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Cohen v. Metropolitan Life Insurance Co.

United States District Court, E.D. Pennsylvania

October 16, 2014

NORMAN COHEN, Plaintiff,
v.
METROPOLITAN LIFE INSURANCE COMPANY, Defendant.

MEMORANDUM OPINION

NITZA I. QUIÑONES ALEJANDRO, District Judge.

INTRODUCTION

Before this Court are cross-motions for summary judgment filed by Plaintiff Norman Cohen ("Plaintiff"), [ECF 25], and by Defendant Metropolitan Life Insurance Company ("Defendant" or "MetLife"), [ECF 27], pursuant to Federal Rule of Civil Procedure (Rule) 56. These motions stem from Plaintiff's lawsuit brought under the Employment Retirement Income Security Act of 1974, as amended, ("ERISA"), 29 U.S.C. § 1101, et seq., wherein Plaintiff seeks a reversal of MetLife's decision to terminate his long-term disability benefits under the Novartis Long-Term Disability Plan ("Plan"). The Plan was established and maintained by Plaintiff's employer, Novartis Corporation ("Novartis"), to provide short-term and long-term disability benefits to its participating employees. MetLife is the claim administrator of the Plan.

For the reasons stated herein, Defendant's motion for summary judgment is granted, and Plaintiff's motion for summary judgment is denied.

BACKGROUND

The Plan vests MetLife, as the claims administrator and fiduciary, with the discretionary authority to interpret the terms of the Plan agreement and to determine eligibility for benefits under the Plan. Pertinent to these motions, the relevant Plan provisions stipulate:

MetLife (as the short-term and long-term disability plan's claims administrator and fiduciary), has the authority and discretion to interpret these plans, to determine all questions arising under or related to the plans, including all questions of fact and questions of obtaining benefits, and to determine the amount, manner, and time of payment of any benefits under the plans. MetLife's decisions are final and binding. (ML 0004).
* * *
Short-term disability and long-term disability benefits are paid by contract with MetLife. In addition, MetLife is responsible for processing and deciding all claims for benefits under these plans, as well as all appeals of denied claims. Benefits are payable under the short-term disability plan or long-term disability plan only if MetLife determines, in its discretion, that the claimant is entitled to them.
MetLife is also the plan's fiduciary under the short-term disability plan and long-term disability plan, which means that MetLife has the authority and discretion to interpret these plans, to determine all questions arising under or related to the plans, including all questions of fact and questions of eligibility to participate and obtain benefits, and to determine the amount, manner, and time of payment of any benefits under the plans. MetLife's decisions are final and binding. (ML 0014).

The Plan defines "disability, " as follows:

By "disabled" or "disability, " we mean that because of sickness, pregnancy, or accidental injury you are receiving appropriate care and treatment from a doctor on a continuing basis, and: during your elimination period (see above) and the next 24-month period, you are unable to earn more than 80% of your pre-disability earnings or indexed pre-disability earnings at your own occupation for any employer in your local economy, or after the first 24 months LTD benefits are paid, you are unable to earn more than 60% of your indexed pre-disability earnings from any employer in your local economy at any gainful occupation for which you are reasonably qualified, taking into account your training, education, experience and pre-disability earnings. (ML 0007).

The Plan provides a maximum benefit period of 24 months for disabilities that are the result of certain conditions (ML 0008):

Monthly LTD benefits under this plan are payable for up to a maximum of 24 months during your lifetime if you are disabled because of a mental, nervous disorder or disease or neuro-musculoskeletal or soft tissue disorder, unless the disability results from:
- Schizophrenia
- Bipolar disorder
- Dementia
- Organic brain ...

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