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Cassandra J. Houser v. Alcoa

December 6, 2010

CASSANDRA J. HOUSER, PLAINTIFF,
v.
ALCOA, INC. LONG TERM DISABILITY PLAN,
DEFENDANT.



The opinion of the court was delivered by: Ambrose, Senior District Judge

OPINION AND ORDER OF COURT

Plaintiff, Cassandra J. Houser (APlaintiff@ or AHouser@), initiated this action alleging violations of the Employee Retirement Income Security Act of 1974, 29 U.S.C. ' 1001, et seq. (AERISA@), against Defendant Alcoa, Inc. Long Term Disability Plan ("Defendant" or "the Plan@). Specifically, the Complaint alleges that Defendant unlawfully denied Plaintiff long-term disability benefits under the Plan. Pending before the Court is Defendant's motion for summary judgment (Docket No. 17). Plaintiff opposes Defendant's motion. (Docket No. 20). After careful consideration of the parties= submissions and for the reasons set forth below, Defendant's Motion is granted.

I. FACTUAL AND PROCEDURAL BACKGROUND

Unless otherwise indicated, the following material facts are undisputed.*fn1

A. Alcoa's Long Term Disability Plan

Alcoa, Inc. ("Alcoa") hired Plaintiff on December 17, 1979. During the times relevant to this action, Plaintiff worked as a Senior Purchasing Specialist. The Senior Purchasing Specialist Job is sedentary and requires telephone use, computer use, and desk work.

The Plan*fn2 is an employee welfare benefit plan within the meaning of ERISA. The Plan is self-funded, with benefits funded by Alcoa, participating subsidiaries, and employee contributions. Alcoa sponsors and administers the Plan. As Plan Administrator, Alcoa has retained discretionary authority to determine eligibility under the Plan. The Plan provides:

The plan administrator has the discretionary authority to determine eligibility under all provisions of the plans; correct defects, supply omissions, and reconcile inconsistencies in the plans; ensure that all benefits are paid according to the plans; interpret plan provisions for all participants and beneficiaries; and decide issues of credibility necessary to carry out and operate the plans. Benefits under the plans will be paid only if the plan administrator decides in its discretion that the applicant is entitled to them.

Summary Plan Description ("SPD") at 7.*fn3 MetLife Disability was the Plan's third-party Claims Administrator until January 1, 2005. After January 1, 2005, Alcoa retained Broadspire Services, Inc. (now Aetna Life Insurance Company) to serve as Claims Administrator.

The Plan provides for two levels of appeals. The Claims Administrator has authority to make initial claims determinations and decide first-level employee appeals. Alcoa has designated its internal Benefits Management Committee to oversee operation of the Plan. The Benefits Management Committee has created a separate Benefits Appeals Committee ("BAC") with authority to decide the second (final) level appeals from adverse first-level decisions.

According to the Plan, "totally disabled" means, during the first 24 months, that because of injury or sickness the claimant "cannot perform each of the material duties of your regular job" (the "own occupation" standard). SPD at 13. After 24 months, "totally disabled" means that because of injury or sickness, the claimant "cannot perform each of the material duties of any gainful occupation for which you are reasonably suited by training, education or experience" (the "any occupation" standard). Id.*fn4 Further, the claimant "must receive appropriate care or treatment from a doctor on a continuing basis." Id. The Plan also provides that "[t]o continue to be eligible for LTD benefits, you may be required by the company or claims administrator to provide satisfactory proof of your continued total disability," and that LTD benefits are not paid for "any period for which you do not provide proof of your continued total disability." Id. at 4; see also id. at 3 ("You also must submit proof of your continued total disability when it is requested by the claims administrator.").

B. Plaintiff's Long-Term Disability Claim

Plaintiff went on short-term disability ("STD") leave at the end of 2001 and again in February 2002. When her STD benefits were exhausted, Plaintiff filed a timely claim with the Plan for LTD benefits due to asthma. Plaintiff's initial claim for LTD benefits was approved as of June 9, 2002. On September 17, 2002, the Social Security Administration denied Plaintiff's application for social security disability benefits.

In a letter to Plaintiff dated April 8, 2003, MetLife Disability stated that "[w]e have recently reviewed your claim. To consider benefits for this claim, specific information will be needed from your physician." AR 126.*fn5 The information requested included: (1) copies of the two most recent office notes, diagnostic test results, operative reports and discharge summaries, if applicable, and rehabilitation or therapy notes, if applicable; (2) names and dosages of all current medications; (3) functional abilities; and (4) expected return to work date. Id. The letter requested that the information be received by April 22, 2003 and stated that "[f]ailure to submit this information timely will result in closure of your claim." Id. Documentation in the administrative record indicates that on April 22, 2003, Plaintiff told MetLife that the information would be late. AR 176. Another electronic diary entry indicates that on May 6, 2003, Plaintiff stated that she had a breathing test on April 30, 2003 and should have the test results before May 15, 2003. Id. The entry states that Plaintiff would make sure her physician sent the updated medical records to the office. An entry dated June 2, 2003, indicates that Plaintiff was contacted on May 16, 2003 and advised the updated information had not yet been received and that Plaintiff again stated she would have her doctor forward the information to the office. AR 152, 177. The June 2 entry further states that the information still had not been received and that Plaintiff's file was now closed. Id. The entry concludes by noting that a "letter has been forwarded to the employee; will reopen file once information is received." Id. Plaintiff admits that on June 2, 2003, MetLife terminated her LTD benefits because her physician had failed to provide the information that the Plan requested. Pl.'s Statement of Material Facts (Docket No. 21) ¶ 16.

Plaintiff responded to the Plan days later and claimed her doctor had in fact submitted the information, but that they would send it a second time. On June 5, 2003, MetLife received four pages faxed from the office of Carl Scheler, Plaintiff's treating physician, consisting of partial test results dated April 15 and April 30, 2003, and illegible office notes from April 25, 2003. AR 127-29. The record indicates that MetLife reviewed this additional information. AR 178-79.

On July 14, 2003, MetLife notified Plaintiff that her LTD benefits were being terminated effective June 1, 2003, because she failed to meet the Plan's definition of "total disability" as of that date. The July 14, 2003 denial letter stated, inter alia:

. . . . We had your complete file reviewed by our Disability Nurse Consultant.

The review indicated that your employer had previously made accommodations for you to return to work. These accommodations included relocating your job to another building, away from the major environmental stressors, but you continued with complications from your asthma, and were not able to work. It is also noted at your April 25, 2003 examination, you continued with severe airway obstruction, although marked improvement after using a broncho-dilator. Your file also contains test results performed on April 30, 2003. The test results did not indicate an obstruction, which would prevent you from returning to work.

Based on a thorough review of your file, it appears your file does not indicate the severity of how your [sic] are functionally impaired from your bronchial asthma, to indicate why you are unable to return to work. Therefore, effective June 1, 2003, you no longer met the definition of disability as outlined in your Plan and your claim is terminated with no further benefits payable.

AR 20-21. The letter further informed Plaintiff that she could "request a review of the claim in writing." Id. In this regard, the letter stated, inter alia:

When requesting this review, please state the reason(s) you believe the claim was improperly denied, and submit any requests to review pertinent documents.

You may also submit additional medical or vocational information and any facts, data, questions, or comments you deem appropriate for us to give your appeal proper consideration. MetLife Disability will evaluate all the information and advise you of our determination in a timely manner.

Id.

Plaintiff, by counsel, submitted a first-level appeal of the LTD denial on January 9, 2004, which the Plan received on January 12, 2004. In support of her appeal, Plaintiff's counsel provided a record of a two-day hospitalization in August 2003 and an administrative law judge decision denying her Social Security Disability benefits in June 2003. Plaintiff's counsel also requested a copy of her disability file, which the Plan promptly provided. The hospital records Plaintiff submitted show she was admitted for shortness of breath, but she was not in acute distress and her symptoms were otherwise unremarkable. A chest examination showed her lungs were normally aerated, the heart and vasculature were normal, and there was no free pleural fluid. Plaintiff was discharged with no activity restrictions and no follow-up tests ordered.

On February 10, 2004, Plaintiff's counsel sent MetLife two undated letters from Dr. Scheler and the results of a pulmonary function test from October 22, 2003. The first undated letter from Dr. Scheler states, inter alia:

As has been briefly outline [sic] above, Cassandra Houser's asthma appears to be worsening with time despite aggressive medical management. She has become increasingly unable to perform activities associated with her position at Alcoa d[u]e to increasing dyspnea. I do not believe that she will be able to work at any other job for the same reason, namely that her asthma has become quite severe and has impaired her ability to do any kind of physical work and is exacerbated by stress.

AR 086-087. The second Dr. Scheler letter discusses pulmonary function tests Plaintiff underwent with pulmonologist Dr. Bajwa after Dr. Scheler's first letter. Dr. Scheler also states in the second letter:

As noted previously Cassandra Houser's asthma continues to worsen despite more aggressive therapeutic interventions, and her exacerbations occur with more severity and frequency and less activity and stress. I believe that she is disabled from her present position at ALCOA and other future employment is highly unlikely.

AR 088. Dr. Bajwa noted in the pulmonary function test results that the results were "[c]onsistent with severe COPD with reversible component." He also noted that "[t]here is significant improvement after bronchodilator." AR 089.

By letter dated March 4, 2004, MetLife denied Plaintiff's first-level appeal for LTD benefits. The denial letter informed Plaintiff that the medical records she provided "do not support an impairment that would prevent [her] from performing the duties of her regular job beyond May 31, 2003." AR 022-023. The letter lists the various medical records considered, including records from Dr. Bajwa and a letter from Dr. Scheler. Id. The letter further states that "[i]n an effort to provide Ms. Houser with a full and fair review, we had ...


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