The opinion of the court was delivered by: MALACHY MANNION, Magistrate Judge
Before the court is the defendants' motion for summary judgment filed
pursuant to Fed.R.Civ.P. 56(c).
The documents submitted by the parties establish that Mr. Knoblauch was
employed by co-defendant Metropolitan Life ("MetLife") as of August 23,
2000, at which time he stopped working as a result of a diagnosis of
pancreatitis, with subsequent serious and prolonged complications. He
applied for and received short term disability benefits under the
Disability Insurance Plan ("plan") maintained by MetLife for the benefit
of its employees. After the required period of short term disability
benefits expired, the plaintiff applied for and received long term
disability benefits under the plan. The plan is administered by
co-defendant Synchrony Integrated Disability Services, Inc. ("Synchrony").*fn1 On May 7, 2002, the plaintiffs long term disability
benefits were terminated retroactive to April 30, 2002. The benefits were
terminated at that time because the defendants concluded, after reviewing
the plaintiff's medical records, including a functional capacity
examination ("FCE"), that the plaintiff had recovered sufficiently from
his medical conditions so that he could return to his regular job duties
as a sales representative, or another similar job in the local economy.
(Doc. No. 20, pp. 111-112). The plaintiff filed an administrative appeal
of this determination with the plan administrator which was denied on
July 16, 2002. (Doc. No. 20, pp. 92-93).
The plaintiff subsequently filed a complaint in the Schuylkill County
Court of Common Pleas seeking a determination as to his ERISA rights
under the MetLife long term disability plan. The matter was removed to
this court on October 8, 2002. (Doc. No. 1). The defendants filed an
answer to the complaint on December 6, 2002. (Doc. No. 9).
The parties agreed to proceed before this Magistrate Judge. (Doc. Nos.
6, 8). The defendants filed a motion for summary judgment, supporting
brief and Appendix ("Record") on March 24, 2003. (Doc. Nos. 18, 19, 20).
After receiving an extension of time in which to do so, the plaintiff
filed a response to the motion for summary judgment, and affidavits, on April 7, 2003; and
a supporting brief and Appendix on April 18, 2003. (Doc. Nos. 24, 25,
26, 27). The defendants filed a reply brief on April 25, 2003. (Doc. No.
28). On June 19, 2003, the plaintiff filed a motion to supplement his
brief in opposition, which was granted by Order dated June 26, 2003. The
defendants' June 24, 2003 response to the motion was also admitted.
(Doc. Nos. 32, 33, 34).
It appears that the substance of the disagreement among the parties
revolves around the nature and extent of the plaintiff's residual medical
condition; the plaintiff's time of injury job description and its
physical requirements, and whether the plaintiff was capable of returning
to work, and performing those, or similar, job requirements as of April
On May 7, 2002, MetLife via Synchrony sent the plaintiff a letter
advising him that he no longer continued to meet the plan's definitional
requirements for long term disability benefits beyond April 30, 2002. The
letter is quoted herein at length as it sets forth with particularity the
facts of the matter, even though there is some dispute as to the proper
interpretation of the medical record as put forth by the defendants. The
letter states in pertinent part:
According to your plan, "disabled means that, due
to sickness, pregnancy or accidental injury, you are
unable to earn more than 80% of your predisability
earnings at your own or any occupation for any employer in your local economy."
Your disability must also be continuous, and you must
be under a doctor's care and receiving active
treatment for the disabling condition. Proof of
disability must be submitted in order to receive
benefits under the plan . . .
Review of the evidence in the file shows that you
have not worked since August 23, 2000 due to
pancreatitis and drainage of a pancreatic abscess on
October 27, 2000. Subsequently you underwent a
laproscopic assisted endileostomy on December 12,
2000. You were then treated for a fistula in your
colon, you underwent a partial colectomy*fn2 on June
18, 2001 with a closure of your colostomy. On July
16, 2001, your provider stated that you were able to
perform light duty work, no strenuous activity, and no
heavy lifting. You had foot surgery to remove two toe
nails; you had problems with bleeding in the back of
your right eye both related to diabetic changes. You
underwent physical therapy to your right shoulder for
adhesive capsulitis. You were released to unrestricted
activity for the right shoulder on October 16, 2001.
On December 12, 2001 your toes were better. A 2 day
functional capacity examination was done on April 3,
2002 and April 4, 2002 to assess your level of
functioning. The test showed that you gave maximum
consistent effort. You showed no overt pain behavior
on either day of testing. You did complain of
dizziness and throbbing in your head during floor to
waist and unweighted rotation standing. You[r] blood
pressure was elevated to 160/90 and 152/98. Dr.
Brislin [the plaintiff's primary care physician] was
contacted with regard to your elevated blood
pressure. Dr. Brislin stated that you had recently
undergone a stress test with negative findings
therefore the testing was continued. According to the
results of the functional capacity exam your general
work capabilities fall into the medium work category
as per the definition in the dictionary of
occupational titles. Since your own occupation is
classified as light duty work and you are able to
perform medium work, you no longer continue to meet
the definition of disability.
After consideration of the above findings, it
is concluded that there is no medical evidence to
support continued functional impairment resulting in your inability to perform
work-related functions of your own or any occupation.
Accordingly, no additional benefits are due or payable
in conjunction with this claim beyond April 30, 2002
. . .
(Doc. No. 20, pp. 114-115)(emphasis added). The letter goes on to
advise the plaintiff of his appeal rights. After the plaintiff appealed
the determination, the defendants had a physician consultant, Joseph M.
Nesta, M.D., review the record. (Doc. No. 20, pp. 94-95). No independent
medical examination was performed.
The plaintiff's response to this letter is that portions of the alleged
medical record are incomplete in some cases, simply incorrect in other
instances, and certainly overly optimistic regarding the plaintiff's
functional capacities as of April 30, 2002. The plaintiff notes that,
prior to the FCE done in April 2002, Dr. Brislin explained to Synchrony
that, despite the plaintiff's progress, he still suffered from severe
peripheral neuropathy, ongoing chronic pancreatic insufficiency described
as very difficult to control despite medication therapy, and that he also
had an unexplained myopathy with severe upper arm muscle pain. He was
noted as having loss of hand strength. Dr. Brislin summarized as follows:
From a physical capacity, his arm and leg strength
and function are severely diminished. His progressive
foot and leg neuropathy is controlled with medication
but it is unlikely to improve. From my perspective, it
is unlikely that he will be able to return to work in
the near future . . .
(Doc. No. 20, p. 131). The plaintiff was required under the terms of the long term disability
plan to apply for Social Security disability benefits, which he did,
III. ERISA STANDARD OF REVIEW
A denial of benefits challenged under Section 1132(a)(1)(B) of ERISA
is to be reviewed under a de novo standard unless the benefit plan gives
the administrator or fiduciary discretionary authority to determine
eligibility for benefits or to construe the terms of the plan. Firestone
Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115 (1989). If the plan vests
such discretion in the administrator, the decision is to be reviewed
under the more deferential arbitrary and capricious standard of review.
Id.; Luby v. Teamsters Health, Welfare and Pension Trust Funds,
944 F.2d 1176, 1180 (3d Cir. 1991); Heaslev v. Belden & Blake Corp.,
2 F.3d 1249, 1256 (3d Cir. 1993).
Where the plan itself confers discretion on the administrator to
determine eligibility for benefits, the district court may reverse the
administrator's decision only if it was arbitrary and capricious, or it
was inconsistent with the applicable plan provisions. The arbitrary and
capricious standard is essentially the same as the "abuse of discretion"
standard. Abnathya v. Hoffman-La Roche, 2 F.3d 40
, 45 (3d Cir. 1993). The
scope of review is narrow and the court is not free to substitute its own
judgment for that of the defendant in determining eligibility for plan
benefits. Abnathya, 2 F.3d at 45. Thus, the Firestone standard is applicable in cases where the
controlling plan documents give the plan administrator discretion over
the payment of benefits. MetLife's plan provides, in pertinent part:
MetLife in its discretion has authority to interpret
the terms, conditions, and provisions of the entire
contract. This includes the Group Policy, Certificate
and any Amendments . . .
In carrying out their respective responsibilities
under the Plan, 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 in
accordance with the terms of the Plan. Any
interpretation or determination made pursuant to such
authority shall be given full force and effect, unless
it can be shown that the interpretation was arbitrary
and capricious . . .
(Doc. No. 20, pp. 206, 231). This language clearly gives the plan
administrator discretion over the payment of benefits, and as such, the
arbitrary and capricious standard applies in this case.
The court notes that plaintiff suggests that this court's standard of
review more appropriately should be de novo. The plaintiff appears to
argue that de novo review is required for two reasons. First, because the
defendants originally approved long term benefits; and, second, because
the plaintiff was required to apply for, and received, Social Security
Disability benefits. These facts do not require a change in the standard
of review to be applied. Firestone, 489 U.S. at 115; Pinto v. Reliance
Standard Life Ins. Co., 214 F.3d 377 (3d Cir. 2000)(discussing an
apparent conflict of interest where an insurer both decides the claim and
pays benefits from its own assets; facts not allegedly present in this case).
The court further notes that the plaintiff has also alleged a suspect
relationship between MetLife and Isernhagen Quality Providers
("Isernhagen"), the company which performed the FCE. As a result the
plaintiff requests this court to apply a heightened standard of review.
The defendants argue that whatever standard this court chooses to apply,
either arbitrary and capricious, or a heightened standard, this court
must conclude that the termination of benefits was reasonably based upon
the evidence before the plan administrator at the time the decision to