standard, an administrator's discretionary decision will not be overturned if it is reasonable, even if the court itself would have reached a different result. Booth, 201 F.3d at 341. The reasonableness inquiry considers numerous factors, including, but not limited to: the language of the plan, the purposes and goals of the plan, the adequacy of the materials used to make a decision and the degree of support they provide, whether the fiduciary's interpretation was consistent with other provisions in the plan and with earlier interpretations of the plan, whether the decision making process was reasoned and principled, whether the decision was consistent with ERISA's procedural and substantive requirements, any external standard relevant to the exercise of discretion, and the fiduciary's motives and any conflict of interest it may have. Booth, 201 F.3d at 342-43. A conflict of interest may also "operate to reduce the deference given" to the fiduciary. Id. at 343 n. 2. Adamson challenges the reasonableness of the defendants' denial of her three claims for benefits. For each of these decisions, Adamson concedes that the relevant plans provide the administrator with discretion. (Mem. Supp. Pl.'s Opp'n to Defs.' Mot. Summ. J. at 1.)
Although the long-term plan provides that a discretionary decision shall be enforced unless shown to be "arbitrary and capricious," see 000668, contractual language may not alter the abuse of discretion standard. Booth, 201 F.3d at 343 ("[W]e do not understand ERISA to allow a plan to alter the established standard of judicial review of discretionary decisions for reasonableness.").
Accordingly, I apply the abuse of discretion standard, and evaluate each denial for reasonableness, subject to possible reduced deference where a conflict of interest exists. Booth, 201 F.3d at 343 n. 2.
A.
The first dispute concerns MetLife's discontinuance of benefits under Raytheon's long-term disability plan in December 1997. Because MetLife was both the administrator and insurer, a potential conflict of interest arises, which may reduce the amount of deference owed to MetLife. See, e.g., Elliot v. Sara Lee Corp., 190 F.3d 601, 605 (4th Cir. 1999) (noting that a potential conflict of interest arises when the fiduciary also insures the plan); Bernstein v. Capitalcare, Inc., 70 F.3d 783, 787 (4th Cir. 1995) (concluding that where a decision to confer benefits impacts the administrator's own financial self-interest, a conflict of interest arises). MetLife's long-term disability policy instructs that a beneficiary is disabled if "due to an Injury or Sickness, [she] require[s] the regular care and attendance of a Doctor" and, inter alia, is "unable to perform each of the material duties of [her] regular occupation." 000655. Adamson was a principal software engineer. Her primary job requirements were sitting and keyboarding, which required fine hand dexterity, repetitive motion, visual acuity, and verbal and written communication. 000226-27. Even allowing for a conflict of interest, it cannot be concluded from the documents in the administrative file that MetLife abused its discretion. First, Dr. Dennis stated in a December 11th note that after Adamson's October 30th shoulder surgery, and after post-surgery examination, Adamson "ha[d] . . . healed sufficiently to enable her to return to work." 000221. Adamson argues that Dr. Dennis treated only her shoulder and that the surgery did not (and could not) improve the myofascial and fibromyaglia symptoms in her right arm and neck, which Dr. Tham treated. There is no dispute, however, that Dr. Tham did not examine or treat Adamson from July 14th until at least December 15th and possibly January 5th. Moreover, Dr. Tham's notes from June and July of 1997 never attributed Adamson's disability to both her fibromyaglia or myofascial pain and to shoulder problems, or to Adamson's non-shoulder problems alone. See 000252 (noting in a June 16th note that "it is not terribly clear what the etiology of [Adamson's] pain is" but she "has a fair amount of pain that starts in the shoulder and she may have some pathology in that region"); 000277 (noting in a July 18th letter to MetLife an early diagnosis of cervical radiculopathy and myofascial pain but a more recent diagnosis of "impingement syndrome of the shoulder" for which surgery was recommended). Adamson has submitted no medical records available to MetLife at that time demonstrating that Adamson's non-shoulder problems alone disabled her from doing her job.
MetLife previously had sent Dr. Dennis a description of Adamson's job duties. 000225-27.
On November 10th MetLife sent a letter to Adamson requesting that she submit further medical information from Dr. Dennis or "your current treating physician" evidencing her disability. 000232-33. Neither Adamson nor Dr. Tham sent documents pertaining to her treatment.
Although Dr. Dennis wrote that shoulder surgery would "not help with her other myofascial symptoms," 000215, 000231, his note offers no evidence that these symptoms alone disabled her from performing the material duties of her job.
MetLife also reviewed a letter from Dr. Tham, dated January 16, 1998. 000209. Although the letter states that Adamson's "period of total disability will very likely continue for an additional three months," it contains no indicia of her problems, only statements that reporting to work as a "systems analyst" would aggravate her neck pain. Id. It also indicated that no x-rays had recently been taken and that bone scans had been negative. Id. On June 1st, MetLife commissioned an independent review of Adamson's claim by NMR. 000178-79. NMR sent a report, written by Dr. Kevin Smith (occupational medicine), on June 12th. 000171-77. Based upon a review of the records, the report found that Adamson's "main limiting condition . . . was her right shoulder impingement and she was released to regular work by her surgeon." 000175.
The letter stated that Dr. Tham had seen Adamson on January 5th and January 16th. In a subsequent letter, Adamson explained that Dr. Tham's January 16th note had omitted her office visit on December 15th. 000193.
Adamson does not argue that MetLife failed to provide NMR with pertinent medical records.
It also noted that although "she had ongoing problems with localized myofascial pain in the trapezius region, . . . the medical records do not support that she had an impairment of a severity to preclude her ability to work." Id. The report noted that Adamson had "a normal EMG/nerve conduction study, a normal bone scan, and an unremarkable cervical spine MRI." Id.
In sum, although Dr. Tham indicated that he had seen Adamson during the relevant time period, Adamson's record sheds little light on the severity of her disability. It does not substantiate a disability based on non-shoulder problems alone. Moreover, Dr. Smith's report concludes that she was not disabled. Adamson has not created a triable issue that MetLife abused its discretion.
B.
On September 25, 1998, MetLife denied Adamson's claim for benefits under Raytheon's Weekly Disability Plan. 000134-35. Because MetLife administered this claim, see 000150, but did not insure or fund the plan, there is no conflict of interest and the unmodified abuse of discretion standard applies. To receive benefits, Adamson had to show that she was "unable to work because of a covered nonoccupational accident or sickness and [was] under the regular care of a doctor." 000641.
This standard does not come from the actual disability plan, but rather from a booklet distributed to employees describing the plan. 000640. Adamson has not argued that this standard is inappropriate.
I find MetLife's decision was reasonable. MetLife's records indicate that Adamson made a telephone claim for disability beginning on July 29th or July 30th. See 000134, 000136-38, 000141-42. The only evidence that her disability began on July 13th is Dr. Tham's notation on MetLife's medical questionnaire. 000146. Adamson has not submitted an affidavit indicating that she offered this date to Dr. Tham. Dr. Tham submitted two office notes, one dated July 13th and the other July 17th. 000145-49. The July 13th note indicated that Adamson was "having a flare-up of her pain which started last week." 000149. The pain started in her neck and radiated down her elbow. Id. "She hasn't had this pain for quite some time now and had been doing reasonably well." Id. Dr. Tham administered a trigger-point injection. The July 17th note indicates that Adamson was "[d]oing much better." 000148. It also mentioned that she would follow up in two weeks. Id. But when MetLife made another request for documents on September 3rd, Dr. Tham did not respond. 000143-44. Dr. Tham's two office notes simply do not evidence a disability from July 29th to August 13th. At most they evidence a "flare up" of her myofascial pain on the days surrounding July 13th. 000149. Adamson has provided no evidence from which a jury could find that MetLife unreasonably denied her claim.
This statement rebuts Adamson's claim that MetLife should have considered Adamson's medical history when evaluating this particular claim for benefits.
C.
On March 23, 1999, MetLife denied Adamson's claim for benefits under another Raytheon short-term plan. Because MetLife was both the administrator and insurer for this plan, I apply the abuse of discretion standard, subject to reduced deference for MetLife's conflict of interest. Under the short-term plan, a person is "fully disabled" if she is "under the regular care and attendance of a Doctor" and "unable to perform all of the essential elements of [her] regular job with reasonable accommodations." 000626.
MetLife's decision was based on a number of documents. First, it received documents from Dr. Calle. 000083. The only document that pertains to the disability period is an office note dated February 11th that deals with cold symptoms. 000087. Dr. Calle also noted in response to a MetLife inquiry that Adamson's return-to-work date was "unknown." 000084. A referral letter written by Dr. Calle to the University of Maryland Pain Clinic refers to Adamson's "fairly unrelenting" pain and her "challenging condition which has rendered her unable to work."
Second, Dr. Sassan Hassassian of the University of Maryland evaluated her on February 15th. 000078. Dr. Hassassian's physical examination revealed, inter alia, a "normal gait with good range of motion over her lumbar spine" and "good range of motion over her shoulders, right and left." 000079. He did notice "spinous tenderness over the thoracic spines, over the trapezius muscles, and over the scapular area on the right side." 000079. Moreover, he notes at one point that "[a]t present she is disabled." 000078.
Third, MetLife reviewed a March 1, 1999 letter from Dr. Tham. 000076-77. Dr. Tham noted Adamson's history of chronic and severe pain. 000076. He stated:
From a functional viewpoint, we have had her off work since January 21, 1999. We plan for her to be off work for at least three months. She will be re-evaluated in April of 1999. There is a definite likelihood that she may never be able to return to her job as a software engineer and may need to be on long term disability.
000077. MetLife also reviewed Dr. Tham's March 12, 1999 letter, an addendum to the March 1st letter. 000055. He states that Adamson "is not capable of typing, reaching overhead, or sitting at a desk in front of a computer for any prolonged period of time without suffering severe pain." 000055. He continued, "It is the combination of her chronic pain, depression, cervicalgia and radiculopathy, and the reflex sympathetic dystrophy of the right shoulder as well as the osteoarthritis which is not allowing her to return to gainful employment." 000055-56. In response to this letter, MetLife also read two independent medical reviews that it obtained from NMR. 000048-49. Both reviews, one by Dr. Smith and another by Dr. Saad M. Al-Shathir (physical medicine), concluded that there was insufficient objective evidence to support a disability finding. 000038-47. Dr. Smith had spoken with Dr. Tham on May 27th and received his input on Adamson's condition. 000042.
Although the question is a close one, in my view a factfinder could not conclude that MetLife abused its discretion in denying Adamson's claim. The documents from Dr. Calle and Dr. Hassassian do not contribute much support to Adamson's case; they do not state medical conclusions that Adamson was disabled. Although Dr. Calle states in a letter that Adamson's symptoms rendered her unable to work, see 000081-82, this is more descriptive than prescriptive.
Similarly, Dr. Hassassian notes that Adamson "[a]t present . . . is disabled." 000078. But this statement appears in the "Affects on Daily Activities" section, alongside comments on Adamson's ability to sleep and do daily chores. 000078-79. Thus, Dr. Calle and Dr. Hassassian seem to indicate that Adamson was not working rather than concluding that she should or could not work. 000079-80.
Dr. Hassassian's report does include an objective finding of tenderness around Adamson's spine and trapezius. 000079.
Dr. Tham alone concludes that Adamson is disabled and recommends her not working. 000055-56, 000076-77. He bases his conclusion on his familiarity with Adamson's condition and his history of treating her. He also details how her job duties would exacerbate her symptoms. 000055.
Although the Fourth Circuit has not directly held in the ERISA context that the opinion of a "treating physician" trumps that of a physician reviewing a cold record, see Elliot v. Sara Lee Corporation, 190 F.3d 601, 607 (4th Cir. 1999), Ellis v. Metropolitan Life Insurance Co., 126 F.3d 228, 234 n. 4 (4th Cir. 1997), I have carefully considered Dr. Tham's opinion because it has not been contradicted by another physician who actually examined Adamson. See Sheppard Enoch Pratt Hosp., Inc. v. Travelers Ins. Co., 32 F.3d 120, 126 (4th Cir. 1994) (recognizing that "the judgment of the treating doctor is crucial to making [a] determination" that a person is disabled); cf. Elliot, 190 F.3d at 606 (refusing to give treating physician's opinion greater weight where other examining physicians found that patient could perform work activities); Ellis, 126 F.3d at 234 n. 4 (refusing to give deference to treating physician where other examining physicians had not reached a consensus on patient's condition). Nonetheless, Dr. Tham's notes provide few objective findings to substantiate Adamson's complaints of pain. Moreover, against his conclusions, I must weigh the medical reports filed by Drs. Smith and Al-Shathir and the minimal objective findings of pathology in Dr. Hassassian's examination. I also note that there is little in the way of procedural irregularity to trigger a suspicion of bad faith. Compare Hines v. Unum Life Ins. Co., 110 F. Supp.2d 458, 462-64 (W.D.Va. 2000). MetLife afforded Adamson numerous reviews and invited her to submit additional evidence of her disability throughout the process. Therefore although a reasonable person could justifiably conclude that Adamson was disabled with regard to her position, Adamson has not provided sufficient evidence that a reasonable person (acting in the absence of a conflict of interest) would be required to do so. Thus Adamson has not created a triable issue that MetLife abused its discretion in denying her claim.
Although Adamson casts aspersions on the impartiality of NMR, she has not produced evidence demonstrating bias or predisposition with regard to the medical examinations conducted in her case. See Ellis, 126 F.3d at 233 n. 3.
An order effectuating the rulings made in this Memorandum is being entered herewith.
ORDER
For the reasons stated in the foregoing memorandum, it is, this ___ day of February, 2001, ordered that:
1. The Plaintiff's Motion to Voluntarily Dismiss counts I — VII is DENIED;
2. The Defendants' Motion for Summary Judgment on counts I — VIII is GRANTED; and
3. Judgment shall be entered for the defendants on counts I — VIII.