United States District Court, E.D. Pennsylvania
Decided: March 25, 2014.
For BONNIE GARDNER, Plaintiff: THAD MELVIN GELSINGER, LEAD ATTORNEY, LEISAWITZ HELLER ABRAMOWITCH PHILLIPS PC, WYOMISSING, PA.
For METROPOLITAN LIFE INSURANCE COMPANY, Defendant: VERONICA W. SALTZ, SALTZ MATKOV PC, WAYNE, PA.
Plaintiff, Bonnie Gardner (" Gardner" ), brings the instant action to challenge the denial of her claim for disability benefits pursuant to the Employee Retirement Income Security Act of 1974 (" ERISA" ), 29 U.S.C. § 1132(a)(1)(B) against Metropolitan Life Insurance Company (" MetLife" ), the insurance company that funded and administered the disability insurance plan provided by her employer. Gardner claims that MetLife's denial of her claim for long term disability benefits was arbitrary and capricious.
The parties have each moved for summary judgment. Gardner argues that the record supports a diagnosis of dementia and therefore, MetLife's determination that she is not entitled to a continuation of long term disability benefits was incorrect. MetLife maintains that its decision to deny Gardner benefits was not arbitrary and capricious, but based on substantial evidence contained in the record that any cognitive impairments Plaintiff suffered from were due to her chronic fatigue syndrome and not dementia. After a thorough examination of the administrative record and applying a deferential standard of review, I find that MetLife did not act in an arbitrary and capricious manner when it denied Gardner's disability benefits after it determined the record did not support a diagnosis of dementia. Therefore, I will grant MetLife's motion for summary judgment and deny Gardner's motion for summary judgment.
Gardner was employed by Siemens Corporation as a systems analyst until March 7, 2008. (Compl. ¶ 6.) Through Siemens, Gardner was covered by a short term and long term disability policy that is both administered and funded by MetLife. (Compl. ¶ ¶ 7, 12.) Gardner elected " Plan C" of the long term disability (" LTD" ) Plan which requires MetLife to provide up to 66 2/3 % of her predisability earnings per month, up to a maximum benefit of $16,667. (MET 0013.)
Gardner stopped working due to constant pain, anxiety attacks and fatigue and was placed on short term disability (" STD" ) pursuant to her STD policy. (Compl. ¶ ¶ 13-14.) She was eventually diagnosed with anxiety disorder with panic attacks, adjustment disorder with mixed anxiety, depressed mood, fibromyalgia and chronic fatigue syndrome. (Compl. ¶ ¶ 15, 17.) Gardner received STD benefits from March 10, 2008 through September 5, 2008. (Compl. ¶ 14.) On August 28, 2008, Gardner submitted a claim for LTD benefits. (Compl. ¶ 23, MET 1313-1327.) On January 23, 2009, MetLife denied Gardner's claim for LTD benefits effective September 8, 2008. (Compl. ¶ 24, Ex. B.) Gardner appealed this denial, and on August 21, 2009, MetLife reversed its decision and reinstated Gardner's LTD benefits. (Compl. ¶ ¶ 25-26, Ex. C.) Gardner then received LTD benefits from September 8, 2008 to September 5, 2010. (MET 0586-0588.) Under the plan in question, Gardner's receipt of LTD benefits was subject to a 24 month limitation for a disability resulting from " mental or nervous disorder or disease, unless the disability results from schizophrenia, bipolar disorder, dementia or organic brain disease." (Compl, Ex. A, p. 16.) Gardner's plan also provides the same 24 month " Limitation for Disabilities" for " chronic fatigue syndrome and related conditions." (Compl. Ex. A, p. 17.) 
On August 16, 2010, MetLife sent Gardner's counsel a letter stating that, as of September 5, 2010, Gardner would have received the maximum benefits available to her under the Plan, as Gardner suffered from a " Mental or Nervous Disorder or Disease," which limited her to 24 months of LTD benefits unless her mental disorder fell under an enumerated exception, which MetLife contended Gardner's did not. (Compl. Ex. E.) On November 29, 2010, MetLife sent Gardner a formal denial of benefits letter. (Compl. Ex. F.)
Gardner appealed her denial to MetLife, claiming that she was entitled to continue receiving LTD benefits beyond the 24 months because she suffered from dementia, which is a specified exception to the 24 month limitation period under the Plan. Gardner based her entitlement to benefits upon the March 10, 2009 report of neurocognitive testing performed by Lawrence Griffin, Ph.D, which diagnosed her with dementia. (Compl. Ex. H.) On August 9, 2011, MetLife informed Gardner that it was upholding its decision to terminate her LTD benefits because the medical information did not support a limited benefit exclusionary diagnosis such as dementia. (Compl. Ex. I.) Gardner filed the instant civil action on February 3, 2012. Gardner contends that MetLife's conclusion that the medical record does not support that she suffers from dementia, a limited benefit exclusionary diagnosis, was unreasonable. For the reasons that follow, I find that MetLife did not act arbitrarily in denying Gardner's claim for LTD benefits.
II. ERISA STANDARD OF REVIEW
The denial of benefits under an ERISA qualified plan is reviewed using a deferential standard. Where the plan administrator has discretion to interpret the plan and to decide whether benefits are payable, the exercise of its fiduciary discretion is judged by an arbitrary and capricious standard. Firestone Tire & Rubber Co. v. Bruch, 489 U.S. 101, 115, 109 S.Ct. 948, 103 L.Ed.2d 80 (1989). Under this limited and deferential review, MetLife's adverse determination may not be reversed unless it was " without reason, unsupported by substantial evidence or erroneous as a matter of law." Miller v. Am. Airlines, Inc., 632 F.3d 837, 845 (3d Cir. 2011), quoting Abnathya v. Hoffmann-LaRoche, Inc., 2 F.3d 40, 41 (3d Cir. 1993).
In conducting a review under ERISA, courts examine both the structural and procedural aspects of the decision-making. Miller, 632 F.3d at 845. The structural inquiry examines whether the structure of the plan is such that there is a financial incentive to deny claims. Id. The procedural inquiry examines how the claim is processed by the administrator to insure a fair and impartial procedure. Id. (citations omitted). The Supreme Court held in Metropolitan Life Ins. Co. v. Glenn, 554 U.S. 105, 128 S.Ct. 2343, 171 L.Ed.2d 299 (2008), that an entity's dual role as claims administrator and insurer creates a structural conflict of interest that " should be weighed as a factor in determining whether there is an abuse of discretion." Id. at 2350 (quoting
Firestone Tire & Rubber, 489 U.S. at 115). This
financial conflict of interest remains a factor to consider along with other factors in determining whether there has been an abuse of discretion. Ellis v. Hartford Life and Accident Ins. Co., 594 F.Supp.2d 564, 566-67 (E.D. Pa. 2009). Gardner's argument, in reliance on Pinto v. Reliance Standard Life Ins. Co., 214 F.3d 377, 387 (3d Cir. 2000), that MetLife's adverse determination should be reviewed under heightened scrutiny due to MetLife's conflict of interest in administering and funding the Plan is incorrect. The sliding scale analysis set forth in Pinto and previously used by the Third Circuit has been superseded by the " combination-of-factors" test set forth by the Supreme Court in Glenn.
In the instant matter, there is no dispute that MetLife, as insurer for the Plan, both funded and administered the award of disability benefits. Therefore, I shall take this conflict of interest into account as one factor, no more significant than any other factor, in determining whether there has been an abuse of discretion in handling Gardner's claim for LTD benefits.
In reviewing the administrator's processing of Gardner's claim, I must also review procedural factors, as procedural irregularities in the review process cast doubt on the impartiality of the administrator.
Miller, 632 F.3d at 845; Post v. Hartford Ins. Co., 501 F.3d 154, 164 (3d Cir. 2007). Gardner argues that MetLife " selectively utilized information favorable to its decision to deny [her] LTD benefits, to the exclusion of evidence which would have required it to grant the benefits at issue." (Pl. Br., p. 12.) While " self-serving selectivity in the use of evidence" is an irregularity that has been identified by courts to warrant enhanced scrutiny,
see Lamanna v. Special Agents Mut. Benefits Ass'n, 546 F.Supp.2d 261, 287 (W.D. Pa. 2008), procedural anomalies are but another factor to be considered under the combination-of-factors method.
Miller, 632 F.3d at 845, n.2.
Gardner moves for summary judgment, claiming that MetLife's decision to deny her LTD benefits was not reasonable. Defendant MetLife moves for summary judgment by first claiming that Gardner's claim is barred because she has failed to exhaust her administrative remedies. MetLife also argues that it is entitled to summary judgment because its claim determination was reasonable, consistent with the plan language and supported by substantial evidence. For ...