Opinion
95 CV 5340 (NG)
March 12, 1998
MEMORANDUM AND ORDER
This action involves a claim that the defendants wrongfully terminated long term disability benefits received by the plaintiff under an employee welfare benefit plan governed by the Employee Retirement Income Security Act of 1974 ("ERISA"), 29 U.S.C. § 1001 et seq. The defendants now move for summary judgment on the ground that the plaintiffs claim presents no triable issue of fact under ERISA and that the defendants are entitled to judgment as a matter of law. The plaintiff has cross-moved for summary judgment on his claim of wrongful termination. For the reasons set forth below, the defendants' motion will be granted and, the plaintiffs motion will be denied.
The defendants also seek summary judgment as to any common law claims brought by the plaintiff on the ground that such claims are preempted by ERISA. Although the amended complaint is somewhat unclear on this point, the plaintiff states on this motion that "this is action [sic] governed by ERISA. We [sic] made no State law claims." Pltf.'s Mem. at 1. Upon this representation, the defendants' motion for summary judgment as to any common law claims is moot.
In addition, the benefit plan at issue mandates that disability benefits be reduced to the extent that a recipient of benefits also receives Supplemental Security Income ("SSI") from the Social Security Administration. The defendants have brought a counterclaim alleging that they are entitled to a reimbursement of benefits to the extent that the plaintiff received SSI. The defendants have not moved for summary judgment on their counterclaim.
UNDISPUTED FACTS
The plaintiff, James Grace, was a "project manager" for the Raytheon Company ("Raytheon") and was a participant in Raytheon's Long Term Disability Plan ("the Plan"). Metropolitan Life Insurance Company ("MetLife") is the Plan Administrator, which position affords MetLife the authority to make eligibility determinations when plan participants make benefit claims. According to the terms of the Plan, long-term disability benefits will be paid to plan participants who become "totally disabled," a term that the Plan defines as follows:
2.24 "Total Disability" or "Totally Disabled" means that, because of sickness or an injury which is not covered by an applicable workers compensation statute:
a) a Participant cannot do the essential elements and substantially all of the duties of his or her job at Raytheon even with reasonable accommodations; and
b) cannot do any other job for which he or she is fit by education, training or experience.
Rucker Aff., Exh. B at 5.
As a project manager, Grace's "principal duty," as defined by Raytheon, was to "[p]rovide direction and control of specific activities on a given program by developing and implementing plans, schedules, and budgets" and to "[m]aintain continuous contact with all functional departments to achieve program goals." Hartz Aff., Exh. D at 1. The position required a "BS Degree in Engineering or Business Administration plus six (6) years experience in project planning, project implementation and schedule control." Id.
On December 5, 1991, Grace filled out an application for disability benefits under the Plan. The application does not ask for the illness or injury upon which the claim is based, but does ask the applicant to describe how that illness or injury "prevent(s) you from performing your usual duties." Hartz Aff., Exh. E at 1. In this regard, Grace stated that he could not sit or stand "for longer than 30-60 min[utes] without pain" and could not "concentrate with unrelieved pain." Id. Grace also submitted a "First Attending Physician Statement," which was completed by P. Warwick Green, M.D. Dr. Green stated that Grace suffered from "cervical spondyloysis, " which caused him "back pain with numbness going down either leg. Also has neck pain." Hartz Aff., Exh. F at 1. Dr. Green stated that Grace was totally disabled within the meaning of the Plan, but also approximated that he could return to work on January 15, 1992. Id. at 2.
In response to Grace's application, MetLife sent him a letter, dated December 23, 1991, informing him that he would receive disability benefits pursuant to the Plan until January 15, 1992. If he wished to receive benefits beyond this date, the letter continued, an Attending Physician's Statement of Functional Capacity, which was enclosed, would have to be submitted.
Thus began a series of reapplications and renewals of Grace's disability benefits. On the appropriate Plan form, dated January 13, 1992, Dr. Green again declared Grace to be totally disabled and approximated that he could return to work on February 15, 1992. In response, MetLife sent Grace a letter, dated January 23, 1992, extending his disability benefits until February 15th Grace's benefits were similarly extended until May 15, 1992.
In a subsequent "Attending Physician's Statement of Functional Capacity," dated May 1, 1992, Dr. Green, while not altering his diagnosis of Grace's condition, stated that it now could not be determined when Grace could return to work. According to the terms of the Plan, this allowed MetLife to conduct an independent examination of Grace, which was performed on June 2, 1992 by Dr. Arthur Bernhang. Dr. Bernhang's assessment, dated June 8, 1992, is strikingly at odds with that of Dr. Green:
This gentleman's presentation is rather bizarre and is strongly suggestive of a variant of a camptocormia. . . . There is a paucity of objective findings except for the absent ankle reflex bilaterally. There is no objective evidence showing any limitation of the cervical spine nor was any presented. As noted, the presentation of his gait pattern, his arising from a chair, his walking and his affect during the entire physical examination was inappropriate and does not correspond to an organic disorder of the lumbosacral spine or cervical spine. If appropriately motivated, I feel certain that Mr. Grace can indeed return to the active work force as reasonably can be expected by his education, experience or training.
At your suggestion I did discuss the findings with the claimant's attending physician, Dr. Warwick Green, who could not offer any further information that would alter the opinion stated above.
Hartz Aff. Exh. N at 3.
In a subsequent "Attending Physician's Statement of Functional Capacity," dated September 29, 1992, Dr. Green repeated his contention that it could not be determined when Grace could return to work and added that he had referred Grace to another physician for an evaluation of whether surgery should be performed on Grace's back. Hartz Aff., Exh. O. The next attending physician's statement filed on Grace's behalf, which is not dated, but which was received by MetLife in February 1993, was not filed by Dr. Green, but by Long Island Spine Specialists, P.C. It contains several new contentions regarding Grace's condition. It states that Grace does not need surgery, but "aggressive physical therapy," that there is "some limitation" as to Grace's ability to sit and stand — as opposed to Dr. Green's assertions that these activities should be avoided completely — and that Grace (not Long Island Spine Specialists, P.C.) "doesn't think he will ever return to work." Hartz Aff., Exh. P. The next physician's statement, dated June 28, 1993, was again submitted by Dr. Green. Dr. Green here returned to the position that Grace should "completely" avoid sitting and standing. Hartz Aff., Exh. Q.
MetLife sent Grace for a second independent examination on October 25, 1993, which was conducted by Dr. Richard Goodman. Dr. Goodman's report of the examination, dated October 29, 1993, concludes as follows:
Based upon the history, physical examination and medical records provided to me, this patient is unable to function as a laborer or in a strenuous activity. However, the job description of a project manager, requires no physical exertion. It appears to be that of an entirely sedentary job. If my estimation of his job description is true then he can return to work.
Hartz Aff., Exh. R. Stating that the continuation of Grace's benefits was being considered, MetLife sent Dr. Goodman's report to Dr. Green for comment. The latter, in a short letter, dated December 8, 1993, asserted without elaboration his disagreement with "Dr. Goodman's conclusions" and reiterated his view that Grace was not physically fit for "any job currently available in the market place. . . ." Hartz Aff., Exh. T. In a letter, dated February 10, 1994, MetLife informed Grace that his benefits would be terminated because "there is no objective evidence of disability from your usual occupation." Grace Aff., Exh. U.
Grace appealed the decision to terminate his benefits, which appeal was supported by a report from Dr. Green and a report from Dr. Mark Gudesblatt, both of which were prepared at the request of plaintiffs counsel and both of which concluded that Grace was disabled. MetLife referred the appeal to Dr. Dennis Allen, whose affiliation is not noted in the record. In a report, dated June 24, 1994, Dr. Allen concluded that the termination of Grace's benefits was correct. The complaint in this action followed.
DISCUSSION
Pursuant to Federal Rule of Civil Procedure 56(c), summary judgment should be granted "if the pleadings, depositions, answers to interrogatories, and admissions on file, together with the affidavits, if any, show that there is no genuine issue as to any material fact and that the moving party is entitled to a judgment as a matter of law." It is the movant's burden to demonstrate the absence of any genuine issue of material fact, see Adickes v. S.H. Kress Co., 398 U.S. 144, 157 (1970), which are facts whose resolution would "affect the outcome of the suit under governing law." Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 248 (1986). Demonstration of the absence of a material fact is defeated by the non-movant's presentation of sufficient evidence to establish "that a reasonable jury could return a verdict for the non-moving party." Id. In making a determination as to whether a genuine dispute as to a material fact exists, "all justifiable inferences" from the factual record before the court are to be drawn in favor of the non-movant." Id. at 255.
The standard of review that the court must apply here is highly deferential to the decision reached by the Plan Administrator. It is undisputed that the Plan affords MetLife the discretionary authority to determine the eligibility of Plan participants for disability benefits. "[W]here the written plan documents confer upon a plan administrator the discretionary authority to determine eligibility, [the court] will not disturb the administrator's ultimate conclusion unless it is `arbitrary and capricious.'" Pagan v. NYNEX Pension Plan, 52 F.3d 438, 441 (2d Cir. 1995) (citing Firestone Tire Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989)). In more detail, the scope of review is as follows:
Under the arbitrary and capricious standard of review, [the court] may overturn a decision to deny benefits only if it was without reason, unsupported by substantial evidence or erroneous as a matter of law. This scope of review is narrow, thus [the court is] not free to substitute [its] own judgment for that of [the plan administrator] as if [the court was] considering the issue of eligibility anew.
The level of deference accorded a plan administrator's decision is significantly lessened in the case where the plaintiff can show that the procedure pursuant to which the decision was reached is in general marked by conflicts of interest that favor the termination of benefits and that such conflicts in fact influenced the plan administrator's decision in the plaintiffs own case. Whitney v. Empire Blue Cross and Blue Shield, 106 F.3d 475, 477 (2d Cir. 1997); see also DeFelice v. American Int. Life Assurance Co. of New York, 112 F.3d 61, 66 n. 3 (2d Cir. 1997). Grace does not attempt to make these showings.
The decision to terminate Grace's benefits was not arbitrary and capricious. In reaching the decision, MetLife had before it an administrative record that included two reports of examinations of Grace conducted by independent physicians, two reports of examinations conducted by physicians of Grace's own choosing and the record of successive statements that had been submitted in support of Grace's receipt of benefits from December 1991 onward. Grace's physicians were presented with the contrary findings of the two independent physicians and had ample time to rebut them. Moreover, Grace was afforded the opportunity to appeal the decision to terminate his benefits. I find that the decision to terminate Grace's benefits was based upon "such evidence that a reasonable mind might accept as adequate to support the conclusion reached," Miller v. United Welfare Fund, 72 F.3d 1066, 1072 (2d Cir. 1995) (citation omitted), and therefore find that no issue of triable fact remains as to its validity.
Grace's assertions to the contrary are unfounded. First, Grace argues that the report of Dr. Goodman is internally inconsistent and, as such, should be treated with considerable scepticism. But there is no inconsistency in Dr. Goodman's report. That Dr. Goodman recognized that Grace had "some limitation" sitting or standing is not necessarily, or even probably, in contradiction with the doctor's conclusion that Grace could perform a sedentary job. Significantly in this regard, Dr. Green, when presented with Dr. Goodman's report for comment, did not assert that the report contained any inconsistencies. Neither did he so assert in the statement he presented in support of Grace's appeal.
Grace also contends that the termination decision may be seen as arbitrary and capricious in light of the fact that he has been awarded SSI benefits in connection with his back problems. However, this award, which is alleged in the amended complaint, but which is otherwise unsupported in the record, is of no moment. It is undisputed that any award of SSI benefits was not raised at any point during the administrative review of Grace's eligibility for disability benefits under the Plan. The issue of an award of SSI benefits cannot be taken into consideration here because, in reviewing the termination decision under the arbitrary and capricious standard, the court is limited to the administrative record before the plan administrator. Miller v. United Welfare Fund, 72 F.3d at 1071.
Grace's other contentions are without merit. I therefore find that summary judgment in favor of the defendants is warranted.
CONCLUSION
The defendants' motion for summary judgment is GRANTED and the plaintiffs motion for summary judgment is DENIED. The defendants are directed to inform the court within ten days of this memorandum and order whether they intend to pursue their counterclaim for reimbursement of certain disability benefits paid to the plaintiff.
SO ORDERED.