Opinion
Civil Action No. 3:03-CV-0777-N.
May 21, 2004
ORDER
Before the Court is the motion for summary judgment of Defendants Raytheon Company Short Term Disability Plan ("Short Term Disability Plan"), Raytheon Company Long Term Disability Plan ("Long Term Disability Plan"), Metropolitan Life Insurance Company ("MetLife"), and Raytheon Company, as Plan Administrator ("Raytheon"). Plaintiff Gloria Audino filed this action challenging MetLife's decision to deny her benefits under the Short Term Disability Plan and the Long Term Disability Plan. Because MetLife's decision was not arbitrary or capricious, the motion for summary judgment is granted.
I. BACKGROUND A. Audino's Disability Claims
Audino worked for Raytheon for seventeen years, most recently as a Software Engineer Administrative Assistant. Throughout that seventeen year period, Audino participated in Raytheon's disability plans — including the Short Term Disability Plan and Long Term Disability Plan at issue here — and paid monthly premiums for enhanced benefits under the terms of the Plans.
In 1999, she was diagnosed with rheumatoid arthritis and continues to undergo drug therapy to control symptoms including pain and swelling in the joints. (MET 0230). In May 2001, Dr. Sanjay Patel, an ophthalmologist, diagnosed Audino with optic neuritis. According to Dr. Patel, the optic neuritis caused her to have "a complete inferior altitudinal defect, which means that the inferior half of her right visual field is completely missing." (MET 0188).
The administrative record was supplied to the Court as an appendix to MetLife's Motion for Summary Judgment, and the Court follows the parties' usage in citing to it as "(MET 00XX)." Audino's appendix includes the text of the Long-Term Disability Plan and is cited as ("AUD 0XX").
Later that month, Audino filed a claim under the Short Term Disability Plan, which MetLife approved. (MET 0453-54). Audino received benefits from May 9, 2001 through June 8, 2001. Id. She returned to work on June 9, 2001 and worked until July 9, 2002, (MET 0455, 0080), when she again applied for short-term disability benefits. (MET 0118.1). At the same time she applied for Social Security Disability Income, submitting the same medical documentation submitted to MetLife. The Social Security Administration approved the claim concluding that Audino became disabled on July 9, 2002. (MET 308). In addition, Raytheon granted Audino unpaid medical leave after Raytheon's consulting doctor reviewed the same medical records. (MET 0311).
B. MetLife's Denial of Audino's Claim
MetLife subsequently denied Audino's claim on three separate occasions. On July 22, 2002, MetLife denied Audino's claim because it claimed it had not received any medical information in support of her claim. (MET 0286). In response, Audino submitted thirty-four pages of medical records from her doctors, but on August 12, 2003, MetLife again denied her claim because it claimed the most recent records submitted were from January 2002 and therefore could not support the claim that Audino could not perform her job duties as of July 10, 2002. (MET 0125-58). On August 13, 2002, MetLife received additional medical records from Audino's rheumatologist and lab results, but denied her claim for a third time on August 21, 2002, because it determined that "there was still insufficient objective medical evidence to support Plaintiff's claim that she was unable to perform the essential elements of her regular job with reasonable accommodations." Defendants' Brief in Support of Summary Judgment at 8.C. Audino's Appeals
Audino appealed the three denials and submitted additional medical records. MetLife referred the records to Dr. Tracey Schmidt, an independent consultant in internal medicine and rheumatology. Schmidt concluded that the administrative record "lacks objective evidence of a physical functional capacity impairment to a full time sedentary job." (MET 0231). Based on the information in the medical records Audino submitted and the report from Schmidt, MetLife upheld the denial of Audino's claim for short term disability benefits, concluding that the medical information did "not support the severity of impairment that would render Ms. Audino unable to perform the essential elements of her job as a Management Assistant Senior." (MET 0096; MET 0257-59).
Upon request from Audino's lawyer, MetLife reopened the administrative record to allow additional review of Audino's optic neuritis and/or any related eye condition. Audino submitted additional records from Patel, her ophthalmologist. MetLife supplied a medical consultant, Dr. David Turok, with the new records submitted by Audino as well as all the records from Audino's previous claim in 2001. (MET 0098; 0422-25). After reviewing these records and consulting with Patel, Turok concluded that "Audino's current level of functionality should allow her to maintain her job as a management assistant. The occupational requirements could be met given her visual function." (MET 0419). Based on Turok's conclusions and analysis, on April 4, 2003, MetLife upheld the denial of Audion's claim for a second time. (MET 0413-16). On April 15, 2003, Audino filed this lawsuit seeking to recover both short term and long term disability benefits. (MET 0274-81; 0416).
Audino expressly waives its response to Defendants' motion for summary judgment on her claim for breach of fiduciary duty under ERISA and Defendants' claim that Raytheon is not a proper party to the lawsuit, conceding that "Defendants have the stronger argument on those two issues." Plaintiff's Response to Defendants' Motion for Summary Judgment at 2 n. 1. Accordingly, the Court confines its discussion to MetLife's denial of short-term and long-term disability benefits.
II. THE STANDARD FOR EVALUATING METLIFE'S DECISION TO DENY BENEFITS IS ABUSE OF DISCRETION
In an action challenging the decision of an ERISA-governed plan to deny benefits, the Court limits its review to the administrative record. Meditrust Fin. Servs. Corp. v. Sterling Chems., Inc., 168 F.3d 211, 215 (5th Cir. 1999); Southern Farm Bureau Life Ins. Co. v. Moore, 993 F.2d 98, 102 (5th Cir. 1993). "[F]actual determinations made by the administrator during the course of a benefits review will be rejected only upon the showing of an abuse of discretion." Meditrust, 168 F.3d at 213. Where, as here, the plan fiduciary or administrator has discretionary authority to determine eligibility for benefits, the Court reviews the fiduciary's decision regarding benefits for abuse of discretion. See Firestone Tire Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989); Vega v. National Life Ins. Servs., 188 F.3d 287, 295 (5th Cir. 1999); Meditrust, 168 F.3d at 213; Sweatman v. Commercial Union Ins. Co., 39 F.3d 594, 598 (5th Cir. 1994).
In the Fifth Circuit, that review is highly deferential. Under the abuse of discretion standard, the Court is limited to determining whether MetLife's decision to deny Audino's claim for short-term benefits was "arbitrary or capricious." See, e.g., Meditrust, 168 F.3d at 214 ("As long as the interpretations or fact-findings are not arbitrary or capricious, we do not upset them.") (citing Penn v. Howe-Baker Eng'rs, Inc., 898 F.2d 1096, 1100 (5th Cir. 1990)). A decision is not arbitrary or capricious if it is supported by "substantial evidence." Meditrust, 168 F.3d at 215. However, a decision is arbitrary if it is "made without a rational connection between the known facts and the decision or between the found facts and the evidence." Bellaire Gen. Hosp. v. Blue Cross Blue Shield, 97 F.3d 822, 828 (5th Cir. 1996).
Audino urges the Court to frame its abuse of discretion analysis on four factors identified by the Fifth Circuit in Lain v. UNUM Life Ins. Co. of Am., 279 F.3d 337, 346 (2002). However, the Lain factors are relevant only to the question of whether a plan administrator's interpretation of the policy constitutes an abuse of discretion. Id. (describing the Court's task as determining whether a plan administrator's "interpretation of the Policy, although legally incorrect, constitutes an abuse of discretion."). Because there is no dispute over the interpretation of policy terms at issue here, the Lain factors do not apply.
Audino urges the Court to apply a "sliding scale" to the abuse of discretion standard because MetLife operates under a conflict of interest as both the insurer and claims administrator. Gooden, 250 F.3d at 333 (applying a sliding scale standard because the insurance administrator "potentially benefits from every denied claim"); Vega v. National Life Ins. Services, Co., 188 F.3d 287, 298 (5th Cir. 1999) ( en banc) (applying the sliding scale standard for a conflict of interests). In this Circuit,
the existence of a conflict is a factor to be considered in determining whether the administrator abused its discretion in denying a claim. The greater the evidence of conflict on the part of the administrator, the less deferential our abuse of discretion standard will be. Having said that, . . . review of the administrator's decision need not be particularly complex or technical; it need only assure that the administrator's decision fall[s] somewhere on a continuum of reasonableness — even if on the low end.Vega, 188 F.3d at 297.
III. THERE IS SOME CONCRETE EVIDENCE SUPPORTING METLIFE'S DENIAL OF BENEFITS
The question before the Court, then, is whether concrete evidence in the administrative record reasonably supports MetLife's decision to deny benefits to Audino. Although there is evidence to the contrary, the Court acknowledges some concrete evidence supporting MetLife's decision.
Under the terms of the Short-Term Disability Plan, an eligible plan participant must be "fully disabled" to receive short-term disability benefits. According to the Plan, one is "fully disabled" if, "due to an injury or sickness, [the employee] is under the regular care and attendance of a Doctor" and is "unable to perform all of the essential elements of [the employee's] regular job with reasonable accommodations." (MET 0058).
As a Management Assistant Senior, Audino served as an administrative assistant to a manager of an organizational unit made up of 400 employees. (MET 0077, 0101, 0327-28). Audino's job was sedentary and required sitting, highly repetitive motion, fine visual attention, and precise verbal or written communication 67-100% of the work day, and standing, walking, climbing stairs, grasping, bending, squatting, stooping, fine hand dexterity, highly repetitive motion and forceful wrist twisting 1-33% of the work day. (MET 0327.5). Audino's job also required lifting objects weighing up to 20 pounds 1-33% of the time. (MET 0328).
Audino stopped working on July 9, 2002, and on July 11, made a claim for short-term disability benefits stating that she could no longer work due to her rheumatoid arthritis and loss of 75% of the vision in her right eye. (MET 0074-78).
MetLife gave Audino reasonable opportunities to develop a full and complete administrative record with regard to both her rheumatoid arthritis and loss of vision. Under ERISA, Audino bears the burden of submitting evidence that supports her claim for benefits under the Plan. See, e.g., Vega, 188 F.3d at 300. MetLife provided Audino three opportunities to submit medical evidence in support of her claim before the appeal process, and then reopened the administrative record to allow Audino to supply additional evidence after she lost her first appeal.
A. Dr. Schmidt's Analysis and Conclusions
MetLife denied Audino's claim relying in part on the analysis of two medical consultants who determined there was insufficient objective evidence in the administrative record to support "full disability" within the meaning of the Short-Term Disability Plan. Dr. Schmidt made the following comments with regard to Audino's rheumatoid arthritis claim:
Physical exams show only some joints to be mildly tender without synovitis, some crepitations of the right knee and a subluxation of the MTP joints in the right foot with a cock of deformity. File also mentions trigger points on exam. File lacks mention of any restricted ROM [range of motion] of joints other than right foot abnormality. File lacks any x-rays to support impairment. File shows an elevated CRP on 9/16/02 but lacks any baseline CRP's in the past for comparison. File mentions an elevated ESR but the value recorded in the file is 25 and if this is corrected for age, it is within the normal range. File lacks any mention of ADL impairment by health care provider, or the need for housekeeper/home health aide.
(MET 0231). Schmidt's analysis is based on some concrete evidence. He identifies specific forms of objective evidence (e.g., x-rays) that might support impairment, but are absent from the administrative record. In addition, Schmidt points out that the available objective evidence (e.g., physical exams) show only mild tenderness and reveal no restrictions on Audino's range of motion.
With regard to Audino's visual impairment claim, Schmidt writes:
File mentions a diagnosis of a unilateral visual field defect in right eye. File lacks any actual visual field testing or office notes from the Ophthalmologist. File also mentions by claimant that the visual field defect has been there for greater than one year and she has continued to work. Dr. Zahabi mentioned she has had many accidents because of her visual field defect and this is going to disable her from working. The claimant states the car accidents are because she falls asleep. The definition of disability does not include transportation difficulties to and from work. File lacks any visual field testing from 1-2 years ago to document change in visual fields. File also mentions a diagnosis of fibromyalgia which is a diagnosis of exclusion and a constitution of symptoms consisting of pain, fatigue, poor sleep, concentrating difficulties, memory impairment and trigger points on exam. File does mention sleep disturbance but lacks actual sleep studies as a workup for her fatigue and to support impairment. A high percentage of fibromyalgia patients have an underlying psychiatric disorder such as depression, anxiety, somatization disorder and malingering. File does mention a diagnosis of depression and treatment with Zoloft but file lacks any psychiatric evaluation for the workup of her excessive fatigue and pain, despite exam lacking synovitis. The literature has shown fibromyalgia patients do better if they continue to work and exercise.
(MET 0231). Again, Schmidt identifies specific objective measures that might support Audino's impairment (e.g., visual testing) but are absent from the administrative record. In addition to visual field tests performed after July 9, 2002, Audino would need to present evidence of earlier visual field tests that serve as a baseline for comparison. Schmidt suggests that without objective evidence that her vision is worsening, Audino could not show the impairment necessary to prove full disability since she was able to work prior to July 9. Schmidt also questions Dr. Zahabi's claim that her car accidents are evidence of visual impairment since Audino claims the cause of the accidents was falling asleep while driving, and, in any case, transportation difficulties are outside the scope of the Plan's definition of disability. These observations are based on concrete evidence in the record, and the Court is therefore obligated to uphold them.
B. Dr. Turok's Analysis and Conclusions
At the request of Audino's lawyer, MetLife agreed to allow Audino to supplement the administrative record after the initial appeal with regard to her visual condition. MetLife supplied the administrative record and new records submitted by Audino to Dr. Turok, a medical consultant board certified in neurology and ophthalmology. (MET 0420). Turok writes:
A thorough review of the medical records was completed. According to the medical records, from an ophthalmology perspective, the primary diagnosis affecting Ms. Audino's ability to work is inferior altitudinal scotoma. This is due to optic atrophy of the right eye, which is due to nonarteritic anterior ischemic optic neuropathy. Given the history with lack of pain, normal MRI scan, no history of pain on eye movement, abrupt onset, and partial involvement of the nerve, this would be a more likely diagnosis than optic neuritis, also given the age of Ms. Audino and other factors.
* * *
Based on the medical records, from an ophthalmology perspective, Ms. Audino has a mild to moderate defect in that she has a monocular inferior field defect. The automated visual field and funduscopic exam both support the presence and severity of the impairment.
(MET 0418-19). With regard to Audino's expected limitations, Turok notes:
Ms. Audino would have some limitation in that she would have some decrease in her visual field peripherally particularly in an inferior and right position. This may necessitate her turning her head a bit more.
Ms. Audino would have some decrease in her depth perception; but with good central acuity, that should not be severely damaged; and again, she should be okay. . . . It is legal to drive in every state of the union including Texas as a monocular patient. Ms. Audino has more than just monocular [vision]; she has her other eye, which has a relatively full field of vision.
(MET 0419). Turok indicates that Audino's vision in her right eye used to be very poor, (MET 0418), but after Dr. Patel treated her with a course of intravenous steroids, she now has good central vision with correction in the right eye. Only the inferior altitudinal portion of her visual field (i.e., a relatively small portion of her lower visual field) remains poor. Moreover, Turok suggests that Audino lacks any significant impairment of her left eye, and retains a relatively full field of vision (after correction) in her right. Accordingly, Turok concludes:
Turok indicates that in the spring of 2001, Audino "had decreased vision in the right eye to 24/100. . . ." 24/100 is likely a typographical or transcription error since ophthalmologists traditionally record vision in the form 20/x, where x represents the distance from which a "normal" person could read what the patient can read from a maximum distance of twenty feet. Thus, Turok probably intended to write 20/400, indicating that Audino would see a line of text that is twenty feet away with the same readability that a person with "normal" vision would see that line of text from 400 feet away.
Ms. Audino's current level of functionality should allow her to maintain her job as a management assistant. The occupational requirements could be met given her visual function. . . . At this point, after my conversation with Dr. Patel and records review, there is not an inability of Ms. Audino to perform the essential elements of her job from 07/10/02.
(MET 0419). Although there is some evidence in the record that cuts against MetLife's decision, MetLife's denial of benefits is not arbitrary and capricious simply because the decision comes down to a permissible choice between the position of MetLife's independent medical consultants and the position of Audino's physicians. Sweatman v. Commercial Union Ins. Co., 39 F.3d 594, 602 (5th Cir. 1994). Because MetLife relied on Turok's analysis, which reflects some concrete evidence in the administrative record, the Court finds that MetLife did not abuse its discretion in denying short-term benefits to Audino.
C. Audino's Claim for Long-Term Disability Benefits
Audino also claims MetLife abused its discretion by refusing to review Audino's claim for long-term disability benefits. It rejects MetLife's claim that one must be approved for short-term disability benefits before one can be considered for long-term disability benefits. Plaintiff's Response Brief at 15 ("Nowhere in the plan documents of either the [Short-Term Disability] Plan or the [Long-Term Disability] Plan does the plan administrator state that one must first be approved for [short-term disability benefits] prior to being considered for [long-term disability benefits]."). However, the Long-Term Disability Plan expressly requires its participants to "exhaust their short term disability benefits before Benefits become payable hereunder." (AUD 007). Accordingly, the Court holds that MetLife did not abuse its discretion in declining to review Audino's claim for long-term disability benefits.
IV. METLIFE COMPLIED WITH THE CLAIM PROCEDURES AND DEADLINES REQUIRED BY THE CODE OF FEDERAL REGULATIONS
Audino claims that as a matter of law MetLife failed to provide her with a full and fair review because it did not comply with the claim procedures and deadlines required by 29 C.F.R. § 2560-503-1. That statute requires administrators to notify a claimant seeking disability benefits within 45 days of claimant's request for review unless the plan administrator determines special circumstances require an extension of time for processing the claim. See 29 C.F.R. § 2560-503-1(i)(3)(i) (45 days for disability claims); 29 C.F.R. § 2560-503-1(i)(1)(i) (extensions). Any extension must include written notice of that fact to the claimant. 29 C.F.R. § 2560-503-1(i)(3)(i); 29 C.F.R. § 2560-503-1(i)(1)(i). Audino claims MetLife violated these provisions because Audino submitted her request for review on September 13, 2002, and MetLife did not complete its review until April 4, 2003.
Audino's argument omits material facts. On October 24, 2002, before the expiration of the initial 45-day period, MetLife sent Audino a letter indicating that an extension was required for MetLife's physician consultant to complete his review. (MET 0225.5). As a result, the additional 45-day period ended on December 15, 2002. MetLife rendered its decision to uphold the denial of benefits by letter dated November 11, 2002, well in advance of the December 15 deadline. (MET 0257-60). MetLife later reopened the administrative record on February 12, 2003, giving Audino another opportunity to submit additional medical documentation. MetLife received records from Audino's ophthalmologist on February 25, 2003, (MET 0098), and upheld the denial of Audino's claim for a second time thirty-eight days later, on April 4, 2003. (MET 0413-16). Accordingly, the Court holds that MetLife complied with the procedures and deadlines required by the Federal Code of Regulations.
CONCLUSION
The Court is required to uphold a plan administrator's decision to deny benefits as long as it not arbitrary or capricious. Because MetLife's physician consultants drew conclusions from some concrete evidence in the record, the Court holds that MetLife did not abuse its discretion in denying Audino's disability claims. Accordingly, Defendants' Motion for Summary Judgment is granted.