Chavarria v. Metro. Life Ins. Co.
| Decision Date | 25 November 2014 |
| Docket Number | Civil Action No. 13–4712. |
| Citation | 69 F.Supp.3d 596 |
| Parties | Albert CHAVARRIA v. METROPOLITAN LIFE INSURANCE COMPANY. |
| Court | U.S. District Court — Eastern District of Louisiana |
James Frederick Willeford, Reagan Levert Toledano, Shane Dee Pendley, Willeford & Toledano, New Orleans, LA, for Albert Chavarria.
Virginia N. Roddy, Jennifer M. Lawrence, Elkins, PLC, New Orleans, LA, for Metropolitan Life Insurance Company.
ORDER AND REASONS
Before the Court are Cross–Motions for Summary Judgment (Docs. 24 & 25). For the following reasons, Plaintiff's Motion is GRANTED and Defendant's Motion is DENIED. The Court will enter final judgment in favor of Plaintiff.
Plaintiff filed this suit seeking reversal of the denial of long-term disability benefits under an employee disability benefit plan governed by the Employee Retirement Income Security Act of 1974 (“ERISA”).1 Defendant is the administrator of the plan.
Plaintiff was employed by DHH Investments as an automobile body repairman (“bodyman”). As part of his employment, Plaintiff participated in a disability benefits plan. Defendant funded the plan through an insurance policy it sold to Plaintiff's employer. Defendant also was responsible for all benefits determinations.
In October of 2009, Plaintiff was awarded short-term disability benefits on the basis of an inguinal hernia
. He was paid benefits until May of 2010, the maximum duration available under the plan. In May of 2010, Defendant opened a new claim on Plaintiff's behalf for long-term disability benefits and Defendant paid these benefits from May of 2010 until April 4, 2012. On April 5, 2012, Defendant contacted Plaintiff and informed him that he no longer met the plan's definition of disabled and that his benefits would be terminated effective April 4, 2012. Plaintiff appealed this decision through Defendant's administrative review process. After receiving a final decision denying his claim for benefits, Plaintiff filed the instant suit.
“The summary judgment standard for ERISA claims is ‘unique,’ because the Court acts in an appellate capacity reviewing the decisions of the administrator of the plan.”2 “Where the decision to grant or deny benefits is reviewed pursuant to ERISA, ‘a motion for summary judgment is merely the conduit to bring the legal question before the district court.’ ”
An administrator's decisions regarding plan terms and eligibility for benefits are subject to de novo review in the district court “unless the benefit plan gives the administrator or fiduciary discretionary authority to determine eligibility for benefits or to construe the terms of the plan.”3 If the plan grants such discretion, the administrator's determinations are reviewed only for abuse of discretion.4 In the Fifth Circuit, an administrator's factual determinations are always reviewed for abuse of discretion, regardless of whether the plan grants the administrator discretionary authority.5 The parties concede, and the Court is convinced that, the abuse of discretion standard applies to this matter.
Under this standard, the Court looks to whether the administrator acted arbitrarily or capriciously.6 “A decision is arbitrary only if ‘made without a rational connection between the known facts and the decision or between the found facts and the evidence.’ ”7 The Court will uphold the administrator's decision “if it is supported by substantial evidence.”8 The Court's review “need not be particularly complex or technical; it need only assure that the administrator's decision fall somewhere on a continuum of reasonableness—even if on the low end.”9 “A district court may not engage in de novo weighing of the evidence.”10
The Court begins its discussion with the issues on which the parties agree. There is no dispute that Plaintiff was entitled to short-term disability benefits as a result of his injury or that Plaintiff was initially entitled to long-term disability benefits. The parties also agree that, under the terms of the plan, Plaintiff was only entitled to long-term disability benefits if “due to sickness, pregnancy or accidental injury, you are receiving Appropriate Care and Treatment from a Doctor on a continuing basis; and ... you are unable to earn more than 80% of your Predisability Earnings ... at your Own Occupation11 for any employer in your Local Economy.”12 Therefore, the sole issue presented is whether, on April 4, 2012, Plaintiff was capable of earning more than 80% of his predisability earnings working as a bodyman. Defendant concluded that he was. This Court must determine whether that decision was arbitrary and capricious. It is helpful to begin with a review of Plaintiff's medical and claim history.
On October 14, 2009, Plaintiff experienced severe pain in his abdominal and groin area while at work. He was transported to the hospital where he was diagnosed with an inguinal hernia
. Plaintiff underwent surgery to repair the hernia. While the surgery appears to have been successful, Plaintiff continued to experience severe pain in his lower abdomen. When Plaintiff's pain failed to abate, he was referred to Dr. Skaribas, a pain management specialist.
Dr. Skaribas first saw Plaintiff on April 8, 2010. Dr. Skaribas diagnosed Plaintiff with bilateral ilioinguinal neuralgia, or severe nerve pain in the groin area.13 Plaintiff was prescribed pain medication and scheduled for a nerve block
procedure. The nerve block was performed on August 17, 2010, and Plaintiff experienced temporary improvement.
On June 23, 2010, pursuant to a request from Defendant, Plaintiff's employer submitted a form detailing the requirements of a bodyman. The form indicated, as relevant to Plaintiff's claim, that a bodyman was required to occasionally lift up to fifty pounds and was never required to lift more than one hundred pounds. Curiously, Plaintiff's employer did not indicate with what frequency bodymen were required to lift fifty to one hundred pounds.
On March 25, 2011, Dr. Skaribas submitted an “attending physician statement” to Defendant. Dr. Skaribas indicated that Plaintiff was suffering from chronic pain syndrome and ilioinguinal neuralgia and that Plaintiff was incapable of standing for any period of time or lifting any weight.
In July of 2011, Plaintiff was in an automobile accident that Dr. Skaribas believed exacerbated Plaintiff's condition.
Dr. Skaribas saw Plaintiff again in October and November of 2011 and noted on both occasions that Plaintiff was continuing to experience severe pain.
On January 11, 2012, Dr. Skaribas saw Plaintiff and reviewed an MRI that was completed in late 2011. The MRI report indicated that Plaintiff had a multi-level disc degeneration in his lumbar spine with multiple herniated discs
.14 Dr. Skaribas noted that Plaintiff was continuing to experience severe pain.
On February 9, 2012, at Defendant's request, Plaintiff underwent an IME with Dr. Silver. Dr. Silver noted that Plaintiff expressed complaints of severe pain in his groin, lower back, and legs. Dr. Silver concluded that Plaintiff was suffering from chronic pain syndrome, ilioinguinal neuritis
, and chronic low back syndrome with herniated discs. Dr. Silver expressed some skepticism regarding the credibility of Plaintiff's pain complaints, as well as Plaintiff's diagnosis of ilioinguinal neuritis, and opined that Plaintiff was able to return to work. Dr. Silver did not identify or discuss the nature of Plaintiff's prior work.
Defendant wrote to Dr. Silver and requested clarification regarding what work Plaintiff would be able to do, noting that Plaintiff had previously worked as a bodyman and that the bodyman job was classified as heavy work. Dr. Silver responded on March 12, 2012 and opined that Plaintiff was able to work no more than eight hours per day and lift no more than fifty pounds.
On March 14, 2012, Dr. Skaribas saw Plaintiff and noted that he was continuing to experience severe pain in his back, groin, and legs. Dr. Skaribas referred Plaintiff to a spine surgeon and reduced Plaintiff's narcotic dosage in an effort to reduce the risks of possible opioid dependency.
On April 5, 2012, Defendant informed Plaintiff that his disability benefits were terminated, effective April 4, 2012. Defendant specifically cited the report of Dr. Silver and noted that Plaintiff was able to lift up to fifty pounds and that his prior job as a bodyman did not require lifting more than fifty pounds.
On May 8, 2012, Dr. Skaribas wrote a letter to Defendant. Dr. Skaribas indicated that he had received a copy of Dr. Silver's report, and that he disagreed with his findings. He further noted that an examination of Plaintiff revealed both objective and subjective findings that supported a finding of disability, and that Dr. Skaribas's evaluation of Plaintiff's functional capacity had not changed since March of 2011.
On June 15, 2012, the Social Security Administration (“SSA”) issued a decision denying Plaintiff's request for Social Security Disability benefits. The Administrative Law Judge (“ALJ”) found that Plaintiff suffered from chronic ilioinguinal neuraliga and degenerative disc disease
and that Plaintiff was not capable of returning to his prior job as a bodyman. Specifically, the ALJ found that Plaintiff was only capable of lifting up to 20 pounds occasionally and that he was “unable to perform past relevant work.”15 Because the ALJ found that Plaintiff had the ability to perform some work, Plaintiff's claim for social security disability benefits was denied.
Dr. Skaribas saw Plaintiff again in May, July, and September of 2012 and noted that Plaintiff continued to experience severe pain. At each of these visits, Dr. Skaribas concluded that Plaintiff needed to continue the prescribed pain medication, including narcotics.
On September 19, 2012...
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