Ellis v. Metropolitan Life Ins. Co.

• Decision Date: 10 September 1997
• Docket Number: No. 96-2711,96-2711
• Citation: 126 F.3d 228
• Parties: Ellen V. ELLIS, Plaintiff-Appellant, v. METROPOLITAN LIFE INSURANCE COMPANY, Defendant-Appellee.
• Court: U.S. Court of Appeals — Fourth Circuit

Page 228

126 F.3d 228

Ellen V. ELLIS, Plaintiff-Appellant, v. METROPOLITAN LIFE INSURANCE COMPANY, Defendant-Appellee.

No. 96-2711.

United States Court of Appeals, Fourth Circuit.

Argued July 18, 1997.

Decided Sept. 10, 1997.

ARGUED: John Bertram Mann, Levit & Mann, Richmond, VA, for Appellant. Alvin Pasternak, New York City, for Appellee. ON BRIEF: Gregory D. Zahs, New York City, for Appellee.

Before ERVIN, Circuit Judge, and BUTZNER and PHILLIPS, Senior Circuit Judges.

Affirmed by published opinion. Judge ERVIN wrote the opinion, in which Senior Judge BUTZNER and Senior Judge PHILLIPS joined.

OPINION

ERVIN, Circuit Judge:

Plaintiff-Appellant Ellen V. Ellis (Ellis) appeals from an order granting Defendant-Appellee Metropolitan Life Insurance Company's (MetLife) cross-motion for summary judgment and denying her own. Ellis had sought review in district court of MetLife's final determination that she was ineligible for long-term disability benefits under an employee welfare benefit plan governed by the Employee Retirement Income Security Act of 1974 (ERISA), 29 U.S.C. § 1001 et seq. Ellis alleged that MetLife had improperly denied her her benefits and engaged in procedural errors in contravention of the statutory and regulatory requirements of ERISA. We affirm.

I.

Ellis was a branch manager for NationsBank Corporation whose principal duties related to originating mortgage loans. She participated in NationsBank's Long Term Disability Plan (Plan). The Plan is an employee welfare benefit plan governed by ERISA, and it is funded by MetLife.

The Plan vests MetLife, a fiduciary under the Plan, with 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 discretionary authority shall be given full force and effect, unless it can be shown that the determination was arbitrary and capricious.

J.A. at 101. The terms of the Plan provide, in pertinent part, that a participant is "disabled" if

due to an Injury or Sickness, [the participant] require[s] the regular care and attendance of a Doctor ... and:

(1) [the participant is] unable to perform each of the material duties of [her] regular job....

J.A. at 92.

In August 1993, Ellis submitted a long-term disability claim form in which she declared that she suffered from blurred vision, balance problems, and chronic pain which precluded her from driving, reading, sitting, or standing for any length of time without rest. She indicated that she believed her disability arose from a dental visit procedure that occurred in April 1992, five days after which she admitted herself to a hospital. MetLife subsequently initiated its review procedure.

At MetLife's request, Ellis's health care providers submitted medical information relating to her claim. Her primary treating provider, Michael Porvaznik, D.O., informed MetLife that, in his opinion, Ellis was disabled, and he diagnosed her difficulties as being due to somatic dysfunction. Records submitted by other health care providers, however, indicated that the etiology of her problems was undetermined, that the results of a neurological examination were normal, and that there were no known limitations on her return to work.

In November 1993, MetLife referred Ellis's claim file to the Independent Board Certified Physicians Roundtable (Roundtable), an independent medical consulting group, for an assessment of Ellis's condition. The Roundtable members who reviewed Ellis's file consisted of an internal medicine and neurology specialist, an internal medicine and cardiology specialist, and an orthopedic surgeon. This panel concluded that no medical diagnosis for her condition could be confirmed. The panel suggested the possibility of an underlying psychiatric disorder, but no such evidence had been submitted to them. Functional ability on the basis of a psychiatric disorder could not be assessed. Nonetheless, assuming that each of Ellis's symptoms were present, the panel concluded that Ellis ought to be able to lift various weights, to walk or stand for three to four hours a day in divided periods, and to sit for eight to ten hours a day.

Based on the Roundtable's findings, MetLife denied Ellis's claim in a letter dated December 9, 1993. MetLife explained why her claim was denied, informed her of the Roundtable's conclusions, notified her that she could request further review within 60 days, and explained that additional documentation could be submitted for review.

Ellis did seek further review, and Porvaznik compiled additional medical reports and information. Porvaznik himself characterized Ellis's problem as severe and disabling but admitted that the etiology remained unclear. Reports by other providers, however, were again inconclusive. A neurobehavioral profile revealed that Ellis possessed "considerable strengths in the majority of skills assessed, including sensory-perceptual abilities, general intellectual abilities, and executive functioning skills." J.A. at 167. That report concluded that "[a]lthough her symptoms are very real, and do apparently preclude her resumption of her previous lifestyle, it is difficult to pinpoint etiology of symptoms with any degree of certainty." J.A. at 168. A further head and neck examination, MRI, audiogram, and otoscopic examination yielded normal results. A physical therapist reported that Ellis's performance on one test was consistent with a patient who has sensory organization dysfunction. Another report suggested that Ellis appears to have a predisposition to fibromyalgia and recommended a treatment of progressive aerobic exercise. And yet another report could find no evidence of neurological disease but admitted that the reported symptoms were incapacitating.

MetLife submitted this new material to the Roundtable, which added a psychiatrist to the panel of the original three members. Based on all the information supplied, the Roundtable, in a May 16, 1994, report, suggested that there was a reasonable basis for a probable diagnosis of fibrositis or fibromyalgia but that it could not be confirmed. ¹ Still, assuming that fibrositis or fibromyalgia was present, as well as a memory deficit, a peripheral vestibular disorder, and some element of depression or dysthymia, ² the Roundtable determined that there was no incompatibility between Ellis's functional capacity and her work requirements, even though her functional limitations could have been over-estimated.

Rather than continue to deny Ellis's claim based on this report, MetLife instead provided copies of the report to Ellis's health care providers to seek their comments. In particular, MetLife requested that they address whether Ellis was totally disabled with respect to her occupation of bank branch manager and to submit objective medical evidence of her continuing disability. Only a few of the health care providers responded. Additional testing of Ellis was arranged, however, and MetLife continued to accept and consider evidence through January 1995. The new reports continued to give a wide variety of assessments. One neuro-psychologist, for example, suggested that the environment of the banking industry, especially NationsBank's merger with Sovran Bank and its attendant layoffs, created the potential for "secondary gain" because of Ellis's access to long-term disability benefits. See J.A. at 238. A clinical social worker, however, discounted that hypothesis, believing that Ellis had been earning more than $100,000 annually whereas her disability payments would amount to only $28,000 annually. See J.A. at 245. A statement by NationsBank placed Ellis's annual earnings at approximately $38,700. See J.A. at 107.

MetLife submitted all of this data for a third time to the Roundtable. In place of the specialist in internal medicine and cardiology, a specialist in internal medicine and rheumatology was substituted; the three other panel members remained the same as on the second panel. In a report of February 4, 1995, the panel concluded that a diagnosis of fibrositis remained probable. But again, assuming that diagnosis, as well as symptoms of muscle tightness, pain, and ocular convergence, the panel determined that Ellis ought to be able to lift even greater weights than indicated before, walk and stand six to eight hours a day, and sit for eight to ten hours a day. This functional capacity was yet again found not to be medically incompatible with Ellis's work requirements.

Following this review of its earlier denial, MetLife informed Ellis on March 28, 1995, that its decision remained the same and that her file was closed.

Ellis filed this action on October 12, 1995, alleging (1) that MetLife had failed to give her adequate written notice of the reasons for its denial of her claim, (2) that she was not given a full and fair review, and (3) that the denial violated the terms of the Plan and ERISA. Following cross-motions for summary judgment, the district court granted MetLife's motion and denied Ellis's. The court determined that, considering the inconclusive evidence of the conflicting reports of Ellis's own health care providers as well as the three determinations of the Roundtable, substantial evidence supported MetLife's denial decision. MetLife, therefore, had not abused the discretion vested in it by the Plan, notwithstanding the slight possibility of a financial conflict of interest. The court also concluded that MetLife had substantially complied with the applicable regulations interpreting ERISA in its denial letters and that, because MetLife had done more than was required to permit Ellis to present her claim, there was no question that she had received a full and fair review.

This appeal followed.

II.

Over the last few years, we have developed a well-settled framework for review of the denial of benefits under ERISA plans. Where a plaintiff...