Opinion
Civ. No. 03-2535 (JNE/JGL).
September 29, 2004
Robert F. Manella, Esq., Babcock, Neilson, Manella, Lafleur Klint, appeared for Plaintiff Susan J. Johnson.
Doreen A. Mohs, Esq., Rider Bennett, LLP, appeared for Defendant Metropolitan Life Insurance Company.
ORDER
Susan J. Johnson brought this action contesting the denial of long-term disability (LTD) benefits by Metropolitan Life Insurance Company (MetLife). MetLife is the administrator of Johnson's employer's health insurance plan (the Plan), which is governed by the Employee Retirement Income Security Act (ERISA), 29 U.S.C. §§ 1001-1416 (2000). The case is before the Court on the parties' cross-motions for summary judgment. For the reasons set forth below, the Court denies Johnson's motion and grants MetLife's motion.
I. BACKGROUND
Wells Fargo employed Johnson as an accounting clerk. It listed the job requirements for the position as including the following: five-to-six hours of sitting; three-to-four hours of walking; no repetitive use of hands; and five-to-six hours of fine finger dexterity. Beginning in October 2000, Johnson began experiencing pain in her hands and feet that prevented her from working consecutive days at Wells Fargo. She began seeing Dr. William Fox, a primary care physician, and Dr. Asim Khan, a rheumatologist. Dr. Fox eventually diagnosed Johnson as having rheumatoid arthritis, polyarthritis, and possibly fibromyalgia. From October 2000 through January 2002, Johnson received short-term disability (STD) benefits. This case does not concern Johnson's STD benefits.
Fibromyalgia is defined as "a syndrome of chronic pain of musculoskeletal origin but uncertain cause." Stedman's Medical Dictionary 671 (27th ed. 2000).
Johnson then applied for LTD benefits in the fall of 2001. In response, MetLife contracted with Dr. Jeffery Lieberman, an independent physician consultant who is board certified in internal medicine and rheumatology, to review Johnson's medical records and other documentation contained in Johnson's administrative file. Johnson's medical records revealed that Dr. Fox and Dr. Khan did not necessarily agree on the severity of Johnson's condition. Specifically, in his records Dr. Fox consistently noted that he had found objective evidence to confirm Johnson's complaints whereas Dr. Khan's notes reveal that he recognized some improvement in Johnson's condition after his first evaluation of her. For instance, in an August 21, 2001, letter to MetLife, Dr. Fox details Johnson's disability and offers his opinion that Johnson is unable to work based on "pain," "morning stiffness," and "the inability to sit, type, or do the work she is required" to do. Conversely, in November 2001, Dr. Khan noted that Johnson had some "positive synovitis" in her wrists joints, which was "better than her previous exam" and that he finds it "very hard to figure out if [Johnson] really does have significant flares or if there is any other motive that needs to be achieved." By February 2002, Dr. Khan's files reveal that he observed "no evidence of active synovitis," that Johnson had a "good grip in her hands but she complains of tenderness," and that "it is alarming to [Dr. Khan] that maybe [Johnson] has been having these complaints because she wants disability." After reviewing Johnson's file, Dr. Lieberman concluded that prior to and in November 2001, Johnson had some active synovitis but that since that time, there was no objective evidence that Johnson had active synovitis. Based on Dr. Lieberman's findings, in a letter dated March 27, 2002, MetLife denied Johnson's request for LTD benefits. In that letter, MetLife explained that it was denying Johnson's request, in part, because there was "no objective evidence of active synovitis in any joint area" and because Johnson's file did not support a finding that Johnson's condition was "significant or severe" enough to preclude her from performing the requirements of her job.
The synovium is a tissue that surrounds and encaplulates a joint. Synovitis, which can be acute or chronic, is inflammation of that tissue, and "when unqualified, [is] the same as arthritis." Stedman's Medical Dictionary 1773 (27th ed. 2000).
Approximately two months after receiving MetLife's denial letter, Johnson submitted a lengthy letter to MetLife, appealing MetLife's denial and detailing her painful condition. Johnson sent a copy of this letter to Dr. Fox but not to Dr. Khan. In response, MetLife obtained Johnson's updated medical records from Dr. Fox and Dr. Khan in July 2002. Dr. Khan's records noted that some of Johnson's pain had been resolved through the use of the medication Medrol, that a bone scan and MRI were negative, and that Johnson had repeatedly failed to do physical therapy. Dr. Fox's notes from January through June 2002 reveal that he continued to find evidence to confirm Johnson's complaints. For example, in March 2002, he noted that he found "foot and wrist tenderness," and in April 2002, he noted that his examination revealed, "marked tenderness [that] is quite exquisite in the palms of her hands" and "some synovitis in Johnson's wrist areas." However, by June 2002, Dr. Fox's records reveal that he found "no active synovitis." Throughout his notes, Dr. Fox diagnoses Johnson's condition as rheumatoid arthritis and "possibly" or "likely" fibromyalgia.
MetLife contracted with Dr. Tracey Schmidt, an independent physician consultant who is board certified in internal medicine and rheumatology, to review Johnson's updated medical history, Dr. Lieberman's report, and Johnson's job description. In her report, Dr. Schmidt noted the negative test results and the lack of other testing results, which Johnson's doctors — not Johnson — could or should have ordered. She then concluded "the file documentation did not show any restrictions of range of motion of joints or neurological changes that would support an impairment that would disable Johnson from doing her job." Then in a letter dated September 17, 2002, MetLife informed Johnson of its decision to uphold its denial of LTD benefits because, based on Dr. Schmidt's report, "[s]elf-reported, subjective complaints, without supporting objective medical findings of documented functional impairment, are insufficient to provide proof of disability." MetLife also informed Johnson that she had exhausted her administrative remedies and that she could bring a civil action under ERISA.
In March 2003, Johnson initiated this suit in Minnesota state court, seeking payment under the Plan for Johnson's LTD benefits. Pursuant to 28 U.S.C. § 1441 (2000), MetLife removed the action to this Court because the case is governed by ERISA. Johnson did not contest the removal. Later, both parties moved for summary judgment.
II. DISCUSSION
Summary judgment is proper "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." Fed.R.Civ.P. 56(c). The moving party "bears the initial responsibility of informing the district court of the basis for its motion," and must identify "those portions of [the record] which it believes demonstrate the absence of a genuine issue of material fact." Celotex Corp. v. Catrett, 477 U.S. 317, 323 (1986). If the moving party satisfies its burden, Rule 56(e) requires the party opposing the motion to respond by submitting evidentiary materials that designate "specific facts showing that there is a genuine issue for trial." Matsushita Elec. Indus. Co. v. Zenith Radio Corp., 475 U.S. 574, 587 (1986). In determining whether summary judgment is appropriate, a court must look at the record and any inferences to be drawn from it in the light most favorable to the party opposing the motion. Anderson v. Liberty Lobby, Inc., 477 U.S. 242, 255 (1986).
A participant in an ERISA plan may bring suit "to recover benefits due to him under the terms of his plan, to enforce his rights under the terms of the plan, or to clarify his rights to future benefits under the terms of the plan." 29 U.S.C. § 1132(a)(1)(B). Typically, a court reviews a denial of benefits challenged under that section under a de novo standard of review. Firestone Tire Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989). However, when a plan gives discretionary authority to the plan administrator or reviewing committee to determine eligibility for benefits or to construe the terms of the plan, a court reviews the decision to deny benefits for an abuse of discretion. Id. Here, the Plan provides that "the Plan administrator and other Plan Fiduciaries shall have discretionary authority to interpret the terms of the Plan and to determine eligibility for and entitlement to Plan benefits." Accordingly, the parties and the Court agree that this language is sufficient to trigger the "abuse of discretion" standard of review.
Under that standard, a court must uphold the plan administrator's decision if it was "reasonable" or supported by "substantial evidence." McGee v. Reliance Standard Life Ins. Co., 360 F.3d 921, 924 (8th Cir. 2004). Based only on the evidence that was before the plan administrator at the time the decision was made, a court focuses on whether a "reasonable person could have reached a similar decision, given the evidence before him, not that a reasonable person would have reached that decision." Phillips-Foster v. UNUM Life Ins. Co. of Am., 302 F.3d 785, 795 (8th Cir. 2002).
MetLife contends that it is entitled to summary judgment because its decision to deny Johnson LTD benefits was reasonable and supported by substantial evidence. MetLife notes that the Plan required Johnson to provide "documented proof of [her] Disability" and "proof of continuing Disability." According to MetLife, Johnson failed to do so; instead, it asserts that Johnson provided evidence only in the form of self-reported symptoms and subjective complaints. Furthermore, MetLife asserts that its denial was reasonable based on the review of Johnson's records by two independent physicians, both of whom separately concluded that her condition had improved by the time Johnson applied for LTD benefits. Finally, MetLife explains that substantial evidence supported its decision, especially in light of the fact that one of Johnson's treating physicians could find no objective evidence to confirm Johnson's complaints.
In response, Johnson contends that she is entitled to summary judgment because her condition meets the Plan's definition of long-term disability. According to Johnson, she qualifies for LTD benefits under the Plan if (1) she is being treated by a doctor and (2) she experiences a loss of earning capacity. Because she meets these two requirements, Johnson asserts that there is no genuine issue of material fact that MetLife's decision to deny her LTD benefits was an abuse of discretion.
Johnson is correct about the Plan's definition of disabled. The Plan defines "disability" as "sickness, pregnancy, or accidental injury," for which "you are receiving Appropriate Care and Treatment from a Doctor on a continuing basis," and from which you are unable to earn a specified portion of your income. However, in advancing her argument, Johnson fails to reference other portions of the Plan that require her to provide, among other things, "proof of disability," "evidence of continuing Disability," and "any other material related to your Disability which may be requested by MetLife." As the Eighth Circuit Court of Appeals has observed, "[i]t is not unreasonable for a plan administrator to deny benefits based upon a lack of objective evidence." McGee, 360 F.3d at 925. In McGee, the Eighth Circuit reversed the district court's grant of summary judgment in favor of the plaintiff because the defendant's denial of the plaintiff's claim was based on substantial evidence. Id. at 924-25. In reaching that conclusion, the Eighth Circuit focused on the fact that the plaintiff's healthcare providers' records were inconsistent. Id. at 925.
This Court recently addressed the issue of whether a plan administrator can require a claimant to submit objective evidence to confirm his or her disability. See Pralutsky v. Metro. Life Ins. Co., (Pralutsky I), 316 F. Supp. 2d 840 (D. Minn. 2004). In Pralustsky I, the plaintiff was diagnosed with fibromyalgia, which is a disease with entirely subjective symptoms and for which "there are no laboratory tests for the presence or severity." Pralutsky I, 316 F. Supp. 2d at 842. The defendant denied her request for LTD benefits because she failed to present objective evidence of her disease. Id. at 843. The plaintiff appealed the denial, and this Court granted summary judgment in favor of the plaintiff because the defendant's denial of her claim was not supported by substantial evidence. Id. at 853. In reaching that conclusion, this Court reviewed the relevant case law, including McGee, concerning a plan administrator's ability to require a claimant to submit objective evidence and concluded that "the Eighth Circuit takes no single approach to subjective and objective evidence in the context of ERISA." Id. at 848. This Court then concluded that requiring objective evidence could be "arbitrary and capricious" in the face of "an elusive and mysterious disease like fibromyalgia." Id. at 853; see also Pralutsky v. Metro. Life Ins. Co., Civ No. 03-4389, 2004 WL 1701033 at * 1 (D. Minn. July 29, 2004) (awarding attorney's fees in Pralutsky I and noting that an administrator's requirement of objective proof in certain situations creates an improper ex post facto exclusion).
In this case, like in McGee, the Court finds MetLife's requirement of objective proof to be reasonable because Johnson's own treating physicians offered conflicting opinions. Moreover, the Court finds that this case is distinguishable from Pralustsky I because Johnson's primary diagnosis was that she suffered from rheumatoid arthritis, as opposed to fibromyalgia, the "entirely subjective" disease the plaintiff in Pralustsky I had. Because the record reveals that several objective tests, including blood tests and X-rays, can be used to aid in the diagnosis of rheumatoid arthritis, MetLife's requirement of objective proof in this case was reasonable. Finally, the Court finds that MetLife's decision was supported by substantial evidence. Although a plan administrator is not required to accord special weight to the opinions of a claimant's treating physicians, see Black Decker Disability Plan v. Nord, 538 U.S. 822, 823-24 (2003), substantial evidence can be found in that both Dr. Khan's and Dr. Fox's records support MetLife's decision. Specifically, Dr. Khan evaluated Johnson on numerous occasions and eventually concluded that she no longer had active synovitis. Dr. Fox eventually reached the same conclusion in June 2002. Moreover, the tests ordered by both Dr. Fox and Dr. Khan, including the MRI, blood tests, and bone scans, failed to show any evidence of rheumatoid arthritis.
The Court recognizes that Johnson's ailments, as described in her May 20, 2002 letter, can indeed be debilitating. However, there is also substantial evidence in the record that Johnson improved from the time her STD benefits were given to when she applied for LTD benefits. Therefore, under the deferential standard of review accorded to a plan administrator's denial of benefits, the Court concludes that MetLife's decision to deny Johnson LTD benefits must be upheld because a reasonable person could have reached a similar decision. Accord Mallwitz v. Penn Ventilator Co., Civ. No. 02-3762, 2004 WL 114944 at * 8 (D. Minn. Jan. 20, 2004) (concluding that plan administrator reasonably denied benefits); Savick v. Fortis Benefits Ins. Co., Civ. No. 02-1742, 2003 WL 21555697 at * 7 (D. Minn. July 7, 2003) (same). Accordingly, the Court denies Johnson's motion for summary judgment and grants MetLife's motion for summary judgment.
III. CONCLUSION
Based on the files, records, and proceedings herein, and for the reasons stated above, IT IS ORDERED THAT:
1. Metropolitan Life Insurance Company's Motion for Summary Judgment [Docket No. 10] is GRANTED.
2. Susan J. Johnson's Motion for Summary Judgment [Docket No. 13] is DENIED.
3. This case is DISMISSED WITH PREJUDICE.
LET JUDGMENT BE ENTERED ACCORDINGLY.