Summary
construing Miller to support the "general argument that when the plan allocates the burden of proving disability, it is binding on the parties and finding plaintiff failed to meet the burden in MetLife's contract when she failed to provide information of her full disability that was "satisfactory to" the plan administrator
Summary of this case from Borys v. Metropolitan Life Insurance Co. Metlife DisabilityOpinion
Case Number 03-10045-BC.
February 10, 2005
OPINION AND ORDER GRANTING DEFENDANTS' MOTION TO AFFIRM PLAN ADMINISTRATOR'S DECISION AND DENYING PLAINTIFF'S MOTION FOR SUMMARY JUDGMENT
The plaintiff, Diane M. Wilson, has brought this action against the defendants in their capacity as administrators of an employee welfare benefit plan as defined by the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. § 1001, et seq. because they denied the plaintiff's application for long-term disability benefits. She alleges that she became unable to work in July 2001 and was eligible for benefits under the plan six months later. Although the plaintiff acknowledges that this Court may not order benefits unless it finds that the defendants' decision to deny benefits was arbitrary and capricious, she insists that she has met that standard. The Court disagrees and therefore will deny her motion, mis-styled as a motion for summary judgment, and grant the defendants' cross-motion to affirm the plan administrator's decision.
I.
Ms. Wilson began working for the Dow Chemical Company in January 1987. She held various administrative positions throughout her tenure there and was employed as an "Administrative Specialist" at the time her employment ended. Ms. Wilson was diagnosed with depression in 1995 and sought treatment with counselors then, acknowledging that she had a history of alcohol abuse. Her condition worsened through a stormy course of unfortunate family events, and she took periods of medical leave during the first half of 2001. She eventually began seeing a psychiatrist in the April 2001. Her condition nonetheless deteriorated, and she alleges that she became unable to work after July 27, 2001. Her employer commenced paying salary continuation and sick leave benefits three days later.
The parties agree that the plaintiff was eligible to participate in Dow's fringe benefit plan and that the plan constitutes an "employee welfare benefit plan" governed by ERISA. See 29 U.S.C. § 1002(1)(A), et seq. Among the plan's benefits afforded to Wilson was a long-term disability insurance policy that provided monthly payments if a sickness or injury prevented her from performing the regular duties of her occupation. The policy was underwritten by the defendant, MetLife, Inc., which also administered the disability plan.
Dow's long term disability plan contains a mandatory six-month waiting period before the commencement of benefits. That period would have expired for Ms. Wilson on January 24, 2002, and in anticipation Wilson completed a claim form on December 12, 2001. She alleged an "[i]nability to handle any stress, to concentrate on details without becoming anxious and stressed (shaking, trembling, crying), to remember simple details or things I'm supposed to do, and a strong tendency to procrastinate because of fear of stress and/or failure. Plus slee [sic] disorder makes getting up on time very difficult." Administrative Record (AR) at 144. The plaintiff listed her current medical treaters and counselors that she had seen from March of 2000 to the date of the application as Dr. David Easton, a family physician; John Martin, a physician's assistant; Laurie McGuire, a physical therapist; Robert Plummer, Ph.D., a counselor; Ann Clynick, a counselor, Kathy Sargent, a counselor; Dr. Syed, a psychiatrist; James Casey, a counselor; and Janet Fromhold, another counselor. AR at 146. The plaintiff stated that she visited Janet Fromhold on "8/01, 2/02 to Present," but noted that she "[n]eeded to continue counseling therapy with Janet Fromhold in 2001, but I couldn't afford the $60 for each visit. I had used nearly all the 20 mental health visits allowed per year, and I needed what few were left for my appointments with Dr. Syed." Ibid. The plaintiff signed a form to authorize MetLife to obtain records from these providers, and Dr. Syed completed an Attending Physician Statement diagnosing the plaintiff with major or "severe depression affecting all her ability," anxiety, panic, and fear. Id. at 152-153. He classified her as having "significant loss of phychological, physiological, personal and social adjustment." Id. at 152. His objective findings consisted of observing "lethargy" and "crying," and he recommended that the plaintiff not return to work due to "severe depression affecting all her abilities." Id. at 152, 153.
A representative from MetLife gathered medical records, and on April 8, 2002 claims administrator Connic Higgins conducted a telephone interview with Ms. Wilson. On April 17, 2002, Higgins sent Wilson a letter denying her claim for benefits, stating:
Our records indicate that your date last worked was July 6, 2001. However the progress note from Dr. Syed indicates that you were not informed until July 25, 2001 that you should go on disability. Therefore, you were out of work without certification of disability from a licensed physician from the period of July 7, 2001 through July 24, 2001.
We also reviewed the Mental/Behavioral Function Assessment form that was completed by Dr. Syed on March 21, 2002. Dr. Syed indicates that you have the ability to remember short and simple tasks, carry out short and simple instruction and are aware of normal hazards and have the ability to take appropriate precautions.
After giving careful consideration of this information as well as all other medical and vocational information contained in your file, it is Metlife's determination that the submitted records do not support the severity of a condition that would prevent your from performing your regular work or any other reasonably appropriate work Dow can provide as stated by your employer's Long Term Disability plan. Furthermore, the medical documentation does not support a disability from your date last worked. Therefore, your claim for Long Term Disability benefits is denied.
AR at 194-95.
On June 14, 2002, the plaintiff sent a letter to MetLife challenging its initial determination and requesting further consideration of her claim. AR at 196. She enclosed a copy of a letter from her supervisor at Dow stating that her last date worked was July 27, 2001 and first absence was July 30, 2001. AR at 200. MetLife provided the plaintiff with an opportunity to supplement her appeal with additional medical evidence, although it did not require her to submit additional information. The plaintiff advised MetLife that she had submitted all the information she wished to have considered.
On September 7, 2002, MetLife forwarded the plaintiff's file to Dr. Ernest Gosline, its own psychiatric consultant, who concluded that the evidence did not support the plaintiff's claim. On September 18, 2002, MetLife sent Wilson another letter telling her that the finding on her last day of work had been corrected, but the initial determination denying benefits was upheld. The letter stated in relevant part:
The records indicated that your sessions with Dr. Syed had been half-sessions and appeared to be based on a once every 4-6 week basis for half-sessions and are more directed toward medication management. On the first note from Dr. Syed dated May 4, 2001, counseling and psychotherapy was recommended. As of February 15, 2002, you are still without a counselor despite several recommendations in the record.
Dr. Syed completed a Mental/Behavioral Assessment on March 21, 2002. Dr. Syed indicated that you had the ability to remember short and simple instructions, were aware [of] normal hazards, and had the ability to take appropriate precautions.
It should be noted that we receive no documentation or medical rationale to support your inability to perform your regular work.
On appeal, you submitted a letter from your former supervisor correcting your date last work, and your personal comments from Dr. Syed's report of March 21, 2002.
In our ongoing review of your claim, we had your file reviewed by an independent physician consultant, who is board certified in psychiatry.
The physician consultant noted that your medical records do not indicate any evidence of a specific plan of return to work was being followed. The consultant noted that there was no evidence of psychotherapy and there was no evidence that there was justification for a lack of progress based on an active treatment program.
The consultant noted that your medical records do not provide an objective basis for functional impairment that would prevent you from performing your regular work.
Based on all the above information, we must uphold the previous denial of your Long Term Disability claim. We have not received appropriate medical documentation of a disability. Therefore, the original claim determination was appropriate.
AR at 208-09.
The plaintiff filed a complaint against the defendants in Midland County Circuit Court on January 16, 2003 alleging that her application for benefits was improperly denied and claiming primary benefits under the plan. The defendant timely removed the case to this Court on February 14, 2003 and filed an answer on March 3, 2003. The administrative record was filed on April 25, 2003. The plaintiff then filed a motion for summary judgment dated July 31, 2003 arguing that the defendants' denial of benefits was arbitrary and capricious. The defendants filed a response and a cross motion for judgment requesting the Court affirm the plan administrator's decision and grant judgment on the administrative record. The plaintiff filed a reply to the defendants' response. The Court has reviewed the parties' submissions and finds that the relevant law and facts have been set forth in the motion papers and that oral argument will not aid in the disposition of the motion. Accordingly, it is ORDERED that the motions be decided on the papers submitted. See E.D. Mich. LR 7.1(e)(2).
II.
The plaintiff challenges the denial of benefits under Section 502(a)(1)(B) of ERISA, which authorizes an individual to bring an action "to recover benefits due to [her] under the terms of [her] plan, to enforce [her] rights under the terms of the plan, or to clarify [her] rights to future benefits under the terms of the plan." 29 U.S.C. § 1132(a)(1)(B). She makes four specific arguments as to why the plan administrator's decision ought not stand: first, she argues that when evidence supporting her position otherwise disregarded by the defendants is considered including her job description, the employer statement attached to her application for benefits, and her treating physician's findings and diagnoses — it is clear that her depressed condition prevented her from meeting the performance requirements of her position, even on a part-time basis thereby qualifying her for long term disability benefits, a decision that the Court should review under a less stringent standard because of the conflict of interest that arises from the circumstance of the plan administrator also being the same entity that funds the plan benefit payments. Second, she asserts, contrary to the defendants' conclusions, that she pursued the recommended treatment of her doctor because psychotherapy was not prescribed as treatment and she did receive psychotherapy treatment from her counselors. Third, she asserts that the Court should exclude from consideration the report of the consulting psychiatrist added to the record during the plaintiff's administrative appeal because that report was biased, unsupported by the record, based on less than all the medical records submitted for consideration, not provided to the plaintiff for rebuttal, based on evidence unavailable to the plan administrator when initially denying benefits, and unavailable to the plan administrator at the time. Fourth, she contends that the denial of her benefits should not be contingent on her having a specific plan to return to work. The defendants counter with the arguments that the denial of benefits was proper because the plaintiff has not met her burden of demonstrating objective evidence of her disability and has not demonstrated that she sought psychotherapy treatment as recommended by her treating psychiatrist; the consulting psychiatrist's report was made part of the record before a final determination of the plaintiff's application for benefits; and the plaintiff failed to present any evidence establishing a conflict of interest requiring that the Court apply a less deferential standard than arbitrary and capricious.
The parties agree that the standard of review of the plan administrator's decision in this case is the arbitrary and capricious standard. This deferential review is appropriate when the ERISA plan at issue, as here, provides a clear grant of discretion to the plan administrator and the decision being appealed was made in compliance with plan procedures. Sanford v. Harvard Indus., Inc., 262 F.3d 590, 595, 597 (6th Cir. 2001). The arbitrary or capricious standard of review "is the least demanding form of judicial review of administrative action. When it is possible to offer a reasoned explanation, based on the evidence, for a particular outcome, that outcome is not arbitrary or capricious." Shields v. Reader's Digest Ass'n, Inc., 331 F.3d 536, 541 (6th Cir. 2003) (internal quotes and citation omitted). When applying this standard, the court must determine whether the administrator's decision was reasonable in light of the available evidence. Put another way, if there is a reasonable explanation for the administrator's decision in light of the plan's provisions, then the decision was not arbitrary or capricious. Williams v. Int'l Paper Co., 227 F.3d 706, 712 (6th Cir. 2000). A decision reviewed according to this standard must be upheld if it is supported by "substantial evidence." Baker v. United Mine Workers of Am. Health Retirement Funds, 929 F.2d 1140, 1144 (6th Cir. 1991). Substantial evidence supports an administrator's decision if the evidence is "rational in light of the plan's provisions." See Smith v. Ameritech, 129 F.3d 857, 863 (6th Cir. 1997).
Although the plaintiff has raised several issues, the crux of this case is whether there is evidence in the administrative record to justify the defendants' actions in light of the applicable review standard. "[T]he validity of a claim to benefits under an ERISA plan is likely to turn on the interpretation of terms in the plan at issue." Firestone Tire Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989). In such an action, the court generally considers only that evidence presented to the plan administrator at the time he or she determined the employee's eligibility in accordance with the plan's terms. Smith, 129 F.3d at 863. The court's review thus is limited to the administrative record. Wilkins v. Baptist Healthcare Sys., Inc., 150 F.3d 609, 618 (6th Cir. 1998).
The defendants in this case cite Miller v. Metropolitan Life Ins. Co., 925 F.2d 979, 986 (6th Cir. 1991), for the proposition that the plaintiff cannot prevail because she did not offer additional evidence of disability when invited to do so during the appeal period. Although that was the holding in Miller, the Sixth Circuit based that determination on plan language that obliged the plaintiff to bring forward additional evidence at that stage of the proceedings, language that is not part of the present plan. However, Miller does support the general argument that when the plan allocates the burden of proving disability, it is binding on the parties. Another Judge in this District recently applied Miller to make the point:
The plan places the burden of proving continued disability on the insured. The plan states, "Written proof of loss must be sent to The Hartford within 90 days after the start of the period for which The Hartford owes payment." "After that, The Hartford may require further written proof that you are still disabled." "The Hartford reserves the right to determine if proof of loss is satisfactory."
In Miller v. Metro. Life Ins. Co., the Sixth Circuit construed a similar provision to mean that the insured bears the burden of proving continued disability. 925 F.2d 979, 984 (6th Cir. 1991). The language of the plan in Miller stated that "[O]n demand from the Insurance Company[,] further satisfactory proof, in writing, must be submitted to the Insurance Company that the disability continues." Id. at 980. The Sixth Circuit held that due to this type of language, "it is the employee who must continue to supply on demand proof of continuing disability to the satisfaction of the insurance company." Id. at 985.Donatiello v. Hartford Life and Acc. Ins. Co., 344 F.Supp.2d 575, 580 (E.D. Mich. 2004) (citations to the administrative record omitted).
The plan in this case states that when making a claim for long term disability benefits, the employee "must give proof you continue to be . . . Fully Disabled during the Primary Benefit Period." AR at 112. The plan also warns that "[n]o Monthly Benefits will be paid with respect to a Full Disability and/or a Total Disability . . . if you fail to give us proof, when we ask for it, such disability still exists." AR at 103.
The proof submitted by the plaintiff "must be satisfactory to" the plan administrator. AR at 112. The plan provides for payment of disability benefits for a primary benefit period of twenty-four months, following a six-month waiting period, for participants who establish that they are "Fully Disabled" during the period of coverage. AR at 101, 103.
"Full Disability" or "Fully Disabled" means that because of a sickness or an injury, you cannot perform your regular job or any other reasonably appropriate job your Employer can provide. The term "Full Disability" has the same meaning as the term "Phase I Disability" which is used in the Summary Plan Description distributed to you by the Employer.
AR at 100.
Because the plan defines disability in terms of the claimant's ability to perform her usual job (or a similar one), Dow submitted detailed descriptions of the duties of an Administrative Specialist, the position the plaintiff held on her last day worked. The job required five to six hours of sitting per day, one to two hours of standing and walking per day, and no bending, twisting, or climbing. Df.'s Mot. for J. Ex. C, Job Description. Performance of duties required engaging in interpersonal relationships from thirty-four to sixty-six percent of the time and stressful situations up to thirty-three percent of the time. Ibid. Dow described the position as follows:
The purpose of this job is to provide administrative support and assistance to a diverse group in Superabsorbent Products comprising of RD, TSD, including a non-resident Global RD director when in town, as well as a Global Marketing Manager. The candidate would act as a focal point and informational resource for the various discipline members, business partners and Dow customers. Typical duties include; maintaining file server uses, scheduling meetings (including a qtly [sic] global communications meeting), scheduling interviews, answering phones, making travel arrangements, maintaining product safety files, entering time exceptions, data book management, CRI reports etc.
Finally, the successful candidate would assume administrative duties for 1603 building, such as maintaining distribution lists, mailing slots, check-in/out boards, maintaining safety filed, coordination of ordering and recharging building and safety supplies assisting in records management of new employee safety orientation and training etc. The spread of effort would be estimated at 80% RD/10% Commercial/10% Building.Ibid. The employer also listed the following critical tasks for the plaintiff's job position:
Initiative-Should have a demonstrated record in self-sufficiency and working authority to successfully complete their role. Must be self-motivated and able to work independently.
Interpersonal Effectiveness-Must be able to communicate effectively and in a timely manner. Success will depend on working effectively with internal and external customers in addition to working with people and teams at various levels and in various functions within the organization. Must practice interpersonal versatility in interactions with others with diverse backgrounds, needs and styles. Builds rapport and effective relations.
Learning-Must have the ability to continuously improve skills as new technologies and processes are introduced.
Teamwork-Candidate must be able to work within a diverse organization and possess the ability to create a positive working environment around the group.
Communications-Ability to communicate in both a verbally and written fashion. The candidate will interact with Dow personnel at various levels, globally, as well as persons from other companies (including customers) and organizations.
Flexibility-Demonstrated ability to balance multiple priorities and work schedule is a must.
Technical Knowledge-Strong base in administrative management systems, technology and organizational effectiveness is important in this role. Excellent computer skill is also essential.Ibid.
The plaintiff argues that Dr. Syed's reports and office notes establish without contradiction that she cannot perform her regular jobs as they are set forth above. The medical record supports this argument, but only superficially. Although Dr. Syed says the plaintiff cannot perform many of the categorical tasks listed in the job description, there is nothing in his office notes that explains why she cannot. A review of the record illustrates the incongruity.
The plaintiff first saw Dr. Syed on April 20, 2001 on the advice of one of her counselors, Kathy Sargent. The plaintiff told Dr. Syed that her mother suffered from depression and her father engaged in inappropriate sexual conduct toward her and her older sister. Dr. Syed reported that the plaintiff recounted that she had been married on two different occasions with the first marriage lasting for a year or two. She divorced her first husband, and also informed Dr. Syed that she had a twenty-five-year-old son whose father is black. Wilson had been married to her present husband for a few years but at the time was separated. However, she was trying very hard to keep the relationship. Wilson also reported that her son was in prison for five years for sexual assault on a minor. A portion of the doctor's report of that first meeting states: MENTAL STATUS: When seen today the patient was alert, pleasant, very talkative but circumstantial but coherent, relevant, female who appeared to have a lot of self doubts. She also seemed to have a lot of guilt related to her son. She feels responsible for different things particularly her marriage and appeared to be quite conflicted. She denies any hallucinations. No expression of delusional thinking. Her speech was goal directed. Her affect appropriate. She did not show any psychomotor retardation or agitation. She maintained good eye contact.
DIAGNOSIS:
Axis I: 1. DYSTHYMIC DISORDER.
2. ALCOHOL ABUSE.
Axis II: PERSONALITY DISORDER NOT OTHERWISE SPECIFIED.
Axis III: HYPOTHYROIDISM.
Axis IV: MODERATE TO SEVERE DUE TO MARITAL PROBLEMS, STRESS AT WORK, PROBLEMS WITH HER SON.
Axis V: GAF [Global Assessment of Functioning] OF 55.
I will continue this patient on Serzone but increase the dose to 150 mg daily. I strongly advised that she does not drink explaining the rationale for it. I believe she needs a lot of psychotherapy to help her deal with the internal and external stressors. She has a lot of conflict in areas relating to her father, conflict with her son and with her present husband which needs to be dealt with. Her response to medication would not be consistent since she reacts to the stressors and then thinks the medication is ineffective which was discussed with the patient. I will see her again in about four weeks.
AR at 182-83. The doctor prescribed Serzone as the plaintiff's treatment.
Dr. Syed became the plaintiff's attending physician. The plaintiff missed her next appointment with Dr. Syed on May 4, 2001, but the notes of the second meeting on May 9, 2001 state:
Diane reported to be doing fairly well since her last evaluation stating she was doing better and was ready to return to work until her husband came over and started to play games with her. . . .
The patient was alert, pleasant, coherent, relevant, anxious, at times tearful talking about the divorce. No psychosis. No hallucinations or delusions. Her speech was goal directed. Her affect appropriate. No thought disorder was noted.
AR at 179. The doctor prescribed Ambien for the patient and wrote a statement recommending the plaintiff work on a part time basis for one week. Dr. Syed's notes of a May 18, 2001 meeting state:
Diane reported to be doing fairly. Today however she talked about her not remembering Monday and how upset she was after having talked to her husband. . . . She stated she cannot function at work, however has been doing better at times than others. This appeared to depend on what goes on in her life. . . . She reports to be sleep walking also. She was advised not to use over the counter sleeping medication and not keep it around. She still feels anxious and apprehensive.
The patient was alert, pleasant, anxious, apprehensive, somewhat concerned and fearful. No hallucinations, delusions or psychosis. Her speech was goal directed. Her affect appropriate. No thought disorder was noted. She still has a lot of difficulty dealing with her marital situation.
AR at 178. At this meeting, the doctor increased the dosage of Serzone. Around this time, plaintiff received a letter from her employer threatening termination if her performance did not improve. Dr. Syed advised her to only work on a part-time basis on May 30, 2001 and modified the Serzone dosage. In all, the plaintiff worked on a part time basis from May 3, 2001 until July 6, 2001.
The doctor's observations of the plaintiff remain consistent throughout their meetings of May 30, 2001, June 13, 2001, June 27, 2001, and July 11, 2001. This comment from the June 27, 2001 office note is representative:
The patient was alert, pleasant, coherent, anxious, apprehensive lady who denies any affective symptomatology. She denies any symptoms indicating psychosis. She however, gets very anxious and apprehensive and tearful when she talks about the stress at work. No thought disorder. No memory or orientation problems. She also talked about the insensitivity of her boss and as to how he threatened her that she better get well in seven weeks which is the length of time she has.
AR at 175. The doctor's diagnosis of the plaintiff during this period was also consistent:
Axis I: 1. DYSTHYMIC DISORDER.
2. ADJUSTMENT DISORDER WITH MIXED EMOTION.
3. ALCOHOL ABUSE.
Axis II: PERSONALITY DISORDER NOT OTHERWISE SPECIFIED.Ibid. The doctor started the plaintiff on Risperdal, continuing Serzone and Ambien on an as-needed basis. AR at 176. On July 11, 2001, the doctor adjusted his diagnosis to include "MAJOR DEPRESSION PARTIAL REMISSION" and "ALCOHOL ABUSE IN REMISSION." AR at 174. On July 11, 2001, the plaintiff reported that she was "doing poorly:"
She stated that at times she gets depressed and helpless. She feels hopeless as well, although denies any suicidal ideas. She stated that she still works, but feels stressed at work. She feels as if things are not going to get better.Ibid. On July 25, 2001, she told Dr. Syed that her supervisors suggested she go on disability since she missed several days of work. The doctor decreased the Serzone dosage and started her on Effexor. On August 17, 2001, Dr. Syed wrote this report of a meeting with the plaintiff:
Diane reported to have been doing the same stating that she has been sleeping for about twelve hours a day. This has been happening since she has been on Effexor. She is still using Ambien. She also ran out of Risperdal and wondered if she still needed it, but started to get very anxious and apprehensive a couple of days later, at which time she called in for it. She was using Ambien every two nights, skipping it the third night. She however, has not been able to do that in the past few days, since she feels very anxious and insomniac. She is off from work on sick leave, for the next three months or so, for which she will have to file for disability. She reports no side effects to the medication, except for having some visual distortions. She states that she sees webs or net like things, which she has noticed for the past two weeks. This will be observed. She was advised to call if it becomes worse. She sounds not as bad, like she has in the past, but does not feel that she is feeling any better. She was quite withdrawn, she does not socialize much, does not go to church and prefers for sleep.
When seen, patient was alert, pleasant, coherent, relevant, fairly talkative, casually dressed and groomed female who denies any suicidal ideas. No psychotic symptoms. She exhibited some psychomotor retardation. No thought disorder was noted.
AR at 172. He diagnosed the plaintiff with dysthymic disorder, major depression recurrent, alcohol abuse in remission, and personality disorder not otherwise stated. The doctor continued to prescribe Effexor and Risperdal for the plaintiff, but substituted Sonata for Ambien.
At the September and October meetings, the plaintiff reported she was doing poorly or not as well, but the doctor recorded his personal observation as follows:
Patient was alert, pleasant, coherent, relevant, fairly talkative, fairly animated, relaxed female who denies any affective symptomatology. No psychomotor retardation or agitation. No symptoms indicating psychosis. Her affect was appropriate. No thought disorder was noted.
AR at 170. Wilson reported that her landlord had asked to leave her apartment for failure to pay rent. By October 18, 2001, the plaintiff's drug regimen consisted of Effexor, Desyrel, Risperdal, and Ambien.
At the next meeting on December 19, 2001, the plaintiff reported to the doctor that she had been dealing with her on-going issues, and Dr. Syed noted that "[s]he wants to see a therapist to help her deal with some of these feelings, which was encouraged." AR at 169. Dr. Syed's description of the plaintiff at the December meeting states:
Patient was alert, pleasant, coherent, fairly talkative female who was relatively more objective although continued to struggle with her feelings, which seemed to overwhelm her at times. She denies any symptoms indicating psychosis. No psychomotor retardation or agitation. Her speech was goal directed. Her affect appropriate. She was carelessly dressed and groomed.
AR at 169. From August to December 2001, the doctor's diagnosis of the plaintiff had not changed. She suffered from recurrent major depression, dysthymic disorder, alcohol abuse in remission, and personality disorder not otherwise stated.
Dr. Syed consistently described the plaintiff in pleasant, alert, talkative and behaving appropriately, and he never found evidence of pathology or psychosis. Yet he completed the attending physician's statement that was filed with Wilson's benefit application stating that the plaintiff suffered from "severe depression affecting all her ability," anxiety, panic, and fear. AR at 152-153. He classified her as having "significant loss of psychological, physiological, personal and social adjustment." AR at 152. His objective findings consisted of observing "lethargy" and "crying," and he recommended that the plaintiff not return to work due to "severe depression affecting all her abilities." AR at 152, 153. He classified the level of the plaintiff's psychological impairment as "Class 5," which describes severe limitations. The doctor did not select a box that would indicate he recommended the plaintiff receive psychological counseling.
As stated above, the plan administrator's final denial of the plaintiff's application was based in part on an opinion from a medical consultant who "noted that your medical records do not provide an objective basis for functional impairment that would prevent you from performing your regular work." AR at 209. Although the plan itself does not require "objective" proof of disability, the proof must be "satisfactory." AR at 112. Dr. Syed's findings do not document symptoms that support his diagnosis. It is not unreasonable for a plan administrator to demand a medical or psychiatric explanation tying the conclusion that the claimant is disabled to some medical finding that supports it, or an explanation as to how intuitively benign findings actually are indicative of a disabling condition. See Yeager v. Reliance Standard Life Ins. Co., 88 F.3d 376, 381 (6th Cir. 1996) (holding that "[i]n the absence of any definite anatomic explanations of plaintiff's symptoms, we cannot find that the administrator's decision to deny benefits was not arbitrary and capricious"); see also Donato v. Metropolitan Life Ins. Co., 19 F.3d 375, 382 n. 6 (7th Cir. 1994) (finding that a claim for benefits based on psychiatric disability "require[s] objective psychiatric evidence linking [the] symptoms to a psychiatric disorder that is totally disabling"). The defendants' conclusion that the evidence submitted by Dr. Syed did not fulfill that requirement was "rational in light of the plan's provisions." Smith, 129 F.3d at 863.
Because the plaintiff did not meet her burden of proof, the denial of benefits by the plan administrator was neither arbitrary nor capricious.
The parties have raised other contested issues, which need not be addressed in great detail. The defendants claim that the denial of benefits can be based on a plan provision that states: "No Monthly Benefits will be paid with respect to a Full Disability and/or a Total Disability . . . for any period of time during which you do not follow your Doctor's prescribed treatment with respect to your Full and/or Total Disability." AR at 103-04. The defendants argue that Ms. Wilson disregarded a doctor's order to start psychotherapy or psychological counseling, thereby disqualifying her from benefits. That argument is not supported by the administrative record. Although there are notations in Dr. Syed's records in which he encouraged the plaintiff to restart counseling, he never actually prescribed individual or group therapy. When Dr. Syed completed the Attending Physician Statement attached to the benefits application, he did not check a box that would indicate he recommended the plaintiff receive psychological counseling. AR at 153. Moreover, the record contains the uncontradicted explanation that the plaintiff saw a counselor named Janet Fromhold on "8/01, 2/02 to Present." AR at 146. Wilson stated that she "[n]eeded to continue counseling therapy with Janet Fromhold in 2001, but I couldn't afford the $60 for each visit. I had used nearly all the 20 mental health visits allowed per year, and I needed what few were left for my appointments with Dr. Syed." Ibid.
The plaintiff also complains that the defendants' psychiatric consultant's report was submitted after the initial benefits denial decision and should not be considered. The plan language, however, makes clear that the administrative process continues after the initial denial and extends into any review requested by the claimant. See AR at 119. All the material collected during that process becomes part of the administrative record and is subject to review by this Court. Wilkins, 150 F.3d at 614-15.
Finally, the plaintiff contends that a structural conflict of interest exists because MetLife both funds the long term disability plan and passes on the benefits applications. The presence of a conflict of interest does not require relaxation of the deferential arbitrary and capricious review standard or mandate de novo review of the plan administrator's decision. Marchetti v. Sun Life Assur. Co. of Canada, 30 F.Supp.2d 1001, 1007 (M.D. Tenn. 1998). Rather, the conflict of interest is a factor taken into account when evaluating the decision under the arbitrary and capricious standard. Id.; see also University Hosps. of Cleveland v. Emerson Elec. Co., 202 F.3d 839, 846 (6th Cir. 2000). The mere existence of a structural conflict of interest is not enough to justify heightened scrutiny of the plan administrator's decision. The plaintiff must provide actual evidence that the conflict of interest had some effect on the administrator's decision. See Peruzzi v. Summa Med. Plan, 137 F.3d 431, 433 (6th Cir. 1998). No such evidence was presented in this case.
III.
The Court finds that there is a reasonable explanation for the administrator's decision to deny benefits in this case in light of the plan's provisions and the evidence contained in the administrative record.
Accordingly, it is ORDERED that the defendants' motion to affirm the plan administrator's decision [dkt # 14] is GRANTED.
It is further ORDERED that the plaintiff's motion for summary judgment [dkt # 10] is DENIED, and the plaintiff's complaint is DISMISSED WITH PREJUDICE.